Every finding on record at Holt Senior Care and Rehab Center

Based on observation, interview and record review the facility failed to implement care planned interventions to prevent falls in 1 of 3 sampled residents (Resident #69) assessed for falls, resulting in repeated falls during staff assisted transfers and the potential for continued falls and/or serious injury. Findings include:Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference Date of 1/22/26, reflected R69 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included cerebral infarction with hemiparesis affecting left non-dominant side(left side paralyzed , vascular dementia, left above the knee amputation, atrial fibrillation(heart arrythmia with use of blood thinners), cognitive communication deficit, and major depressive disorder The MDS reflected R69 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for bed mobility, and all transfers.During an observation and interview on 4/07/2026 at 12:30 PM, R69 was in room sitting in wheelchair and appeared calm and pleasant with minimal difficulty answering questions. R69 had a above the knee left leg amputation and left arm was resting on padded arm rest of wheelchair. R69 reported was unable to use left side of body related to history of stroke and never used prostatic leg since admission. R69 reported had several falls at facility including when staff were assisting with transfers and was unsure of injuries. Review with the facility Matrix, dated 4/7/26, reflected R69 had history of fall with injury.Review of R69 Nurse Progress Note, dated 10/20/2025 at 11:23 a.m., reflected, CNA [Certified Nurse Aid] alerted this nurse that resident had fallen on the floor. This nurse entered resident's room to find resident laying on her right side, with arm beneath her. Left hand bleeding from skin tear. Resident reports that her left hand is painful at skin tear site, denies pain in wrist her left and arm. Reports slight pain in right shoulder, 2/10 on pain scale. ROM [range of motion] at baseline for this resident. VSS [vital signs stable], neuro check wnl [within normal limits], no other injuries noted, resident and CNA deny hitting head. With a gait belt, resident assisted off the floor and into her wheelchair by 2 staff members. CNA states she was transferring resident from her bed to wheelchair, wheelchair was not locked, when CNA attempted to sit resident in chair when w/c slipped from under her bottom and aid dropped resident onto the floor. 3cm x 4cm skin tear cleaned steri-strips applied, covered with adhesive bandage, order written to change bandage q 3 days until healed. Daughter notified via telephone, Dr. [named] notified, no changes or new orders at this time.Review of R69 Progress Note, dated 10/25/2025 at 4:15 p.m., reflected, Resident had a witnessed fall incident where her head did not hit anything. Resident was being transferred from bed to w/c [wheelchair] and slipped out of CNA's arms. Primary assessment showed no injuries. BP:124/64, P:57, R:18R, and O2Sats:94%. Assisted into w/c via 3 staff members. Resident denies discomforts, secondary assessment showed no injuries, Resident denies pain/discomfort. Dr. [named] notified of incident-no orders received, POA [power of attorney], [named], notified.Review of R69 Nurse Progress Note, dated 2/10/2026 at 6:00 a.m., reflected, Resident was being transferred from her bed to her wheelchair with the assistance of 2 staff members. The brakes had been applied to the wheelchair prior to the transfer, however, the brakes didn't completely stop the wheelchair from moving backwards when staff attempted to transfer the resident into it. The wheelchair moved backwards as staff began to sit the resident in it and the resident was assisted to a sitting position on the floor. Upon inspection of her skin, it is noted that there is an abrasion to her left mid-back region. Resident reports that it is tender to the touch. Other than that she denies pain. No other obvious injury noted. Resident is able to move her right arm and leg without complaints of pain or discomfort. The left arm has been affected by her stroke, and she hasn't been able to use that arm since.Resident was assisted up onto her right leg and then into the wheelchair with the assistance of 2 staff members. She was then assisted to the toilet. Throughout the transfers from the wheelchair to the toilet then to the wheelchair and back into her bed, she maintained that she was only experiencing tenderness on her back. No report of any other pain. She was transferred to her bed with the assistance of the staff. She is able to verbalize her wants and needs.Review of R69 Nurse Progress Notes, dated 3/4/2026 at 2:43 a.m., reflected, Roommate yelled out to writer that she needs two people. Writer entered room and noted resident on floor. Resident was noted sitting on floor on buttock with feet pointed southwest facing southwest, with her back facing northeast wall, near toilet and w/c. Res.[resident] denied hitting head.Staff reported that resident was lowered to the floor.Intervention: Staff education.Review of R69 Fall Assessment Review, dated 8/25/25, reflected, Fall assessment in conjunction with MDS quarterly assessment. Resident had 3 falls including one fall with fracture to left wrist during look back period (5/12/25-8/5/25). Continues to need two-person extensive assistance with transfers. Remains at risk for falls secondary to impaired mobility, cognitive deficits, and poor safety awareness. Fall precautions and safety interventions are in place. Able to make needs known. Call light accessible and able to use appropriately.Review of R69 Fall Care Plan, revised 3/20/24, reflected, I have an actual ADL[activity of daily living] deficit related to weakness and impaired mobility due to left side weakness secondary to CVA [cerebral vascular accident], left AKA [above knee amputation], left humerus fracture, CKD-3 [chronic kidney disease], and cardiac conditions. I try to maintain my independence and will transfer myself to bed without using my call light or waiting for assistance. I have been educated on the importance of assistance with ADLS.TRANSFERS: 2 Person Assist. Date Initiated: 01/11/2024.SAFETY: I am at risk for falls related to impaired mobility secondary to left side weakness secondary to CVA, left above the knee amputation.Do not leave me in the restroom or on the toilet without staff present. Date Initiated: 01/11/2024.I will wear non-skid footwear for all transfers. Date Initiated: 01/11/2024.Make sure my brakes are locked before every transfer. Date Initiated: 01/11/2024.Email request was sent to facility on 3/8/26 at 1:38 p.m., that reflected, Can you please provide Incident/Accident reports with complete investigations for past six months for [named R69].Received four Incident/Accident reports for R69 on 3/8/26 at 1:53 p.m., dated 10/20/25, 10/25/25, 2/10/26 and 3/3/26 that involved staff assisted transfers that resulted in falls. Continued review reflected that R69 had a fall on 10/20/25 during a staff assisted transfer of one person and no gait belt. The notes reflected that the wheelchair brakes were not locked, staff transferred R69 with one person assist with no gait belt and staff education was provided. Continued review reflected that R69 had a fall on 10/25/25 during a staff assisted transfer of one person with no gait belt. (five days after R69 prior fall when staff failed to follow care planned safety interventions to prevent falls). The document reflected the Root Cause Analysis was staff did not follow care plan/Kardex. Continued review of reports reflected R69 had fall on 2/10/26 during a staff assisted transfer with two staff moving R69 from the bed to the wheelchair when the chair moved during the transfer and the R69 was lowered to the ground that resulted in tender bruised area to R69 left side that measured 11 cm by 7.5 cm. The report did not mention if gait belt or non-slip shoes were in place. Continued review of the reports reflected R69 had another fall on 3/3/26 during a staff assisted transfer with one person. The notes reflected the Root Cause Analysis was the staff did not follow Kardex for transfers and education was provided. (R69 had four falls in past six months that involved staff assisted transfers when staff failed to follow care planned interventions to prevent falls.) Continued review of the provided Incident/Accident reported for R69 reflected no staff names for staff involved and did not appear to be complete investigations as requested.During an interview on 4/8/2026 2:48 PM, Certified Nurse Aid (CNA) O reported routine worked with R69 on day shift and reported R69 required two-person extensive assist with transfers. CNA O reported that meant that two persons, one on each side of R69 with use of gait belt and reported know what each resident require by reviewing the Kardex prior to providing care. CNA O reported was not involved in any of R69 falls since October of 2025 and reported facility provided individual education to staff involved and verified did not received education related to falls after R69 falls. During a telephone interview on 4/08/2026 3:48 PM, R69's Daughter P had concerns because facility staff had dropped her mother R69 several times during transfers. R69's Daughter P reported was told had been new staff each time and stated, they dropped her a lot, too much, concerned for her safety. R69's Daughter P reported her mothers Kardex had always been two-person assist and one staff member was known to always only use one person. R69's Daughter P reported R69's Kardex also requires staff to remain in bathroom with R69 and witnessed nurse staff leave R69 in bathroom alone and immediately questioned staff because they make a choice to repeatedly not follow the Kardex interventions that are meant to keep R69 safe.During an interview on 4/08/2026 at 5:02 PM, Licensed Practical Nurse (LPN) F reported working at the facility for over two years and often worked with R69. LPN F reported R69 required two-person assist with transfer along with gait belt as long as she could remember. LPN F reported R69 was a very high risk for falls related to prior falls, left above the knee amputation, and history of stroke with left side paralysis. LPN F reported was not present for R69 falls and reported R69 had several falls with and without staff present. LPN F reported make her very angry when R69 had falls with staff assist when R69 Care Planned safely interventions were not being followed and reported no excuse for not following Kardex and reported most of R69's falls during staff assistance have happened on second and third shift. LPN F reported R69 Daughter was also very agree that staff have dropped R69 several times because Kardex was not followed. LPN F reported R69 had skin tear after one fall and recalled clearly after 2/10/26 fall had significant bruising to side and back the same day and verified R69 was taking blood thinners.Review of R69, SW- Skin Check Progress Note, dated 2/10/2026 9:00 p.m., reflected, Skin warm & dry, skin color WNL[within normal limits] and turgor is normal.No skin issues identified. (Incident reported reflected 11 cm x 7.5 cm abrasion and bruised area to R69 left side.) The note was completed LPN Q, who was unavailable for interview prior to survey exit. During an interview on 4/09/2026 at 8:15 AM, Certified Nurse Aid (CNA) R reported R69 required two-person assist with use of gait belt with transfers. CNA R reported new staff educated on first day that Kardex must be reviewed prior to care and to reviewed frequently and reported was not involved in R69 falls but had heard about them. CNA R reported facility provided individual education to staff involved in falls and all staff. During an interview on 4/09/2026 at 8:43 AM, Director of Nursing (DON) reported had only provided R69 incident/accidents for last six months not complete investigation and would provide. This surveyor verified email request was for complete investigation, including staff involved. DON reported had provided working schedules for the dates of R69 falls and verified had not provided correct schedule for the 2/10/26 fall that occurred on the evening of 2/9/26 schedule and would provide. DON reported staff involved were given one on one education and discipline and would provide as part of investigation.During an interview on 4/09/2026 at 9:17 AM, DON reported was currently working on gathering requested information. This Surveyor requested to review complete employee files for staff involved in R69 most recent four falls. DON reported had located three and still working on 4th staff. (should have been five in total)Review of provided employee files on 4/09/2026 at 9:45 AM, reflected four CNA files. According to Incident reports should be five staff directly involved with R69 past four falls. Review of working schedules, Incident reports and provided files reflected one missing employee file for CNA S. Continued Review of the employee files revealed three staff, CNA T (failed to follow Kardex on 10/20/25), and CNA U(failed to follow Kardex on 10/25/25) had completed, Employee Corrective Action for failure to follow Kardex interventions resulting in fall. Continued review of CNA S file reflected no evidence of staff education provided for not following Kardex related to one person transfer resulting in fall on 3/3/26.During an interview on 4/09/2026 at 10:11 AM, Licensed Practical Nurse (LPN) V reported was R69 nurse at time of fall on 10/20/25. LPN V reported was notified by CNA T that R69 had fallen. LPN V reported was standing at medication cart outside R69 room and immediately entered R69 room and observed R69 was laying on floor next to the bed with left arm skin tear observed. LPN V reported after R69 was assessed was transferred to bed. LPN V reported CNA T reported she transferred R69 with alone because she could not find another staff and did not use gait belt because she did not have one. LPN V reported CNA T became very angry with LPN V and refused to work with LPN V after incident. LPN V reported had heard about R69 fall on 2/10/26 but was not present but reported R69 had large abrasion and bruised area to side. LPN V reported makes her so angry staff know R69 is very high risk fall and continue to transfer her with one assist instead of two-assist. LPN V reported was questioned by management yesterday if this surveyor had called about R69 fall During a telephone interview on 4/09/2026 at 11:21 AM, CNA S reported was R69 aid on 10/25/25 at time of fall. CNA S reported she transferred R69 alone with no gait belt and R69 fell. CNA S reported R69 was change to two-person assist after that and reported did not use gait belt because she could not find one and reported she should have used one. CNA S reported received education after incident.During an interview on 4/09/2026 at 11:40 AM, Clinical Care Coordinator (CCC) E reported was responsible for completing fall root cause analysis for cedar unit. CCC E reported would expect staff to follow Kardex and verified R69 falls for 10/20/25, 10/25/25 and 3/3/26 the staff failed to follow the care planned intervention on the Kardex to prevent falls. CCC E was queried what interventions were implemented after each of R69 falls? CCC E reported they performed one on one staff education for staff who did no follow Kardex. CCC E was queried if that intervention was effective and CCC E stated, No, [named R69] still fell. During an interview on 4/09/2026 at 12:10 PM, DON reported would expect staff to follow Kardex and care plan interventions. DON verified R69 falls on 10/20/25, 10/25/25 and 3/3/26 staff failed to follow Kardex and transferred R69 with one assist instead of two person assist and staff involved were provided one on one education. DON was queried of one on one education was effective DON stated, no and reported same staff not involved but intervention did not prevent additional falls for R69.

Based on observation, interview and record review, the facility failed to ensure accurate coding of a Minimum Data Set (MDS) assessment for one (R80) of 19 reviewed.Findings include: Review of the medical record reflected R80 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included end stage renal disease and dependence on renal dialysis. The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/3/25, reflected R80 received dialysis. The Quarterly MDS, with an ARD of 1/27/26, reflected R80 was not coded as receiving dialysis. On 04/09/2026 at 11:40 AM, R80 was observed lying in bed. A Physician's Order, with a revision date of 4/16/25, reflected R80's scheduled dialysis days were Monday, Wednesday, Friday and as needed. In an interview on 04/08/2026 at 3:36 PM, MDS Nurse H acknowledged R80's Quarterly MDS, with an ARD of 1/27/26, should have been coded for receiving dialysis.

Based on observation, interview and record review the facility failed to ensure comprehensive care plans were accurate and implemented for two out of 19 residents (Resident #8 & 69).Resident #8 (R8): Review of R8's electronic medical record (EMR) revealed R8 was admitted to the facility on [DATE] with a code status of full code by default. Review of a Code Status Form dated [DATE], revealed R8 was a full code by default and was signed by the Physician and two witnesses. Review of a Code Status Form dated [DATE], revealed R8 was a full code by default and was signed by the Physician and two witnesses. Review of a Code Status Form dated [DATE], revealed R8 was a full code by default and was signed by two witnesses, but no Physician. Review of a Code Status Form dated [DATE], revealed R8 was a DNR (do not resuscitate) and was signed by the Physician and two witnesses. Record review of R8's care plan revealed a care plan in place with a Focus of Advanced Directives:, Advance Directives have been discussed & the following has been decided (CPR [cardiopulmonary resuscitation] by default). The care plan was dated [DATE] and last revised on [DATE]. The care plan was not updated when R8 was changed to a DNR status. In an interview on [DATE] at 8:16 AM, Registered Nurse (RN) E stated R8's son had to get R8's Durable Power of Attorney (DPOA) paperwork to the facility so code status could be determined. RN E said Social Services is ultimately responsible for the updating of the care plan at the time of the change in the code status. In an interview on [DATE] at 8:36 AM, Social Worker (SW) D said R8's care plan should have been changed or updated when her code status changed. SW D said she did not know how or why R8's care plan was not updated to her current DNR code status. Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference Date of [DATE], reflected R69 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included cerebral infarction with hemiparesis affecting left non-dominant side(left side paralyzed , vascular dementia, left above the knee amputation, atrial fibrillation(heart arrythmia with use of blood thinners), cognitive communication deficit, and major depressive disorder The MDS reflected R69 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for bed mobility, and all transfers. During an observation and interview on [DATE] at 12:30 PM, R69 was in room sitting in wheelchair and appeared calm and pleasant with minimal difficulty answering questions. R69 had a above the knee left leg amputation and left arm was resting on padded arm rest of wheelchair. R69 reported was unable to use left side of body related to history of stroke and never used prostatic leg since admission. R69 reported had several falls at facility including when staff were assisting with transfers and was unsure of injuries. Review with the facility Matrix, dated [DATE], reflected R69 had history of fall with injury. Review of R69 Nurse Progress Note, dated [DATE] at 11:23 a.m., reflected, CNA [Certified Nurse Aid] alerted this nurse that resident had fallen on the floor. This nurse entered resident's room to find resident laying on her right side, with arm beneath her. Left hand bleeding from skin tear. Resident reports that her left hand is painful at skin tear site, denies pain in wrist her left and arm. Reports slight pain in right shoulder, 2/10 on pain scale. ROM [range of motion] at baseline for this resident. VSS [vital signs stable], neuro check wnl [within normal limits], no other injuries noted, resident and CNA deny hitting head. With a gait belt, resident assisted off the floor and into her wheelchair by 2 staff members. CNA states she was transferring resident from her bed to wheelchair, wheelchair was not locked, when CNA attempted to sit resident in chair when w/c slipped from under her bottom and aid dropped resident onto the floor. 3cm x 4cm skin tear cleaned steri-strips applied, covered with adhesive bandage, order written to change bandage q 3 days until healed. Daughter notified via telephone, Dr. [named] notified, no changes or new orders at this time. Review of R69 Progress Note, dated [DATE] at 4:15 p.m., reflected, Resident had a witnessed fall incident where her head did not hit anything. Resident was being transferred from bed to w/c [wheelchair] and slipped out of CNA's arms. Primary assessment showed no injuries. BP:124/64, P:57, R:18R, and O2Sats:94%. Assisted into w/c via 3 staff members. Resident denies discomforts, secondary assessment showed no injuries, Resident denies pain/discomfort. Dr. [named] notified of incident-no orders received, POA [power of attorney], [named], notified. Review of R69 Nurse Progress Note, dated [DATE] at 6:00 a.m., reflected, Resident was being transferred from her bed to her wheelchair with the assistance of 2 staff members. The brakes had been applied to the wheelchair prior to the transfer, however, the brakes didn't completely stop the wheelchair from moving backwards when staff attempted to transfer the resident into it. The wheelchair moved backwards as staff began to sit the resident in it and the resident was assisted to a sitting position on the floor. Upon inspection of her skin, it is noted that there is an abrasion to her left mid-back region. Resident reports that it is tender to the touch. Other than that she denies pain. No other obvious injury noted. Resident is able to move her right arm and leg without complaints of pain or discomfort. The left arm has been affected by her stroke, and she hasn't been able to use that arm since.Resident was assisted up onto her right leg and then into the wheelchair with the assistance of 2 staff members. She was then assisted to the toilet. Throughout the transfers from the wheelchair to the toilet then to the wheelchair and back into her bed, she maintained that she was only experiencing tenderness on her back. No report of any other pain. She was transferred to her bed with the assistance of the staff. She is able to verbalize her wants and needs. Review of R69 Nurse Progress Notes, dated [DATE] at 2:43 a.m., reflected, Roommate yelled out to writer that she needs two people. Writer entered room and noted resident on floor. Resident was noted sitting on floor on buttock with feet pointed southwest facing southwest, with her back facing northeast wall, near toilet and w/c. Res.[resident] denied hitting head.Staff reported that resident was lowered to the floor.Intervention: Staff education. Review of R69 Fall Care Plan, revised [DATE], reflected, I have an actual ADL[activity of daily living] deficit related to weakness and impaired mobility due to left side weakness secondary to CVA [cerebral vascular accident], left AKA [above knee amputation], left humerus fracture, CKD-3 [chronic kidney disease], and cardiac conditions. I try to maintain my independence and will transfer myself to bed without using my call light or waiting for assistance. I have been educated on the importance of assistance with ADLS.TRANSFERS: 2 Person Assist. Date Initiated: [DATE].SAFETY: I am at risk for falls related to impaired mobility secondary to left side weakness secondary to CVA, left above the knee amputation.Do not leave me in the restroom or on the toilet without staff present. Date Initiated: [DATE].I will wear non-skid footwear for all transfers. Date Initiated: [DATE].Make sure my brakes are locked before every transfer. Date Initiated: [DATE]. Received four Incident/Accident reports for R69 on [DATE] at 1:53 p.m., dated [DATE], [DATE], [DATE] and [DATE] that involved staff assisted transfers that resulted in falls. Continued review reflected that R69 had a fall on [DATE] during a staff assisted transfer of one person and no gait belt. The notes reflected that the wheelchair brakes were not locked, staff transferred R69 with one person assist with no gait belt and staff education was provided. Continued review reflected that R69 had a fall on [DATE] during a staff assisted transfer of one person with no gait belt. (five days after R69 prior fall when staff failed to follow care planned safety interventions to prevent falls). The document reflected the Root Cause Analysis was staff did not follow care plan/Kardex. Continued review of reports reflected R69 had fall on [DATE] during a staff assisted transfer with two staff moving R69 from the bed to the wheelchair when the chair moved during the transfer and the R69 was lowered to the ground that resulted in tender bruised area to R69 left side that measured 11 cm by 7.5 cm. The report did not mention if gait belt or non-slip shoes were in place. Continued review of the reports reflected R69 had another fall on [DATE] during a staff assisted transfer with one person. The notes reflected the Root Cause Analysis was the staff did not follow Kardex for transfers and education was provided. (R69 had four falls in past six months that involved staff assisted transfers when staff failed to follow care planned interventions to prevent falls.) Continued review of the provided Incident/Accident reported for R69 reflected no staff names for staff involved and did not appear to be complete investigations as requested. During an interview on [DATE] 2:48 PM, Certified Nurse Aid (CNA) O reported routine worked with R69 on day shift and reported R69 required two-person extensive assist with transfers. CNA O reported that meant that two persons, one on each side of R69 with use of gait belt and reported know what each resident require by reviewing the Kardex prior to providing care. CNA O reported was not involved in any of R69 falls since October of 2025 and reported facility provided individual education to staff involved and verified did not received education related to falls after R69 falls. During a telephone interview on [DATE] 3:48 PM, R69's Daughter P had concerns because facility staff had dropped her mother R69 several times during transfers. R69's Daughter P reported was told had been new staff each time and stated, they dropped her a lot, too much, concerned for her safety. R69's Daughter P reported her mothers Kardex had always been two-person assist and one staff member was known to always only use one person. R69's Daughter P reported R69's Kardex also requires staff to remain in bathroom with R69 and witnessed nurse staff leave R69 in bathroom alone and immediately questioned staff because they make a choice to repeatedly not follow the Kardex interventions that are meant to keep R69 safe. During an interview on [DATE] at 5:02 PM, Licensed Practical Nurse (LPN) F reported working at the facility for over two years and often worked with R69. LPN F reported R69 required two-person assist with transfer along with gait belt as long as she could remember. LPN F reported R69 was a very high risk for falls related to prior falls, left above the knee amputation, and history of stroke with left side paralysis. LPN F reported was not present for R69 falls and reported R69 had several falls with and without staff present. LPN F reported make her very angry when R69 has falls with staff assist when R69 Care Planned safely interventions were not being followed and reported no excuse for not following Kardex and reported most of R69's falls during staff assistance have happened on second and third shift. LPN F reported R69 Daughter was also very agree that staff have dropped R69 several times because Kardex was not followed. LPN F reported R69 had skin tear after one fall and recalled clearly after [DATE] fall had significant bruising to side and back the same day and verified R69 was taking blood thinners. Review of provided employee files on [DATE] at 9:45 AM, reflected four CNA files. Continued Review of the employee files revealed three staff, CNA T (failed to follow Kardex on [DATE]), and CNA U(failed to follow Kardex on [DATE]) had completed, Employee Corrective Action for failure to follow Kardex interventions resulting in fall. Continued review of CNA S file reflected no evidence of staff education provided for not following Kardex related to one person transfer resulting in fall on [DATE]. During an interview on [DATE] at 10:11 AM, Licensed Practical Nurse (LPN) V reported was R69 nurse at time of fall on [DATE]. LPN V reported was notified by CNA T that R69 had fallen. LPN V reported was standing at medication cart outside R69 room and immediately entered R69 room and observed R69 was laying on floor next to the bed with left arm skin tear observed. LPN V reported after R69 was assessed was transferred to bed. LPN V reported CNA T reported she transferred R69 with alone because she could not find another staff and did not use gait belt because she did not have one. LPN V reported CNA T became very angry with LPN V and refused to work with LPN V after incident. LPN V reported had heard about R69 fall on [DATE] but was not present but reported R69 had large abrasion and bruised area to side. LPN V reported makes her so angry staff know R69 is very high risk fall and continue to transfer her with one assist instead of two-assist. LPN V reported was questioned by management yesterday if this surveyor had called about R69 fall During a telephone interview on [DATE] at 11:21 AM, CNA S reported was R69 aid on [DATE] at time of fall. CNA S reported she transferred R69 alone with no gait belt and R69 fell. CNA S reported R69 was change to two-person assist after that and reported did not use gait belt because she could not find one and reported she should have used one. CNA S reported received education after incident. During an interview on [DATE] at 11:40 AM, Clinical Care Coordinator (CCC) E reported was responsible for completing fall root cause analysis for cedar unit. CCC E reported would expect staff to follow Kardex and verified R69 falls for [DATE], [DATE] and [DATE] the staff failed to follow the care planned intervention on the Kardex to prevent falls. CCC E was queried what interventions were implemented after each of R69 falls? CCC E reported they performed one on one staff education for staff who did no follow Kardex. CCC E was queried if that intervention was effective and CCC E stated, No, [named R69] still fell. During an interview on [DATE] at 12:10 PM, DON reported would expect staff to follow Kardex and care plan interventions. DON verified R69 falls on [DATE], [DATE] and [DATE] staff failed to follow Kardex and transferred R69 with one assist instead of two person assist and staff involved were provided one on one education. DON was queried if one on one education was effective DON stated, no and reported same staff not involved but intervention did not prevent additional falls for R69.

Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records for one (R2) of 19 reviewed. Findings include:Review of the Face Sheet and Minimum Data Set (MDS) with an Assessment Reference Date 3/12/26, reflected R2 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included cirrhosis of the liver, kidney failure, heart failure, diabetic, anxiety and depression. The MDS reflected R2 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required staff assist with dressing, hygiene, bathing, transfers, and toileting.During an observation on 4/07/2026 at 11:47 AM, R2 was in bed with guest at bedside. R2 reported currently had Hospice services since December and often Hospice services want pain medication given according to there direction and facility staff do not agree and stated, seems like they do not speak to each other.Review of R2 Progress Note, dated 4/7/2026 at 11:08 a.m., reflected, Hospice collaboration meeting with [named hospice service]. Reviewed resident's current condition and hospice services provided.Continues to express pain, continues to decline pain medication secondary to increased sleepiness when taking medication. Continues to take ativan as needed secondary to anxiety.Review of R2 Electronic Medical Record(EMR), dated 12/12/25 through 4/8/26, reflected no evidence of Hospice visit notes since 1/14/26(two months ago). Unable to determine Hospice recommendations for changes with pain control.During an interview on 4/08/2026 at 11:15 AM, Clinical Care Coordinator (CCC) E verified R2 was seen by Hospice services since admission in December and reported had binder at Nurse Station. CCC E verified was unable to locate Hospice visit notes in R2 EMR or Hospice binder since 1/14/26 and had verified with Medical Record they did not have additional hospice visit notes for R2. CCC E reported R2 had recent pain medication changes yesterday.During an interview on 4/08/2026 at 11:35 AM, Medical Records W reported R2's most recent hospice documents, including visit notes, was from 1/14/26 and reported was not responsible for obtaining visit notes from hospice and advised to speak with MDS staffDuring an interview on 4/08/2026 at 11:55 AM, Director of Nursing (DON) reported would expect Hospice visit notes to be added to resident EMR within one month. DON reported would expect staff to verify at monthly hospice coordination meeting that visit notes were up to date in EMR and verified was unable to locate R2 hospice notes since 1/14/26 in EMR.

Based on observation, interview, and record review, the facility failed to ensure an antibiotic was administered as ordered for one (R4) of five reviewed. Findings include: Review of the medical record revealed R4 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, diabetes, and peripheral vascular disease. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/19/26 revealed R4 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/07/26 at 11:30 AM, R4 was observed sitting in her wheelchair in her room. R4 reported she was currently receiving an antibiotic for cellulitis in her right leg. R4's right leg was observed wrapped with a bandage. Review of the Physician's Order dated 3/4/26 and ordered to start on 3/4/36 at 2:00 PM, revealed an order for cephalexin (antibiotic) 500 milligrams (mg) three times a day for 7 days for cellulitis of the right lower extremity. Review of the Medication Administration Record (MAR), revealed R4's cephalexin was not signed out as administered on 3/4/26 at 2:00 PM, 3/6/26 at 9:00 PM, 3/7/26 at 2:00 PM, and 3/10/26 at 9:00 PM. Review of the Nurse's Note dated 3/11/2026 revealed Resident's last dose of abx [antibiotic] given, resident's right lower extremity noted with continued erythema and warm to touch, per [physician's name] extend keflex [cephalexin] x 1 more week. Review of the Physician's Order dated 3/11/26 and ordered to start on 3/11/26 at 2:00 PM, revealed an order for cephalexin 500 mg three times a day for 7 days for cellulitis of the right lower extremity. Review of the MAR revealed R4's cephalexin was not signed out as administered on 3/11/26 at 2:00 PM, 3/11/26 at 9:00 PM, 3/12/26 at 2:00 PM, 3/12/26 at 9:00 PM, and 3/14/26 at 9:00 PM. Review of the Physician's Order dated 4/6/26 and ordered to start on 4/6/26 at 9:00 PM, revealed an order for cephalexin 500 mg three times a day for 7 days for cellulitis of the right lower extremity. In an interview on 04/09/2026 at 10:25 AM, Infection Preventionist (IP) N reported they monitor antibiotic use multiple times per day. IP N reported R4's cellulitis has been complicated and seemed to have resolved last month, but then symptoms returned again on 4/6/26. When asked if R4 received all doses of cephalexin from 3/4/26 to 3/18/36, IP N reported it was unclear and she would have to look into it. In an interview on 04/09/2026 at 10:35 AM, Director of Nursing (DON) reported nothing was brought to her attention that R4 did not receive all antibiotic doses prescribed from 3/4/26 to 3/18/26. When asked if R4 received all their antibiotic doses between that timeframe, DON reported she could not say because there was missing documentation on the MAR. Review of the backup medication inventory available in the facility, revealed 15 capsules of cephalexin 500 mg were available. In an interview on 04/09/26 at 11:47 AM, IP N reported they did not locate any doses of R4's cephalexin that were left in the cart from the dates of 3/4/26 to 3/18/26. IP N reported any leftover doses would have been returned to pharmacy. IP N reported the facility contacted the pharmacy today and received an email that the pharmacy did not receive any leftover doses returned to them. The facility was able to provide documentation staff removed a dose of cephalexin 500 mg for R4 on 3/4/26 at 11:58 AM, however the first dose scheduled for 3/4/26 at 2:00 PM was not documented as administered on the MAR. Review of the Consolidated Delivery Sheets printed 3/4/25 at 10:35 PM, revealed the facility received 21 capsules of cephalexin 500 mg for R4. Review of the Consolidated Delivery Sheets revealed the facility received 21 capsules of cephalexin 500 mg for R4 on 3/12/26 at 12:40 AM. The facility provided documentation that they received 42 capsules of cephalexin 500 mg for R4 from pharmacy deliveries on 3/4/26 and 3/11/26 and also removed two capsules from the backup supply on 3/4/26. In total, the facility had 44 doses of cephalexin 500 mg for R4. The facility was not able to provide documentation that R4 received the other doses of cephalexin 500 mg that were not documented as administered. R4's MAR indicated 9 of the 42 doses from 3/4/26-3/18/26 were not documented as administered as ordered.

Based on observation, interview, and record review the facility failed to safely transport portable oxygen tank, resulting in the increased likelihood of severe injury, potentially affecting all 92 residents in the facility, staff and visitors.Findings include:During an observation on 4/07/2026 at 12:07 PM, during the initial tour of the facility and screening process, Licensed Practical Nurse (LPN) F was observed carrying a portable oxygen tank down entire Hall C, past Hall C Nurse station and halfway down beginning of Hall C to the oxygen storage closet without oxygen transport cart. LPN F exited the oxygen storage room with portable oxygen tank in a transport cart and wheeled cart down both C Halls and entered room C23. Several Residents and staff were present in both C Halls at the time. During an interview on 4/08/2026 at 5:02 PM, Licensed Practical Nurse (LPN) F reported working at the facility for over two years and had been a nurse for over 30 years. LPN F was queried about how to safely transport portable oxygen tanks. LPN F reported was called to management office on 4/8/26, after this surveyor had observed staff transport oxygen tank without a cart and received education about safe transport of portable oxygen tanks. LPN F reported prior to that had not received education and did not know you could not carry a tank and stated she knows now. LPN F verified had carried empty tank from resident wheelchair to the oxygen storage room and returned full tank on transport cart. During an interview on 4/09/2026 at 11:40 AM, Clinical Care Coordinator E for Hall C reported would expect portable oxygen tanks to only be transported in wheeled oxygen cart. During an interview on 4/09/2026 at 12:10 PM, Director of Nursing (DON) reported would expect portable oxygen tanks to be transported in oxygen carts because if accidentally dropped they could become like a missile. DON reported LPN F was provided education on 4/8/26. Review of the facility, OXYGEN ADMINISTRATION & SAFETY, policy, dated 4/12/16, reflected, POLICY: Oxygen administration will be provided per physician's order observing appropriate safety measures .When using oxygen cylinders, secure oxygen cylinders in appropriate holder .

Based on observation, interview and record review, the facility failed to ensure appropriate personal protective equipment (PPE) was utilized for contact precaution and ensure hand hygiene was performed for four (Resident #22, 26, 52, and 57) of reviewed for contact precautions. Findings include: On 1/13/25 at 10:34 AM, a contact precaution sign was observed outside of the room of Resident #22 (R22) and Resident #57 (R57). The contact precaution sign indicated that hand washing prior to entry of the room, as well as donning a gown and gloves (PPE) was necessary prior to entering the room. On 1/13/25 at 10:37 AM, a contact precaution sign was observed outside of the room of Resident #26 (R26) and Resident #52 (R52). The contact precaution sign indicated that hand washing prior to entry of the room, as well as donning a gown and gloves was necessary prior to entering the room. In an interview on 1/13/25 at 10:38, Licensed Practical Nurse (LPN) P stated that both rooms were contact precautions due to a gastroenteritis virus that was affecting the residents. LPN P confirmed that hand hygiene should be performed and a gown, and gloves needed to donned prior to entering the room. Upon exit, staff should be discarding the PPE in a trash receptacle inside the room and performing hand hygiene. On 1/13/25 at 10:43 AM, Staff member T was observed entering the room wearing gloves and not performing hand hygiene where R26 and R52 resided. Staff member T changed the liner in the trash receptacle and exited the room wearing the same gloves and without performing hand hygiene. Staff member T proceeded to obtain a broom, and reenter the room wearing the same gloves and without performing hand hygiene. Staff member T swept the floor from the doorway to the opposite side of the room. Staff member T proceeded to exit the room wearing the same gloves and without performing hand hygiene, obtained a mop, and reentered the room with the same gloves and without hand hygiene. Staff member T mopped the room in the same manner, crossing over both sides of the room. Stall member T exit the room wearing the same gloves and without performing hand hygiene, and proceeded down the hall. On 1/13/25 at 11:11 AM, staff member S entered the room of R22 and R57 without performing hand hygiene or donning required PPE. Staff member S exited the room without performing hand hygiene. On 1/13/25 at 11:13 AM, staff member S entered the room of R26 and R52 without performing hand hygiene or donning required PPE. Staff member S exited the room without performing hand hygiene and proceeded down the hallway with a laundry cart. On 1/13/25 at 11:15 AM, staff member S entered a resident room without performing hand hygiene and exited shortly after without performing hand hygiene. In an interview on 1/13/25 at 11:18 AM, staff member S stated that hand hygiene, gown and gloves are required when entering a contact precaution room. Upon exit, discard the PPE inside the room and perform hand hygiene. Staff member S confirmed that she did not don PPE in either contact precaution rooms and denied performing hand hygiene upon entry and exit. On 1/13/25 at 12:43 PM, Certified Nursing Assistant (CNA) U was observed entering the room of R26 and R52 to deliver a glass of apple juice without performing hand hygiene or wearing proper PPE. On 1/13/25 at 12:47 PM CNA U was observed entering the room of R26 and R52 to deliver a lunch tray. CNA U did not perform hand hygiene or don the required PPE. On 1/13/25 at 12:47 PM, CNA F observed CNA U in the room without the required PPE and advised that she step out and don the required PPE. CNAU stated that she was not aware of the need for contact precautions in the room. Review of Physician Order's revealed R52 and R57 were both under contact precautions for gastroenteritis type symptoms. In an interview on 1/15/25 at 1:06 PM, Registered Nurse (RN) O confirmed that she was responsible for the infection control program in the facility. RN O stated that staff should be performing hand hygiene, donning required PPE of gown and gloves prior to entering the rooms of R22, R26, R52, and R57. Staff should be doffing the required PPE of gloves and a gown, and performing hand hygiene upon exiting he room. RN O stated that the required contact precautions should be followed even if staff is momentarily entering the room to drop an item off.

Based on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA) timely for one (Resident #91) of 20 reviewed for Minimum Data Set (MDS). Findings include: Review of the clinical record reflected Resident # 91 (R91) was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and chronic kidney disease. R91's Minimum Data Set (MDS) dated [DATE] reflected a BIMS of 4. Review of R91's monthly physician orders revealed a physician order for hospice dated 12/16/24. Hospice notes dated 12/16/24 revealed R91 was admitted on to hospice care as of 12/16/24. Further review of R91's clinical record revealed the SCSA MDS was initiated on 01/13/25 (incomplete as of 1/14/25). On 01/14/25 at 02:01 PM, during an interview with MDS Nurse D she acknowledge the SCSA MDS should have started in December when R91 was signed onto hospice care. MDS Nurse D offered no explanation why the Significant Change MDS was late.

Based on interview and record review, the facility failed to transmit Minimum Data Set (MDS) assessments to Centers for Medicare & Medicaid Services (CMS) timely for two (Resident #49 and #89) of 20 reviewed. Findings include: Resident #49 (R49): Review of the medical record reflected R49 admitted to the facility on [DATE], with diagnoses that included diabetes and dependence on renal dialysis. R49's MDS history reflected a discharge return not anticipated MDS, with an Assessment Reference Date (ARD) of 8/31/24, which was completed on 9/11/24. The MDS had not been transmitted to CMS. Resident #89 (R89): Review of the medical record reflected R89 admitted to the facility on [DATE], with diagnoses that included aftercare following surgery for neoplasm (abnormal growth of tissue). R89's MDS history reflected a discharge return not anticipated MDS, with an ARD of 8/30/24, which was completed on 9/11/24. The MDS had not been transmitted to CMS. In an interview on 01/14/25 at 2:00 PM, MDS Nurse D reported the facility had 14 days from the date of MDS completion to transmit the MDS data to CMS. MDS Nurse D acknowledged that R49 and R89's discharge return not anticipated MDS assessments had not been transmitted to CMS.

Based on interview and record review, the facility failed to ensure accurate coding on a Minimum Data Set (MDS) assessment for one (Resident #96) of 20 reviewed. Findings include: Review of the medical record reflected Resident #96 (R96) admitted to the facility on [DATE], with diagnoses that included wedge compression fracture of the second thoracic vertebra. The discharge return not anticipated MDS, with an Assessment Reference Date (ARD) of 12/9/24, reflected R96 was coded for discharge to a short-term hospital. A Progress Note for 12/9/24 reflected R96 discharged home. In an interview on 01/15/25 at 12:03 PM, MDS Nurse D reported R96 discharged home, not to the hospital. MDS Nurse D acknowledged there was a coding error on the MDS.

Based on interview and record review the facility failed to confirm that the Pre-Admission Screening And Resident Review (PASARR Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a level II Omnibus Budget Reconciliation Act (OBRA) evaluation prior to their admission to the facility for 1 residents (#83) of 2 reviewed. Review of the clinical record reflected Resident # 83 (R83) was admitted to the facility on [DATE] with diagnoses that include morbid obesity and bi-polar disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Status Score of 15 out of 15 (cognitively intact). The mood section of the same MDS reflected R83 felt down, depressed or hopeless several days a week. Review of R83's clinical record reflected a 3877 dated 2/26/24 revealed R83 had a mental illness diagnosis and received psychotpic medication that included an anti-psychotic medication. Review of the 3878 dated 2/28/24 and signed by the physician reflected R83 was admitted on an exemption and would likely need less than 30 days of nursing home care. A second 3877 dated 11/22/24 signed by the facility MDS Nurse D reflected R83 had a mental illness and received psychotropic medications. Further review of the clinical record revealed no documentation that CMH was aware of R83's admission 6 months prior. On 01/14/25 at 03:10 PM, during an interview with Social Worker (SW) M reported R83 had a level II completed by another county. When queried why it was not in the medical record SW M offered no explanation. A request to review R83's Level II completed by CMH was requested at that time. SW M stated there was some confusion regarding the status and would follow up with surveyor tomorrow. On 01/15/25 at 12:07 PM, during an interview with MDS Nurse D she reported she was not responsible for tracking when 3877/3878's were due, she just completed them when notified to do so by the facility's Social Work Department. On 01/15/25 at 12:25 SW M reported R83 was at another facility in another county for several months prior to being admitted at their facility. R83 stayed well beyond the 30 day exemption at the other facility and CMH in the other county started a Level II evaluation but did not complete it. When queried how/why R83's 3877/3878 screen completed in February 2024 determined to be acceptable 4 months after the exemption period SW M offered no explanation. When queried why the facility did not complete a second 3877 screen until 4 months after R83's admission, SW M offered no explanation.

This citation pertains to intake MI00146126: Based on observation, interview and record review the facility failed to meet the needs of residents with regard to the timeliness of providing laboratory services and reporting laboratory results for one residents(R104) of three residents reviewed for medications, resulting in delayed treatment and intervention related to lab results, and impaired coordination of care. Findings include: Resident #104(R104) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R104 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included history of deep vein thrombosis/pulmonary embolysis(blood clot), hypertension (high blood pressure), pelvic fracture, dementia, chronic kidney disease, anxiety and depression, The MDS reflected R104 had a BIM (assessment tool) score of 7 which indicated her ability to make daily decisions was severely impaired, and she required maximal physical assist with toileting, bathing, dressing, and moderate assist with hygiene and dependant on staff for bed mobility. During an observation and interview on 8/20/24 at 1:18 p.m. this surveyor entered facility with signs posted on front entry that reflected positive Covid cases starting 8/16/24 with all staff wearing facial masks. Nursing Home Administrator A reported the current census was 91 residents. During an observation and interview on 8/20/21 at 2:05 p.m., during the facility initial tour, this surveyor entered R104 room after permission was granted by R104 and family. R104 was sitting up in wheelchair with her husband at the bedside. R104 appeared pleasantly confused with poor memory recall with simple questions. R104 husband F reported R104 was at the facility for rehabilitation after accident with broken pelvic bone. R104 husband F reported was upset with care at facility because he had spoken with physician over two weeks ago and had reported concerns with R104 swelling in both feet, symptoms of urinary tract infection(UTI) and concerns about not being able to regulate Coumadin dosing. R104's husband F reported physician assured family concerns would be addressed but nothing happened until physician returned yesterday and family was again upset about continued concerns. R104's husband F reported compression socks were then applied and informed medications could cause changes in Coumadin dosing and reported medication had not changed until yesterday when antibiotic was started for UTI. R104's husband F reported routinely visited facility twice daily. Review of R104 complete Medical Record, dated 7/18/24 through 8/22/24, reflected no evidence of prothrombin time/international normalized ratio (PT/INR)(measures how long it takes blood to clot) flowsheet. Review of R104 Physician Progress Note, dated 8/22/24 at 7:59 a.m., reflected, LABORATORY . INRs 7/29/24 INR 4.1 - Coumadin 5 mg daily put on Hold 7/30/24 INR 3.45 7/31/24 INR 2.8 - Start Coumadin 3 mg daily 8/02/24 INR 2.1 - Continue Coumadin 3mg daily 8/05/24 INR 1.73 - Increase Coumadin to 4 mg daily 8/12/24 INR Not drawn 8/14/24 INR 2.57 8/15/15 INR 3.50 Hold Coumadin x 1dose (16th) Given 17th, 18th. 8/19/24 INR not drawn. Coumadin given on 19th, then held. 8/21/24 INR 1.44 Start Coumadin 4 mgMWF 3 mg STTHSat. Repeat 7/26[8/26/24]. Discussed with Nurse and Nurse Manager. Review of R104's Medication Administration Record(MAR), dated 7/18/24 through 7/31/24, reflected R104 received Coumadin (blood thinner) dosing as noted below as indicated by staff initials: Dates of 7/18/24 through 7/29/24(including 7/29/24)-Coumadin 5 mg 1 tablet daily at 5:00 p.m. On 7/30/24-Coumadin dose was on HOLD(not given) On 7/31/24-Coumadin 3mg daily started Review of the MAR, dated 8/1/24 through 8/22/24, reflected R104 received Coumadin dosing as noted below as indicated by staff initials: 8/1/24 through 8/5/24 Coumadin 3 mg daily 8/6/24 through 8/15/24(including 8/15/24) Coumadin 4mg daily 8/16/24 Coumadin dose was on HOLD 8/17/24 and 8/18/24 Coumadin 4mg daily 8/19/24 through 8/20/24 Coumadin dose on HOLD 8/21/24 No Coumadin given(hole on MAR) 8/22/24 Coumadin 4mg one time dose given at 11:54 a.m., Coumadin 3mg dose given at 5:00 p.m.(total 7mg Coumadin) Review of the Laboratory Report, dated 7/31/24, reflected R104 had PT/INR collected with results of 2.8. The report included Physician hand written note that included, Coumadin 3mg daily INR on Friday[8/2/24]. No Physician Order was located in R104 Medical Record. Review of the Physician Orders, dated 8/3/24, reflected R104 had an order for PT/INR to be drawn on 8/5/24. Review of the Contracted Laboratory Report, collected on 8/5/24 at 12:14 p.m., reflected R104 PT/INR results were 1.73 (oral anticoagulant therapeutic range 2.00-3.00 according to report). The report included Physician had written undated note that included, Increase Coumadin to 4mg daily .INR 1 week R104 did not receive increased Coumadin dose until 8/6/24 evening. Review of the Physician order, created on 8/6/24, reflected R104 had an order for PT/INR to be drawn 8/12/24. Review of R104 Complete Medical Record reflected no evidence of Physician ordered PT/INR on 8/12/24 had been completed. No evidence Physician had been notified was located. Review of the Contracted Laboratory Report, collected 8/14/24, received 8/15/24, reflected R104 PT/INR was 2.57. No physician order was located for 8/14/24 lab draw that was three days after physician ordered request. Review of the Contracted Laboratory Report, collected 8/15/24, received 8/15/24, reflected R104 PT/INR was 3.50. R104 had labs drawn both 8/14/24 and 8/15/24 that were both received to the lab and reported to the facility on [DATE]. The 8/15/24 report included the Physician hand written note that included, 8/14/24 INR 2.57 INR not drawn today put Coumadin on hold . No physician order was located for 8/15/24 lab draw that was three days after physician ordered request. Review of R104 Nursing Progress Note, dated 8/15/24 at 2:49 p.m., reflected, INR-2.57. Call placed to [named provider] and orders received to continue Warfarin 4mg QD. Recheck INR on 8/19/24. The rest of the labs faxed per provider request. Review of R104 Physician Progress Note, dated 8/15/24 at 3:22 p.m., reflected, Reviewed resident's labs. INR was 2.57. Continue current Coumadin dose and recheck level on Monday [8/19/24] Review of the Physician orders reflected no evidence of repeat PT/INR for R104 on 8/19/24 was created. Review of R104 Physician Progress Note, dated 8/16/24, reflected, Labs were drawn again today and reviewed. Sodium is improve at 146 from 148. Other labs are stable. PT/INR was 36.0 and 3.50. Instructed the nurse to hold tonight's dose. The resident is discharging tomorrow, so redraw can not be done on Monday. Nurse is to give the most recent INR level to SW to fax to PCP. Resident should follow-up with PCP. Review of R104 Physician Progress Note, dated 8/19/24 at 5:22 p.m., reflected, Follow up: Seen at daughters request re: confusion and increased edema .ASSESSMENT & PLAN .R/O UTI: She has confusion, some lower abdominal discomfort, and very cloudy urine. UA C&S ordered. Foley is for urinary retention .Hx DVT: Hx reviewed. Hx left DVT after hip surgery in 2015. Hx right DVT about 1-2 years ago. On one of these occasions, she had pulmonary emboli. INR late last week 2.57-3.5 and one dose of Coumadin held. INR not drawn today as ordered - believe it best to hold Coumadin and repeat INR on Wednesday. Husband had questions about why INR was so variable .Daughter [named] left before I had the opportunity to answer my questions. She expressed a lot of dissatisfaction about care . Review R104 Physician Progress Note, dated 8/21/2024 at 12:28 p.m., reflected Brief follow up at request of nurse/husband .UA obtained on 8/19 as ordered. I started Cipro at that time because in my opinion benefits outweighed risks. Symptoms improved. Unfortunately, due to lab issue, UA was not picked up and had to be discarded. Repeat UA was obtained today, but she has been on antibiotics so results will not likely be helpful for decision making. Complete Cipro . During an interview on 8/22/24 at 1:20 p.m. Registered Nurse (RN) G reported facility was no longer able to use local hospital lab related to cost and reported changes were made about one month ago. RN G reported facility was only allowed to use lab company American Health Associates(AHA) based out of Florida that only comes to facility every Monday, Wednesday and Thursday. During an observation and record review on 8/22/24 at 2:02 p.m., observed Oak Hall Lab binder located at the nurse station. Review of the binder reflected R104 had a printed order for PT/INR on 8/12/24(Monday) with R104 listed on the, iPowerDoc Daily Log, for labs 8/9/24 to 8/12/24, printed 8/9/24, with no documentation that phlebotomist has drawn ordered labs. The Log included 11 other residents with orders and no documentation that had been drawn that day. Continued review of the binder with log dated, 8/14/24, printed 8/13/24 at 1013 pm., reflected R104 had bmp, cbc, pt/inr drawn on 8/14/24 according to initials from phlebotomist. Continued review of the binder reflected R104 had an order entered on 8/19/24 at 6:40pm for STAT urinalysis with culture and sensitivity(UA with CS) lab company American Health Associates(AHA) out of Florida requested by facility staff. (No evidence of UA with CS located in R104 medical record). Continued review reflected R104 was on the 8/21/24 ipowerdoc daily log dated 8/21/24 printed 2:40 pm. signed by phlebotomist with comments picked up urine spec. Continued review of the Lab Binder reflected R104 had orders for repeat PT/INR for 8/19/24 that were not on the lab log that was printed 8/13/24 at 3:46 p.m.(Seven days prior to lab draw 8/19/24, and two days prior to R104 Physician order entry on 8/15/24 for PT/INR. Review of the Physician Order, dated 8/19/24, reflected R104 had an order for UA and CS. During an interview on 8/22/24 at 2:30 p.m., Clinical Care Coordinator(CCC) H reported was R104 CCC and was not present on 8/12/24 and reported was unsure if 8/12/24 labs were collected by contracted lab but appeared several residents had orders with no lab staff initials. CCC H reported contract lab comes to facility every Monday,Wednesday and Thursday only unless Physician orders STAT orders. CCC H reported if labs are not drawn the day the physician ordered the labs draws on the next scheduled day (Monday, Wednesday, Thursday). During an interview on 8/22/24 at 3:25 p.m., CCC H reported was unsure why R104 PT/INR was not draw on 8/19/24 as ordered but was later collected 8/21/24 on the next contracted lab scheduled day. During an interview on 8/22/24 at 3:40 p.m., R104 family I verified R104 Coumadin dose was stable at home prior to admission and facility has not been able to regulate and reported goes from sub-therapeutic to elevated with no medication changes until 8/19/24. During an interview and record review on 8/22/24 at 5:00 p.m., Nursing Home Administrator (NHA) A and Nurse Consultant(NC) K verified Director of Nursing (DON) B was out of facility that week. NHA A and NC K reported would expect labs to be completed as ordered. NC K verified contracted lab company obtains labs on Monday, Wednesday or Thursdays unless STAT labs ordered. NC K reported contracted lab company does not allow labs to drawn by staff and labs to be taken to other lab facilities. NC K verified facility had issues with contracted lab company related to staffing concerns with timeliness of labs and results. NC K verified facility did not use Coumadin Flow sheets, however, planned to implement moving forward. NC K reported R104 had an order for PT/INR on 8/12/24 that was not completed until 8/14/24 related to lab issues and scheduled days. NC K reported was unable to locate Physician order for 8/15/24 PT/INR and reported staff would enter order with contracted lab but not facility Physician order and would need to provided staff education to enter Physician order.NC K verified R104 had Physician order for PT/INR on 8/19/24 not completed until 8/21/24(two days later for blood thinning dose monitoring). NC K verified AHA (contracted lab) followed printed orders and log on day of lab draws that should be printed close to date. NC K verified labs for 8/19/24 were printed 8/13/24 (several days prior) and verified R104 was not listed on page (orders entered either 8/14 or 8/15). NC K provided documents that reflected R104's UA & CS ordered STAT on 8/19/24 at 6:31 p.m. was picked up by Lab on 8/20/24 at 9:57 a.m. and was dropped off at the lab 8/20/24 at 6:34 p.m.(24 hours later speciman was delivered to the lab). During an interview on 8/22/24 at 5:40 p.m., NC K reported lab was at the facility on 8/12/24 but was unable to obtain labs from a few residents and would provide evidence of communication. Surveyor did not receive evidence of missed Physician ordered labs prior to exit for R104 on 8/12/24. During an interview on 8/22/24 at 5:56 p.m., NHA A reported was responsible for the Quality Assurance and Performance Improvement meetings at the facility and the topic of labs challenges had been discussed that included no negative outcomes but there was not a performance improvement project started to date.

Based on observation, interview, and record review the facility failed to accommodate two out of four residents (Resident #81 and 86) with briefs that fit them, resulting in red marks and painful skin irritation. Findings Included: Resident #81 (R81): Review of R81's electronic medical record revealed R81 was recently admitted to the facility on [DATE]. R81 had a diagnosis of, MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIES. Review of a BRIEF INTERVIEW OF MENTAL STATUS assessment dated [DATE], revealed R81 scored a 15 out of 15, which indicated R81 had no impairment in her cognition. In an interview on 12/18/2023 at 9:45 AM, R81 stated that her briefs were too small. R81 said she had asked staff (could not recall names of staff) several times for the larger size brief, but said staff told her corporate had to approve her to have a larger size brief. During the interview an observation of R81's dresser drawer revealed the drawer was full of yellow briefs. The briefs did not have the size marked on them. R81 stated the yellow briefs was what she and other residents were given, because that was all the facility had available. R81 also said that the yellow briefs caused a sore in her groin area, because they were to small. In an interview on 12/19/2023 at 9:11 AM, Certified Nurse Aid (CNA) C said the yellow briefs were the XX large (extra extra large), and those were the briefs R81 wore. CNA C said R81 did complain that the yellow briefs were too small. CNA C also said that the Velcro straps (used to hold the brief together while wearing) for R81's briefs could not be pulled all the way up to the middle of the brief, because the yellow briefs were to small for R81. CNA C further stated that R81 had red areas where the edges of the brief rubbed on her skin. CNA C said lotion had to be put on her skin when a new brief was put on for skin protection. CNA C said the facility used to have the 22 bariatric size, but said those were not available anymore, and she did not know why. In an interview and observation on 12/19/2023 at 9:36 AM, R81 stated that she had some red marks located on her skin in the area where her brief was. An observation of R81's skin and brief revealed the Velcro was not able to be pulled up to the middle of the brief, but had to be attached to the side of the brief. CNA C stated the Velcro had to be attached on the side so the brief so it was not too tight, and the Velcro would just come apart. Observation of R81's skin revealed two long raised red marks on R81's right groin area, and on R81's left groin a large area was observed to have red irritated skin right where the edge of the brief touched her skin. R81 stated that her left groin area was painful where her skin was red and raw. In an interview on 12/19/2023 at 10:32 AM, Central Supply (CS) D employee said that it had been about two weeks ago when the bariatric size briefs were removed from the supply closet. CS D said she would have to fill out a request form, send it to corporate to get approval to order the bariatric size for R81. CS D said measurements of R81's hip and waist area had to be documented, and R81's measurements did not meet the criteria for use of the bariatric size, so she was provided with the yellow briefs size XX large. CS D said R81 would be provided with the next size brief if her skin was red and irritated from the yellow briefs, but said no one ever told her that R81 had skin irritation/redness from the yellow briefs being to small. In an interview on 12/19/2023 at 11:42 AM, Administrator A stated that the bariatric briefs could not be ordered unless the resident met the criteria, which was based on the resident's height and weight. Administrator A said if a resident was experiencing red and raw skin because of the brief being too small, then the resident would be given a bariatric size brief even if they did not meet criteria. In an interview on 12/19/2023 at 11:46 AM, Regional Clinical Coordinator (RCC) E said if a resident needed a bigger size brief a request form would be filled out and sent to the supplier for approval, if the resident met the criteria for bariatric size briefs. RCC E said an order override could be done if a resident needed bariatric briefs but did not meet the criteria. In another interview on 12/19/2023 at 12:39 PM, CNA C stated that she did tell other staff members about one month ago of R81's skin in her groin area having red marks and skin irritation from the briefs being too small. Other staff members also cared for R81 and were aware of the problem. In an interview on 12/19/2023 at 1:02 PM, Director of Nursing (DON) B said that today was the first time a request form was sent out for approval for bariatric briefs for R81. DON B stated that she was never informed that R81's skin was red and irritated from the yellow briefs being to small. 30337 Resident #86 (R86) On 12/18/23 at 11:24 AM R86 was observed lying on back in bed and during an interview he stated facility staff had told him he had to buy his own briefs if he wanted a larger sized bariatric brief. In review of R86's Minimum Data Set (MDS) with an assessment reference date of 8/17/23 revealed he was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a cognitive screener, score of 15 (13-15 Cognitively Intact). The same MDS revealed R86 was occasionally incontinent of bowel and bladder and had not been in a toileting program. In review of R86's electronic medical record (EMR), he was 311.8 pounds (lbs.) on 08/10/23 and is most recent weight was 288 lbs. on 12/07/23. R86's same EMR revealed R86 had the diagnoses of morbid obesity, pulmonary disease, heart disease and abdominal aortic aneurysm (AAA) enlargement in the aorta (main vessel through which oxygen-rich blood travels from the heart to the rest of the body) that extends through the abdomen. Nursing Home Administrator (NHA) A was interviewed on 12/19/23 at 11:41 AM and stated there was a criteria used for residents to determine need for bariatric brief and if a resident did not meet criteria, and the resident requested the bariatric sized briefs, the facility would provide bariatric briefs. NHA A stated it was the first he had heard of an issue with residents' brief sizes. During an interview on 12/19/23 at 1:04 PM R86 stated he was told by numerous facility staff that he had to buy his own briefs if he wanted a bariatric size; and was explained to him that it was a corporate decision. Certified Nurse Assistant (CNA) V was interviewed on 12/19/23 at 1:07 PM and stated he was told R86 did not meet bariatric guidelines for bariatric briefs. CNA V stated he did not tell R86 that he had to purchase his own bariatric briefs. Licensed Practical Nurse/Unit Manager (LPN) U was interviewed on 12/19/23 at 1:19 PM and stated last month he obtained measurements (weight/height/waist) for residents. LPN U stated the facility would supply bariatric briefs for R86 if he wanted them. During an interview on 12/20/23 at 8:41 AM, R86 stated he was grateful he received the bariatric briefs and used them yesterday during the night. R86 stated the smaller briefs the facility had provided previously left red marks because they were to tight and when he turned in bed the briefs would un-fasten.

Based on observation, interview, and record review, the facility failed to prevent pressure ulcers in 1 of 2 residents reviewed for pressure ulcers (Resident #251), resulting in pain, wound treatments, and the potential for additional skin breakdown and infection. Findings include: Resident #251 (R251) During an observation and interview on 12/18/23 at 10:21 AM with R251's family member, R251 was admitted to the facility for rehabilitation after she fell and fractured her left leg at home. R251's family member stated R251 had developed a blister on her left heel while a resident at the facility. R251 was observed lying in bed on her back with her heels directly resting on her mattress. In review of R251's admission assessment dated [DATE], R251 did not have any wounds or reddened areas. R251's Skin assessment dated [DATE] revealed no new wounds. In review of R251's Skin Management Care plan dated 12/08/23, she was at risk for skin breakdown due to weakness, impaired mobility, pain, high blood pressure, lung disease, dementia, incontinence, and heart disease. The same care plan initiated on 12/08/23 revealed R251 had a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough, may also present as an intact or open/ruptured serum-filled blister) to her left heel with treatment in place. The same care plan instructed to assist R251 with floating her heels. In review of R251's electronic medical record, there were no measurements of her Stage 2 pressure ulcer on her left heel, description of the wound bed, or type and amount of drainage. R251's Skin assessment dated [DATE] indicated she had one new wound. R251's Physician Order dated 12/10/23 revealed to cleanse left heel with wound cleanser, pat dry, apply barrier skin prep around wound (to protect skin outside of wound). Apply foam dressing with boarder. Change every day and as needed for open area. R251's Brief Interview for Mental Status, a short performance-based cognitive screener, score was 00 (00-07 Severe Cognitive Impairment). In review of R251's nurses note dated 12/11/23 at 12:00 PM, blanchable erythema (redness) noted to resident's left heel. New orders given to discontinue current treatment and apply Aquacel heel foam dressing (combination dressing- hydrocolloid with absorbent material that transforms into a gel on contact with wound fluid, with ionic silver to manage serosanguinous fluid) every 5 days for protection. Resident made aware of new orders and in agreement with current plan of care. On 12/19/23 at 8:45 AM R251 was observed sitting in the dining room, feet resting on foot pedals, wearing non-skid socks. On 12/19/23 at 11:59 AM R251 was observed sitting in a wheelchair in lobby wearing socks and feet were resting on foot pedals. During an observation on 12/20/23 at 10:52 AM R251 was observed lying in bed. Unit Manager/Licensed Practical Nurse (LPN) U removed dressings wrapped around her left heel and heel presented with an open blister, had drainage and a red wound bed. LPN U measured R251's pressure ulcer. Certified Nurse Assistant (CNA) W was interviewed on 12/20/23 at 11:06 AM and stated R251 had an open blister on her left heel and thought it had been there since she was admitted . LPN U was interviewed on 12/20/23 at 11:14 AM and stated R251's left heel was 3.1 cm by 3.3 cm. LPN U stated on 12/11/23 a nurse documented R251 had a blister on her left heel, and no photos were taken. LPN U stated the wound nurse looked at R251's pressure ulcer on 12/11/23 and her heel was blanchable erythema. (Stage 1 pressure ulcer was defined as non-blanchable erythema). During an interview with wound nurse (WN) I on 12/20/23 at 11:23 AM she stated she looked at R251's left heel on 12/11/23 and it was blanchable erythema and intact. WN I stated a dressing was ordered for prevention of skin breakdown. WN I was unable to explain why the R251's skin on her heel was to be cleansed with a wound wash cleaner.

Based on observation, interview, and record review, the facility failed to provide supplements and fortified foods to prevent weight loss in one of one residents reviewed for weight loss (Resident #91), resulting in a severe weight loss of 7.8 pounds. Resident #91(R91) Admission History and Physical dated 11/09/23 and Dietary Profile dated 11/10/23 revealed R91 had a history of heart disease, kidney disease, arthritis, bone loss, moderate protein-calorie malnutrition and history of gastric bypass [AGE] years prior. R91 had been admitted to the facility following a hospitalization for pneumonia and respiratory failure. R91 was alert and oriented to person and place only. R91 received supplements twice a day during her hospitalization and took a protein supplement when at home. R91 did not have any swelling of her extremities. R91's current weight was 125 pounds (lbs.) and her ideal body weight was 135 lbs. The same Dietary Profile indicated when R91 was made aware of her current weight of 125 lbs., she responded by asking for pie. Physician's order with start date of 11/09/23 indicated R91 was to be provided supplements and fortified foods (boosted nutritional value) per dietary. R91's nutritional care plan dated 11/09/23 indicated her goal was to maintain stable nutritional status with adequate intake and weight would be stable within 5 percent (%) of lbs. Weight change progress note dated 11/17/23 at 4:21PM, R91's weight was 119 lbs.; and had lost 6 lbs. in one week. The same note indicated intravenous fluids received during hospitalization may have contributed to weight loss. The same note indicated R91's usual body weight was 114 lbs., per her daughter. Weight Change note dated 12/13/23 at 2:46 PM revealed a weight warning, R91's weight was 116.2 lbs., a loss of 8.8 lbs./ 7 % in one month. Weight change note dated 12/15/23 at 10:07 AM indicated R91's weight was 111.2 lbs., 7.8-pound weight loss in one month; and a juice supplement would be provided twice daily. R91 was observed on 12/19/23 at 8:58 AM sitting at a table with other residents. A staff member was observed going table to table, offering residents oatmeal from a soup kettle. R91 was offered and accepted oatmeal from the same soup kettle, in which other residents were served from. In observation of entire breakfast meal, no dietary supplements or fortified foods were offered to R91. On 12/19/23 at 12:48 PM, R91 was offered and accepted Cabbage soup with crackers, from soup kettle that all residents were served from. No other supplements/fortified foods were offered to R91. On 12/20/23 at 8:58 AM R91 was observed sitting in the dining room eating breakfast with a glass of cranberry juice. Dietary Manager X was interviewed on the same date and time and stated they had juice supplements on the drink cart in the dining room, and confirmed R91 had not received her juice supplement. Staff then provided juice supplement to R91 and to other residents in the dining room. Registered Dietitian (RD) H was interviewed on 12/20/23 at 9:13 AM and stated some of R91's weight loss was anticipated because of IV fluids received in the hospital last month and she had a diuretic medication. RD H stated staff knew R91 had supplements because it was on her food ticket. When asked how do the CNA's know R91 was to receive fortified oatmeal and a juice supplement when the oatmeal, soups and drinks were passed before the main meal, with the food ticket; RD H stated she would go around and check that everyone received their supplements that dietary provided. RD H confirmed she was not present at every meal. RD H confirmed R91 was to receive fortified oatmeal, it was a different recipe and would come directly from the kitchen.

Based on observation, interview, and record review the facility failed to follow pharmacy policy and acceptable practice for maintaining controlled medication for two out of five medication carts resulting in the potential for controlled medication diversion. Findings Included: During observation of the Cedar One medication cart on 12/20/2023 at 09:12 a.m. it was observed that the facility Controlled Accountability Record for this medication cart was last signed by only the out going nurse at 06:30 a.m. on the date of 12/20/2023. The signature box for the on coming nurse was blank. In an interview on 12/20/2023 at 09:37 a.m. Licensed Practical Nurse (LPN) M explained that she was the on coming nurse that took control of the Cedar One Medication cart on 12/20/2023 at 06:30 a.m. LPN M explained that it was policy that controlled medication was to be counted between the on coming nurse and the outgoing nurse when there was a change in the nurse that controlled the medication cart. She explained that once the controlled medication count was completed, the numbers are recorded, and both nurses would sign in the appropriate box of the Controlled Accountability Record . LPN M confirmed that she had not signed as the on coming nurse. LPN M explained that she had forgotten to sign once the count was completed. During observation of the Maple Hall medication cart on 12/20/2023 at 09:43 a.m. it was observed that the facility Controlled Accountability Record for this medication cart was last signed by only the out going nurse at 06:30 a.m. on the date of 12/20/22023. The signature box for the on coming nurse was blank. In an interview on 12/20/2023 at 09:44 a.m. Licensed Practical Nurse (LPN) O explained that she was the on coming nurse that took control of the Maple Hall medication cart on 12/20/2023 at 06:30 a.m. LPN O explained that it was policy that controlled medication was to be counted between the on coming nurse and the outgoing nurse when there was a change in the nurse that controlled the medication cart. She explained that once the controlled medication count was completed, the numbers are recorded, and both nurses would sign in the appropriate box of the Controlled Accountability Record . LPN O confirmed that she had not signed as the on coming nurse. LPN O explained that she has forgotten to sign once the count was completed. In an interview on 12/20/2023 at 09:48 a.m. Director of Nursing (DON) B explained that it was policy that controlled medication was to be counted between the on coming nurse and the outgoing nurse when there was a change in the nurse that controlled the medication cart. She explained that once the controlled medication count was completed, the numbers are recorded, and both nurses would sign in the appropriate box of the Controlled Accountability Record . DON B explained that signature of both nurses would be an attestation of an accurate count for that medication cart. DON B could not explain why the Controlled Accountability Record had not been signed by the on coming nurse, at 0:630 a.m. on 12/20/2023, for the Maple Hall medication cart and the Cedar One medication cart. Review of the provided facility policy 4.2 Medication Storage Controlled Medication Storage, dated 2007, demonstrated #6 At each shift change or when keys are surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurse or per state regulations and is documented on the controlled accountability record or verification of controlled substance count report.

This citation includes intake MI 8592. Based on observation, interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned and non-care-planned interventions, and 3.) ensure that those interventions were functional and in place in 4 of 6 sampled residents (R19, R28, R30, and R37) reviewed for falls, resulting in repeat falls and R28 unwitnessed fall from elevated bed resulting in left lower leg fracture, deep tissue injury, decline and later death. This deficient practice placed 71 residents at risk for increased likelihood for continued falls, serious injury and/or death. Findings include: Resident #19 (R19) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R19 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included [CONDITION(S)], anxiety, and depression. The MDS reflected R19 had a BIM (assessment tool) score of 4 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, transfers, walking, locomotion on unit, dressing, toileting, hygiene, and bathing. During an observation on 9/22/22 at 8:16 AM, R19 was noted to have signs on door that reflected enhanced precautions. R19's door was open and resident in room appeared to be resting. During an observation and interview on 9/20/22 at 1:47 PM, R19 was standing in the doorway of room independently repeating, help me, help me. R19 reported pants were wet and reported needed assistance. R19 call light was observed on as indicated by light on wall in room(no hall light noted). Staff were noted going in and out of Dining Room about 25 feet from R19 room with no response to R19 shouting, help me or activated call light. Certified Nurse Aide (CNA) AA passed R19 room in hall and reported she was one of two CNA staff working on that hall and left area with out answering R19 call light or looking in room at 1:51 p.m Male CNA staff continued to move residents from Dining Room while R19 continued to be on at 01:53 p.m. At 1:56 p.m. R19 self ambulated back to bed and yelled, Help, that's the same one. (referring to this surveyor). At 2:00 p.m. Infection Control Nurse (IC) C passed R19 room and asked if she needed assistance after R19 yelled for help and entered room. (15 minutes after this surveyor observed R19 yelling for help and call light being on). Review of the facility Resident Matrix, dated 9/20/22, reflected R19 had recent fall with injury. Review of the Nurse Progress Notes, dated 9/9/22 at 6:00 a.m., for R19, reflected, Late Entry: DOCUMENT RELEVANT INFORMATION ABOUT THE RESIDENT:: This nurse was called into resident room by CNA, upon arrival resident was observed lying on her back on the floor beside her bed. On the side of the bed that the window is on. Resident stated she was trying to go to the bathroom. resident assisted to her feet by staff members and walked to the bathroom, vital signs taken and neuro-checks initiated, skin assessed .Created Date : 9/11/2022 04:18:13. Review of the Nurse Progress Note, dated 8/7/2022 at 6:49 p.m., for R19, reflected, Resident in bathroom having self transferred, without her walker and resident has several wash rags on the floor trying to wipe up urine. This nurse assisted resident with clean brief. This nurse washed resident's shoes that had urine on them and cleaned up bathroom. Resident reminded to use her call light. This nurse assisted resident back to bed. Resident had eaten 51-75% of her dinner which consisted of only mashed potatoes. Pleasant. No c/o pain. Review of the facility provided Incident/Accident(I/A) Reports, by the Director of Nursing (DON) B reflected the following falls for R19: -I/A reported dated, 8/31/22 at 5:36 p.m., reflected R19 was observed by staff self ambulating in room and attempted to redirect R19 and R19 tripped over own feet and staff lowered R19 to the ground. The report reflected, Immediate action taken-Description: res. assessed; ROM and VS WNL; physician and guardian notified/ res put into her bed and reminded to use her call light when she needed help . -I/A report dated, 8/15/22 at 4:15 p.m., reflected R19 was observed by floor tech staff slide off bed and land on bottom next to bed with call light on resulting in skin tears to right arm. The report reflected under Immediate Action that R19 was assessed and right arm skin tears were treated with no mention of interventions to prevent further falls with possible injury. Continued review of report reflected notes written on 8/18/22 to prevent further falls staff will check with resident and offer to toilet every two hours while awake. -I/A report, dated 7/18/22 at 8:30 p.m., reflected R19 had an unwitnessed fall in hall near the lobby(entire length of Maple hall, past nurse station and Dining Room from R19 room) while independently ambulation without assist and without 2 wheeled walker. The reported reflected under immediate action that R19 was assessed and physician notified with no mention of interventions to prevent further falls. Continued review of the report reflected notes written on 7/18/22 that included R19 required one person assist with use of 2 wheeled walker and had fall day prior on 7/17/22 after recent admission. The notes reflected physician order to obtain orthostatic blood pressures. -I/A report, 7/17/22 at 2:27 p.m., reflected R19 had an unwitnessed fall in bathroom after staff left R19 alone in bathroom. The reported reflected no immediate actions taken and notes included new intervention to not leave resident alone while in there bathroom. The provided I/A reports did not reflected detailed information for complete and though investigation including when residents last cared for(toileted, observed), if care planned interventions were in place or not, and did not reflect evidence actions were taken to prevent further falls with possible injuries. No I/A Reports were provided for 9/9/22 or 8/7/22. Review of R19 ADL Care Plans, dated 7/14/22, reflected, I have an actual ADL deficit secondary to impaired mobility related to falls in the home setting, [CONDITION(S)], AKI, anxiety, and cognitive impairments .Interventions .AMBULATION: One person limited assist using 2ww[two wheeled walker]. Date Initiated: 07/15/2022 . Continued review of the Care plans reflected, Falls due to recent admission/new environment, [CONDITION(S)], chronic kidney disease, anxiety, mild neurocognitive impairments, impaired mobility, altered mental status, impulsive, wandering behavior, impaired right eye vision, and diarrhea .Revision on 8/5/22 .Do not leave me alone while I am on the toilet. Date Initiated: 07/17/2022. I will wear non-skid footwear for all transfers and walking. Date Initiated: 07/14/2022 .Orthostatic B/P's Date Initiated: 07/14/2022 . Review of the Care Plans revealed no mention of interventions added after 7/18/22. Review of the R19 Fall Assessment Note, dated 9/9/22, reflected, Resident is a [AGE] year old woman admitted on [DATE] for Rehab following hospitalization at [named] Hospital for worsening confusion. She is at risk for falls r/t new environment, [CONDITION(S)], CKD, anxiety, neurocognitive impairment, altered mental status, impulsiveness, wandering behavior, impaired vision in right eye, and diarrhea. She is able to ambulate with assist of one and walker. She requires two persons for toileting with pant management. She had previous falls on 7/17/22 and 7/18/22, 8/15/22, 8/31/22. on 9/9/22 0700 resident observed on the floor by the window side of the bed. She states she was attempting to use the bathroom. Call light was not on and feet were bare. Resident had no injuries and was assisted to the bathroom and then back to bed. She didn't have gripper socks on. Resident was given gripper socks. Her only shoes are crocs at this time. Resident has recently been declared not her own person and a guardian was appointed. Will call DPOA for different shoes. During an interview on 9/21/22 at 4:55 p.m., DON B verified did have I/A reported for 9/9/22 that had been in progress. DON B reported an I/A reported was not completed for R19 8/7/22 fall and should have been. During an interview on 9/23/22 at 1:50 p.m., DON B reported started employment at the facility on 7/18/22. DON B verified was unable to locate R19 orthostatic blood pressures ordered after 7/18/22 fall and reported did not see changed made to the R19 Care Plan after 8/15/22, 8/31/22, or 9/9/22 fall. Resident #28 (R28) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R28 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included hypertension(high blood pressure), hearing loss, dementia without behaviors, mood disorder, cerebral vascular accident(stroke), anxiety, depression, +Covid and recent fall with fracture to left lower leg. The MDS reflected R28 had a BIMS (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, locomotion on unit, dressing, toileting, hygiene, bathing and two person assist with transfers. During an observation and interview on 9/20/22 at 2:00 PM, R28 was sitting in reclined broda chair in Dining room facing television with eyes open and ortho boot on left lower leg and appeared thin with moist productive cough noted. R28 appeared calm and not able to answer questions. During an interview on on 9/20/22 at 2:37 PM, R28 was laying in low positioned bed on back with mats on both sides of the bed. During a telephone interview on 9/21/22 at 8:54 AM, R28's Durable Power of Attorney(DPOA) CC reported concerned about R28's recent fall from the bed with left foot fracture when R28 never used feet. DPOA CC reported prior to Covid about 1.5 weeks ago had visited several times each week but had not been able to visit as frequent since Covid outbreak. DPOA CC reported was told by staff that R28's floor mats were not in place at the time of the fall on on 7/18/22. Review of the facility Fall Incident Report, dated 7/18/22 at 12:45 a.m., for R28, reflected, Incident Description Nursing Description: Notified by another Nurse that Res rolled out of bed and was on the floor. She was laying on her right side on the side of the bed closest to the doorway .Resident unable to give description . The Report included CNA HH statement that reflected, CNA had just finished changing Res and walked out to get a blanket for her. When he came back into the room the Res had rolled out of bed and was on the floor. The Report included notes that reflected, She in ext. assist of one for transfers .Will continue winged mattress and bed in lowest position while in it . Continued review of the Report included note, dated 7/22/22, that R28 had X-Ray that showed fractures of the left 1st metatarsal base and left distal fibula fracture. Review of the Electronic Medical Record (EMR), 9/9/2022 at 11:11 a.m., reflected R28 tested positive for Covid. Review of the Nursing Progress Note, dated 7/18/22 at 1:20 a.m., for R28, reflected, 0100 Notified by another Nurse that Res had rolled out of bed and was on the floor. CNA had just finished changing the Res, he left the room to get a blanket and when he returned the Res was on the floor, laying on her right side on the side of the bed facing the door. No injury noted, no bruising, redness, skin tear or open areas noted. Res assisted into bed w/ a 2 staff assist. [MEDICATION(S)] given at 0108 for s/sx of general discomfort. Neuro-checks initiated, VSS. Res currently resting in bed comfortably. Progress note was created by Registered Nurse (RN) DD. Review of the Nursing Progress Note, dated 7/19/2022 at 6:04 a.m., for R28, reflected, CNA stated that resident was guarding right arm when turned for brief change. Resident stated you broke it as she was turned. Resident scored 6/10 on PAINAD scale. PRN [MEDICATION(S)] administered at 0502. After administration, resident stopped yelling out and rocking from side to side. Medication effective. Score reassessment 2/10 on PAINAD scale. Review of the Hospice Collaboration Form, dated 7/19/22 at 1:30 p.m., reflected Hospice Home Health Aid visited R28 with plans to provided bath and documented, bath not given due to pain from recent fall . Review of the Nursing Progress Note, dated 7/19/2022 at 2:03 p.m., for R28, reflected, [named] hospice nurse here at this time and notified by this nurse of resident having fall on 7/18/22 at 0045, and that PRN [MEDICATION(S)] has been given twice since then for c/o pain. Resident assessed by hospice nurse at this time, and resident showed s/s of pain with movement of left leg/hip with facial grimacing, and moaning. Hospice nurse spoke with DPOA son [named DPOA CC] to discuss care of resident and he stated that he would like an x-ray of left hip. This nurse then called [named physician] to notify, and order noted for x-ray of left hip 2 view stat. Review of the Nurse Progress Note, dated 7/19/2022 at 9:15 p.m., for R28, reflected, Resident has no c/o pain at this time. Resident does c/o pain when left leg and hip are moved. Neuro checks wnl. This nurse spoke with [named physician] to report left hip XRAY findings: No acute fracture or dislocation .[named physician] advises to also order a 2 view XRAY of the right hip and a 3 view XRAY of the right shoulder. Review of the Nurse Progress Note, dated 7/22/2022 at 2:06 p.m., for R28, reflected, This nurse was called into the residents room to look at left foot and observed it is swollen and bruised. [named physician] in to see patient notified of swelling and bruising of the left ankle and cough and sputum doctor ordered chest xray and ankle and foot xray to be done STAT. Non weight bearing on left leg also ordered. this nurse elevated the foot and put ice pack on it. Review of the Nurse Progress Note, dated 7/22/2022 at 11:23 p.m., for R28, reflected, X-Ray results confirm fracture of left distal tibia and left 1st metatarsal. Physician viewed x-ray results and spoke with hospice. Decision was made not to send patient to hospital. Dr increased [MEDICATION(S)][pain medication] to BID[two times daily] and orders to be placed for surgical boot. Follow up x-rays in 4-6 months. Spoke with residents son by phone and he is agreeable with plan of care . During an observation on 9/22/22 at 8:14 AM, R28 was laying in low bed with eyes closed and mats on floor on both sides of bed with washcloth over forehead. During an observation on 9/22/22 at 9:59 AM R28 continued to be in same position in bed, eyes closed, low bed, 2 mats on floor with washcloth on forehead. During an observation and interview on 9/22/22 at 1:20 PM, R28's DPOA CC was at R28's bedside with several other visitors. DPOA CC reported he had received call from the facility early that morning related to R28's recent decline and unresponsive. R28 was lying in bed with eyes closed and washcloth over forehead. During an interview on, 9/22/22 at 1:28 PM, Licensed Practical Nurse (LPN) G reported was not present at the time of R28 fall but worked next day and was responsible for documenting neuron checks and post fall Progress Note. LPN G reported facility policy was to document every shift for 72 hours after a fall. During an interview on 9/22/22 at 2:30 PM, Hospice Certified Nurse Aid (CAN) EE reported after each visit she documented on blue communication form in hospice binder. CNA EE verified provided R28 bathing services every Tuesday and Friday and had visit 7/26/22 and 7/29/22 and surgical boot was removed during bath. CNA EE reported nurse [named RN FF] had more detailed records from visits. During a telephone interview on 9/22/22 at 2:55 PM, Hospice RN FF reported assessed R28 on 7/19/22 after the fall and reported R28 was non-verbal and unable to say where pain was initially. RN FF reported R28 was very painful after fall and pain medication added. RN FF reported R28 developed bruising 7/22/22 to left ankle and X Ray was ordered that indicated fracture. RN FF reported delay with boot because facility thought Hospice would provided and boot and they did not and verified boot placed 7/26/22. RN FF reported first made aware of R28 suspected deep tissue injury on the left heel on 8/2/22 reported by facility RN GG. Review of the Fall Care Plan, dated 10/12/18, for R28, reflected, I am at risk for falls due to history of falls, severe cognitive impairments related to dementia and history of CVAs, incontinence, significant [CONDITION(S)] , osteopenia. I have poor safety awareness and may lean over in my chair or scootch in my bed towards the edge. I am receiving hospice services and an expected decline is expected .Interventions .Bed in low position when in bed. Date Initiated: 07/27/2022 .BILATERAL FLOOR MATS to be in place while in bed. Date Initiated: 06/02/2021 . Review of the EMR on 9/23/22 at 8:30 a.m., reflected R28 passed away that morning. During a telephone interview on 9/23/22 at 12:19 PM, RN L reported was present at the time of R28 fall on 7/18/22. RN L reported CNA HH was providing care and stepped out of R28 room to get a blanket and returned and R28 had rolled out of bed. RN L reported arrived to R28 room and observed R28 laying directly on the floor on her left side with no floor mat in place and bed was positioned at waist level. RN L reported was not R28 nurse at that time but was in the area charting when she was alerted of R28 fall. During an interview on 9/23/22 at 1:15pm, uncertified Nurse Assistant (UNA) II reported worked 7/18/22 day shift after R28 fall. UNA II reported was told R28 had fall from bed but not provided details about the fall but reported received reinforcement education that fall mat should be in place of residents are in bed and bed should be in lowest position should be standard practice. During a telephone interview on 9/23/22 at 1:20 PM, RN DD reported did complete R28's fall Incident Report on 7/18/22 at 12:45 a.m. and reported was unsure how R28 was transferred off the floor. RN DD reported was not present at time of fall because she was also working on another hall at that time. RN DD reported had spoke with CNA HH who reported had left R28's room after providing care to get blanket and R28 was on the floor when he returned. RN DD reported did not recall if she asked if fall mats were in place or what the position of bed was. RN DD reported thought manager did investigation. During an interview on 9/23/22 at 1:50 p.m., Director of Nursing (DON) B reported started employment at the facility on 7/18/22. DON B reported aware that falls were an issue and had noticed immediate actions taken on I/A reports were resident assessments and should reflect what was done prevent further falls. DON B verified resident assessments do not not prevent falls. DON B reported that now either herself or Administrator A review all I/A reports prior to being locked. During a telephone interview on 9/23/22 at 2:25 PM, CNA HH reported left R28 room to get a blanket after care and heard R28 make sound in room, returned to room, and found R28 on the floor moaning. CNA HH reported RN DD was nurse at time but was wrap nurse and was on the other hall at the time of the fall. CNA HH reported RN L assisted him to get R28 back to bed and reported was unable to recall if fall mats were in place at the time of the fall and reported R28 should have been a two person assist. During an interview on 9/23/22 at 2:56 PM, DON B reported would expect staff to include as many details as possible on fall reports including if ordered care planned interventions were in place or not at the time of the fall. Resident #30 (R30) A review of the Minimum Data Set (MDS - resident assessment), dated 8/1/22, reflected R30 was admitted to the facility on [DATE] with diagnoses that included history of breast and lung cancer, irritable bowel syndrome with diarrhea, vascular dementia with behaviors, [CONDITION(S)] and moderate cognitive impairment, stroke with right [CONDITION(S)] (difficulty moving extremities, especially right arm) and [CONDITION(S)] (difficulty feeling extremities), History of thoracic vertebrae fracture, depression, anxiety, [CONDITION(S)], [CONDITION(S)] and seizures. A review of the Activities of Daily Living (ADLs) plan of care reflected R30 required limited assist of one staff person with four-wheel walker for ambulation and transfers, and one staff person extensive assist for showers. Care plan interventions for R30 about falls: dated 3/2/22 were assess and treat my pain, non-skid footwear for all transfers and walking, labs/x-rays, medication reviewed by pharmacist, orient to surroundings, orthostatic blood pressures and therapy referral as needed. Dated 4/30/22 resident re-educated on use of call light to request assistance for transferring. Dated 5/2/22 was resident re-educated to ensure her wheelchair brakes are locked before any transfer in or out of her chair. A review of the facility policy titled Fall Reduction Program, last revised on 9/25/16, reflected: Procedure 2. Implement and indicate individualized interventions on Care Plan/Kardex. 3. If fall occurs Charge Nurse to complete the following .Immediate interventions as identified by physical assessment and environmental observation .3.1 Initiate safety interventions and update care plan as applicable .3.3 IDT [interdepartmental team] to review each incident to complete root cause analysis .3.4.3. Identify any additional interventions in the Care Plan/Kardex. A review of fall investigation reports reflected R30 had several falls. Each fall, intervention and if the care plan was updated during a discussion with Director of Nurses (DON) B on 9/23/22 at 1:25 pm as follows: On 8/2/22 at 5:30 am R30 raised the head of her bed, attempted to get into her wheelchair and missed it. There were no injuries. The intervention was to demonstrate call light to use to call for help. This intervention was already entered on 4/30/22 and the date was not updated. DON B did not see this on the care plan since this fall. On 8/8/22 at 7:42 pm R30 was found sitting on the floor of her bathroom. The indwelling catheter was removed that day. There were no injuries. Repeated interventions were demonstrate call light and call staff for help. A new intervention was therapy to assess and treat for toilet transfers which was already in the care plan without an updated date. DON B said no new intervention were added to the care plan until later. On 8/17/22 supervise on toilet was added. On 8/21/22 at 1:00 pm R30 was found on the bathroom floor after attempting self-transfer to the wheelchair. R30 said she was waiting for her aide to get additional help to get off the toilet. There were no injuries. The interventions were turn on call light, maybe yell for help and wait for help/supervision which were already on the care plan. DON B said there were no new interventions. On 9/7/22 at 3:53 pm R30 was yelling for help and observed face down on the bathroom floor. R30 sustained a small skin tear on the forehead. The intervention to supervise on toilet was added, and DON B agreed and said the aide was fired after multiple warnings about supervision to prevent falls for R30. Resident #37 (R37) A review of the MDS, dated [DATE], reflected R37 was admitted to the facility on [DATE] with diagnoses that included moderate cognitive impairment, stroke from a blocked brain artery with right-sided [CONDITION(S)] (difficulty moving extremities, especially right arm) and [CONDITION(S)] (difficulty feeling extremities), [CONDITION(S)], history of falls, and aseptic necrosis of the right resulting in hip replacement surgery, acute kidney failure, depression, anxiety, [CONDITION(S)], dysphagia (difficulty swallowing), history of pneumonia, constipation, flexion (bending) contractures (frozen joint) of both knees, tremors and [CONDITION(S)] of right lower leg, vascular dementia and weakness. A review of the ADL plan of care reflected R37 required the use of a standing lift with two staff assist for toileting and transfers. R37 had a high-back, reclining wheelchair with right arm trough and a reclining lumbar support cushion but could not move in the wheelchair. They require one staff assist to push them. The drag lift is used to lift someone from the bed, chair, or floor by lifting or supporting them under the armpits. This lift strains and damages the cervical and other nerves, tendons, ligaments, and skin, and can cause pain and the inability to use the arm/hand. Drag lifts should never be used. On 9/21/22 at 8:55 am, R37 was observed in his wheelchair in his room. Certified Nurse Assistant (CNA) I repositioned R37 higher in the wheelchair by pulling them up, using their hands in R37's armpits, from behind. When asked, R37 said they were alone at home when they fell on their right side and laid there quite a while. Because of this fall, R37 stated their right arm was almost useless, but My left arm has full mobility. On 9/23/22 at 12:25 PM, Occupational Therapist Assistant (OTC) O demonstrated how to properly lift a resident like R37. They said the axilla was never used due to potential nerve damage. On 9/23/22 at 12:35 PM, CNA P was interviewed. When asked about transferring a resident out of a chair, CNA P said they would always start with a gait belt and would not lift by the armpits.

Based on observation, interviews, and record review the facility failed to establish and maintain an infection prevention, monitoring and control program while residents are in quarantine with Covid, resulting the potential for the spread of microorganisms when staff did not wear personal protective equipment while assisting residents. Staff did not perform hand hygiene before or after care, did not change out gowns, mask or clean goggles before leaving the residents room, resulting in the potential for the spread of infections to (R35, R39, R49, R56, R224) and up to 71 residents who resided at the facility. During observation on 09/23/22 at 08:50 AM, Staff were observed entering and exiting the residents' rooms on quarantine without wiping goggles off or changing out mask. During an interview on 09/23/22 at 08:55 AM with unit manager AA discussion regarding residents coming off quarantine. All staff should be wiping off goggles after exiting rooms. No observation of this task completed between 6 staff members on C hall. During an interview on 09/22/22 at 10:07 AM with Certified Nursing Assistant (CNA) BB regarding the screening process. After screen in, we have a report we go over between shift change and we go room to room and discuss every resident. Observation on 09/22/22 at 10:26 AM of CNA CC not wearing any protective eye wear. Observation on 09/22/22 at 10:34 AM of vital sign machine not being cleansed before or after use, taking it into a resident's room, from hallway into rm 1. Staff walked out of room holding dirty gown in hand and throw away in hallway linen container, not the dirty linen container in the room on two separate occasions within 5 minutes of each other. During an interview on 09/22/22 at 02:02 PM with Infection Control, Infection Prevention (ICIP) C My first thing is to grab the sign in log for staff and visitors, did anyone screen positive, I instruct staff to contact self or charge nurse if they have symptoms. I will do a round to check in and do walk throughs. For infections, we are tracking them on the line list, try to discuss during the morning meetings, same with antibiotics, making sure they meet criteria. Tuesdays and Fridays are staff Covid testing days. Resident's get tested as needed. ICIP was asked about the visitors check in process. Visitors, it's a team approach, nobody is sitting there watching, receptionist is close by, Director of Nursing office is up there, Administrator's office is right there, and human resources is watching. Visitors wear KN95 or any face covering.Continued conversation regarding who watches the staff for compliance. I do multiple rounds, watch hand hygiene, make sure they have personal protective equipment (PPE), watch them use the equipment, touching face mask and washing with hand sanitizer. Discussion on who wears what mask. Fully vaccinated staff wear the KN95, unvaccinated staff wear N95, also reporting Staff are to change out mask when they enter and exit the room, goggles are to be wiped with purple top cleaner, along with any equipment used. On 09/23/22 at 10:19 AM, observation of laundry staff emptying the dirty linen from the quarantined residents' rooms, wearing one glove on right hand, left hand bare, wearing mask and goggles, no gown to protect scrubs from contaminated gowns. Large container for dirty gowns had a bio-hazard sticker on it. Resident #224 (R224) Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition you must wear an N-95/KN95 in the patients room. On 9/20/22 at 1:25 PM, R224's door was observed with signage that indicated transmission-based precautions and enhanced precautions. The signage indicated the use of gown, gloves, face shield, and mask. R224 reported she was a new admission, had received covid vaccines, but not the most recent booster. During the interview, a staff member walked into R224's room wearing only a KN95 mask and a face shield. The staff member pulled down their mask and asked R224 if she had a bowel movement. When asked about the transmission-based precautions, R224 reported staff started wearing full PPE the day before, on 9/19/22. Upon exiting the room, two staff members were observed speaking with Infection Preventionist (IP) C regarding clarification on the transmission-based precaution PPE requirements. Resident #56 (R56) Review of the medical record revealed R56 was admitted to the facility on [DATE] and tested positive for COVID-19 on 9/16/22. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition you must wear an N-95 in the patient's room. On 9/20/22 at 2:17 PM, Maintenance Director X was observed donning PPE to enter R56's room. Maintenance Director X donned the gown with the opening in the front, exposing clothing. Resident #35 (R35) Review of the medical record revealed R35 was admitted to the facility on [DATE] and tested positive for COVID-19 on 9/16/22. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition you must wear an N-95 in the patient's room. On 9/20/22 at 2:21 PM, Activities Director (AD) Y was observed donning PPE to enter R35's room. AD Y wore a KN95 into the room. Upon exiting the room, AD Y did not disinfect the eye protection or change masks. AD Y then left the unit. Resident #49 (R49) Review of the medical record revealed R49 was admitted to the facility on [DATE] and tested positive for COVID-19 on 9/11/22. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition you must wear an N-95 in the patient's room. Resident #39 (R39) Review of the medical record revealed R39 was admitted to the facility on [DATE] and tested positive for COVID-19 on 9/14/22. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition you must wear an N-95 in the patient's room. On 9/20/22 at 4:09 PM, a staff member exited R49's room wearing a KN95 and goggles. The staff member sanitized their hands, prepared beverages, donned a new gown and gloves, and entered R56's room. The staff member did not change their mask or disinfect their goggles. The staff member exited R56's room, wearing a KN95 and goggles. The staff member sanitized their hands, prepared another beverage, donned a new gown and gloves, and entered R39's room without disinfecting their goggles or changing into a N95. In an interview on 9/21/22 at 3:51 PM IP C reported their current PPE supply did not allow for them to dispose of a mask after each room. IP C reported goggles and face shields should be disinfected between each transmission-based precaution room.

Based on observation, interview, and record review, the facility failed to accurately completed Minimum Data Set (MDS) assessments for one (Resident #28) of 18 reviewed, resulting in inaccurate assessments and the potential for unmet care needs. Findings include: Resident #28 (R28) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R28 was a [AGE] year old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R28 had a BIMS (assessment tool) which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with bed mobility, locomotion on unit, dressing, toileting, hygiene, bathing and two person assist with transfers. During an observation and interview on 9/20/22 at 2:00 PM, R28 was sitting in reclined broda chair in Dining room facing television with eyes open and ortho boot on left lower leg and appeared thin with moist productive cough noted. R28 appeared calm and not able to answer questions. During an interview on on 9/20/22 at 2:37 PM, R28 was laying in low positioned bed on back with mats on both sides of the bed. During a telephone interview on 9/21/22 at 8:54 AM, R28's Durable Power of Attorney(DPOA) CC reported concerned about R28's recent fall from the bed with left foot fracture when R28 never used feet. DPOA CC reported prior to Covid about 1.5 weeks ago had visited several times each week but had not been able to visit as frequent since Covid outbreak. DPOA CC reported was told by staff that R28's floor mats were not in place at the time of the fall on on 7/18/22 and R28 had increased pain after fall. Review of the Electronic Medical Records, dated 7/1/22 through current(9/22/22), reflected R28 had several areas of documented increased pain including Progress Notes, Medication Administration Record(MAR), and Hospice Notes post fall on 7/18/22 that resulted in fracture. Review of the MAR, dated 7/1/11 through 7/31/22, reflected R28 received 12 doses of as needed [MEDICATION(S)](narcotic pain medication) between 7/18/22 and 7/30/22 and none prior to 7/18/22(date of fall with fracture.) Review of the Nurse Progress Note, dated 8/2/2022 at 8:00 p.m., for R28, reflected, resident continues on scheduled and PRN [MEDICATION(S)], resident observed yelling out, physician notified and wants to continue with current pain treatment at this time as it was recently increased. Review of the RAI Note, dated 8/4/2022 at 9:28 a.m., for R28, reflected, DOCUMENTATION RELATED TO RAI PROCESS / SKILLED COVERAGE (ADMISSION / SIG. CHANGE / DISCONTINUATION):: MDS quarterly assessment completed for this resident with no significant changes noted this quarter. Continues to reside at the facility for long term care secondary to care needs related to Dementia. Hospice services in place with [named hospice]. Requires extensive to dependent assistance with ADLS, bathing, and toileting tasks. Hoyer lift for transfers. Broda chair in place for seating and locomotion. Always incontinent of bowel and bladder. Assisted with incontinence care as needed. Wears a brief for dignity and protection. Skin intact. Pressure reducing device in place to bed and wheelchair. Skin assessed daily with care and weekly with nursing assessment. Per staff occasional pain related to recent fracture. Pain medication effective for pain management. Resident had one fall during the look back period (5/4/22-7/28/22) with major injury. No dental concerns upon inspection. No adverse reactions to daily medication regimen. Based on data collected for MDS assessment, along with staff and resident interviews conducted, resident continues to qualify for skilled nursing care at this facility by passing through Door 1 of the Michigan Medicaid LOCD. During an interview on 9/23/22 at 8:44 AM, MDS Registered Nurse(RN) JJ reported working as MDS nurse for 2.5 years. RN JJ reported collect information from resident Medical Records to complete MDS assessments including orders, MAR, assessments(forms in EMR), talk to staff including staff who often care of for R28. RN JJ reported MDS assessment for R28 with RAI dated of 8/4/22 staff interview was completed and reported was unsure who she spoke with. MDS RN JJ verified R28's MDS with RAI date 8/4/22 reflected R28 had no pain. During an interview on 9/23/22 at 9:00 AM, MDS RN JJ reported R28 look back was 7/23/22 to 7/28/22 and locked on 8/4/22 and staff reported no pain (5 day period was just after left fibula fracture identified on 7/22/22 with several documented entries of increase pain in EMR). Review of the Pain Care Plan, last revised 5/31/22, for R28, reflected, I am not be able to verbalize my pain, but may exhibit non verbal signs of restlessness or crying out. I have chronic pain secondary to history of [CONDITION(S)] and generalized pain. I have pain medication in place. The pain care plan reflected no updates after 7/18/22 fall with fracture and increased pain.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan to include [CONDITION(S)] and accurate medications for one (Resident #224) of 18 reviewed, resulting in the potential for unmet care needs. Findings include: Review of the medical record revealed Resident #224 (R224) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R224 was dependent on renal [CONDITION(S)]. Review of the Brief Interview for Mental Status (BIMS-cognitive screening tool) dated 9/17/22 revealed R224 scored 15 out of 15 (cognitively intact). On 09/20/22 at 01:25 PM, R224 was observed sitting in a wheelchair in her room. R224 reported the nurse that morning had no idea what to do. R224 reported she had [CONDITION(S)] that morning and the nurse did not have any of the paperwork ready. R224 reported she asked the nurse to write the basic information such as her name and vital signs on a piece of paper. R224 reported on the night of 9/19/22, she was told she would be woke up at 4:00 AM for a 5:30 AM transport time on 9/20/22. R224 reported staff did not wake her up until 5:00 AM, which made her very upset. R224 reported the transport driver had to high tail it to [CONDITION(S)] and that she was five minutes late for her scheduled [CONDITION(S)] time. Review of R224's baseline care plans, revealed there was not a care plan for [CONDITION(S)] until 9/20/22, which was three days after R224 was admitted to the facility. Review of the anticoagulation care plan initiated 9/20/22 revealed an intervention of Review medication list for adverse interactions. Avoid use of aspirin or NSAIDS. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on 09/21/22 at 11:53 AM, Certified Nursing Assistant (CNA) R reported there was miscommunication in shift-to-shift report regarding R224's [CONDITION(S)] transport time on 9/20/22. CNA R reported R224's pick up time was supposed to be 5:45 AM, but she was told 6:45 AM. CNA R reported paperwork was not prepared to send to [CONDITION(S)] with R224 and therefore R224's name, room number, and vital signs were written on a piece of paper. In an interview on 09/21/22 at 12:15 PM, Registered Nurse (RN) S reported she was the Minimum Data Set (MDS) nurse. RN S reported baseline care plans were initiated within 48 hours of admission and included all pertinent care plans, for example activities of daily living, discharge plan, pain, and medications. RN S agreed that R224's [CONDITION(S)] care plan was initiated three days after admission, on 9/20/22. When asked why R224's care plans did not mention [CONDITION(S)] until 9/20/22 (3 days after admission), RN S reported she would have to check to see if [CONDITION(S)] was a requirement of the baseline care plan. In a telephone interview on 09/21/22 at 01:46 PM, RN T reported she was supposed to do R224's [CONDITION(S)] paperwork/communication form on 9/20/22, but she didn't know how. RN T reported R224 was given a piece of paper with her vital signs listed. RN T reported she was not aware of the time R224 was to be transported to [CONDITION(S)] but knows that R224 left at 6:08 AM on 9/20/22. RN T reported the aide also did not know what time R224 was supposed to leave that morning because R224 was a new admission.

This citation refers to intake MI 526. Based on observation, interview, and record review, the facility failed to provide care planned interventions for 1 of 5 residents reviewed for falls (Resident #1), from a total of 17 sampled residents, resulting in a fall with fracture and continued falls for Resident #1. Findings include: According to the MDS/Minimum Data Sets, dated 6/16/16, Resident #1 was an [AGE] year old woman who had memory impairment, needed staff assistance with transfers, and had [DIAGNOSES REDACTED]. On 7/13/16 at 8:30 AM, Resident #1 was observed fully dressed, sitting in a wheelchair outside the door of her room. According to Resident #1's Fall Care Plan, dated 9/15/15, I was originally admitted to the facility after a fall at home. I have a history of multiple falls, with left hip fracture post fall in [DATE]. I have some cognitive deficits with periods of confusion requiring assistance with my ADLs (Activities of Daily Living) .I wear hipsters at all times as tolerated (Date Initiated: 1/15/15) . Please allow me to sleep in, my usual time to rise is 9 am and I do not want to get up early. Date Initiated: 9/18/15. According to an Incident Report, dated 2/07/16 at 12:55 PM, .observed resident lying on bathroom floor .c/o (complaint of) pain in left hip and shoulder .ambu-cab called for transport to hospital .Dx (diagnosis) of left hip fracture . According to an Employee Action Improvement Process document, dated 2/17/16, Nurse Aide O received a written warning for failure to perform job duties satisfactorily as evidence by the employee's failure to follow care plan and notify nurse of resident not wearing hipsters (sic)(padded underwear designed to absorb energy and cushion falls to prevent hip fractures) . The document revealed Nurse Aide O refused to sign because I cannot follow care plan or do my job properly if I am not given the proper equipment . In a telephone interview, on 7/12/16 at 12:00 PM, Nurse Aide O reported Resident #1 did not have hipsters on when she started her shift because Resident #1's hipsters has gotten wet with urine on the previous shift, and she thought there were no others in the building, but did not check other units for them. When asked if she reported this to the nurse on duty, Nurse Aide O said, I don't believe I did. According to an Incident Report, dated 3/26/16 at 6:10 AM, Resident #1 fell trying to self- transfer from her wheelchair into bed. It was reported, on 3/26/16, Resident #1 said at the time, 'I just wanted to go back to bed. Per the Incident Report, .residents usual time to rise at 9 am as resident does not want to get up early. Will educated CNA (Nurse Aide O) on following plan of care (sic). Resident #1 sustained no apparent injury during this fall; however, according to DON/Director of Nursing B, on 7/13/16, no discipline was issued to Nurse Aide O for not following Resident #1's Care Plan regarding her wake up time. In an interview, on 7/12/16 at 9:11 AM, Nurse Aide DD reported she was Resident #1's day shift Nurse Aide and said, Third shift has gotten her up the past couple of days. She told me she normally gets up at 10:00 AM, but the last couple of days they've gotten her up on third shift . According to Resident #1's Kardex (Nurse Aide Care Guide), Please allow me to sleep in, my usual time to rise is 9 am and I do not want to get up early was the second alert/bullet point on the Nurse Aide guide. In an interview, on 7/13/16 at 4:08 PM, Nurse Aide HH reported she woke Resident #1 up that morning at approximately 6:00 AM and got her dressed and ready for the day. When asked if she read the Kardex at the beginning of the shift, she said she had but didn't see that Resident #1 wanted to stay in bed until 9:00 AM. Later in the conversation, Nurse Aide HH said, I knew she liked to get up later, but she would miss breakfast. When I went to get her out of bed, she told me 'It's too early'. When asked what she should do if she thought the Kardex was wrong, she said, I probably should tell the nurse .I could call the kitchen and tell her to send a later tray. When asked if she had been disciplined for not following the Care Plan, Nurse Aide HH said, I don't think so. On 7/12/16 at 1:30 PM, this Surveyor observed a notice posted on the Cedar Hall bulletin board at the Nurses' Station entitled Cedar Early Get Up List, and on the list was, Resident #1's room/bed. This list was brought to DON B's attention by this Surveyor, and she stated the list should not be used. However, it was still posted as of 7/14/16 at 9:00 AM. On 7/12/16 at 1:30 PM, this Surveyor observed a notice posted on the Cedar Hall bulletin board at the Nurses' Station entitled Cedar Early Get Up List, and on the list was Resident #1's room/bed. This Surveyor immediately brought to DON B's attention, and DON B stated the list should not be used. On 7/13/16 at 9:35 AM, Unit Manager EE reported the Cedar Early Get Up List was not made by him and it was not to be used. The following day, on 7/14/16 at 9:00 AM, the same Cedar Early Get Up List was still posted on the bulletin board. ( )

This citation pertains to MI 749. Based on interview and record review, the facility failed to notify the physician of an acute change in condition in 1 of 3 sampled residents (#101) reviewed for an acute change of condition, in a total sample of 3 residents resulting in delayed treatment after Resident #101 was noted to have abnormal vital signs. Resident #101 subsequently died . Findings include: Review of the Admission Record in the medical record dated [DATE] revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE] to the Cedar Unit. Review of a Hospital's Physician Discharge Summary dated [DATE] revealed Resident #101 was admitted with severe back pain due to spinal stenosis and under went back surgery on [DATE], developed septic shock (a potentially lethal drop in blood pressure), and was transferred to the intensive care unit. Resident #101 was discharged from the hospital on [DATE]. Review of the Hospital's After Visit Summary dated [DATE] revealed Resident #101 had [DIAGNOSES REDACTED]. Review of the Hospital's Discharge Summary dated [DATE] revealed Resident #101 was admitted from the facility to the Intensive Care Unit on [DATE] with a [DIAGNOSES REDACTED]. According to Fundamentals of Nursing (Potter and Perry, 6 th edition, 2005), acceptable vital signs for adults include the following: Respirations: ,[DATE] breathes per minute; average blood pressure: 120 (systolic)/80 (diastolic) mm Hg (millimeter of mercury, unit of pressure). According to Fundamentals of Nursing (Kozier, Erb, Blais and Wilkinson, 5th edition, 1995), [MEDICAL CONDITION] is an abnormally low blood pressure below 100 mmHg systolic. "Because blood pressure can vary considerably among individuals, it is important for the nurse to know a specific client's baseline blood pressure. For example, if a client's usual blood pressure is ,[DATE] mmHg and it is assessed...to be ,[DATE] mm Hg, this drop in pressure must be reported". According to Fundamentals of Nursing (Kozier, Erb, Blais and Wilkinson, 5th edition, 1995), An acceptable arterial blood oxygen saturation, or SaO2 (amount of oxygen in the blood) is 95%-100%. According to the Mayo Clinic Website (http://www.mayoclinic.com/health/diabetic-[DIAGNOSES REDACTED]/DS ), [DIAGNOSES REDACTED] (low blood sugar) is defined as a blood glucose level (BGL) below 70 milligrams per deciliter (mg/dL). [DIAGNOSES REDACTED] can lead to [MEDICAL CONDITION] and loss of consciousness and is considered a medical emergency. Review of the Facility's Change of Condition - Resident Physician/NP Notification Policy dated [DATE] revealed the attending physician or physician on call should be notified of acute conditions, which include "Change in vital signs...Significant change in mental or psychosocial status...Significant oxygen saturation level change...Other conditions as deemed necessary". Review of the Facility's Blood Pressure Measurement Policy dated [DATE] revealed after taking resident's blood pressure, the measurement should be recorded and compared to baseline if available, and notify supervisor and physician of abnormal findings or symptoms immediately. Review of the Facility's Blood Glucose Testing Policy dated [DATE] revealed "If patient results are less then 70 (mg/dL) or greater than 400 (mg/dL)...and patient is asymptomatic repeat the test and notify the Physician of the results immediately. If patient is symptomatic notify Physician immediately and document in chart. Review of the Facility's [DIAGNOSES REDACTED] (insulin shock) Policy dated [DATE] revealed if resident's BGL was below 40, this was considered a medical emergency, if the resident was conscious was to be given glucose gel by mouth or [MEDICATION NAME] by injection, and then notify the physician for further orders. Review of the Facility's Standing Orders (physician orders) revised [DATE] revealed, "Call Blood sugars (BGL) to Physician less then 70 or great then 400..." Review of Resident #101's Vital Sign Flow Sheet dated [DATE], [DATE] and [DATE] revealed the following blood pressures and SaO2 results: [DATE] (untimed) ,[DATE] no value [DATE] (11p-7a) ,[DATE] 90% (room air) [DATE] (7a-3p) ,[DATE] 89% (room air) [DATE] (3p-11p) ,[DATE] 93% ,[DATE] [DATE] (11p-7a) ,[DATE] 92% (2 liters of oxygen) [DATE] (7a-3p) ,[DATE] 83% ,[DATE] In an interview on [DATE] at 10:17 AM, Certified Nursing Assistant (CNA) #5 stated that vital signs for Resident #101 were assessed at around 12:00 am on [DATE]. This surveyor provided CNA #5 the Vital Sign Flow Sheet to confirm what Resident #101's vital signs were after measurement. CNA #5 stated Resident #101's Blood Pressure was ,[DATE], CNA #5 stated she could not remember what the SaO2 level was, but did remember that it was below 90%. CNA #5 stated she immediately went and told Licensed Practical Nurse (LPN) #13 of these findings. CNA #5 stated that LPN #13 put oxygen on Resident #101, and had CNA #5 re-check the SaO2 level. CNA #5 stated after re-checking Resident #101's SaO2, it was measured at 92%. CNA #5 stated she did not write the original SaO2 reading down per direction from LPN #13. CNA #5 stated she was unaware of the physician being notified of Resident #101's vital signs and condition. Review of Resident #101's medical record failed to reveal any mention of oxygen being started by LPN #13, or Resident #101's original SaO2 reading. Review of the medical record also failed to reveal documentation that the attending physician was notified of this change in condition. Review of the Nurse's Notes dated [DATE] at 7:30 AM and written by LPN #13 revealed at 6:00 AM Resident #101's BGL was 35. "Res (Resident) conscious but lethargic, oral instant glucose administered". The note revealed at 6:10 AM Resident #101's BGL was 50 "then Quickly droped (sic) again to 37. [MEDICATION NAME] injection was administered sub Q (injected with a syringe) 15 min (minutes) later (no change) in BS (Blood Glucose Level)...A 2nd dose of [MEDICATION NAME] was administered...came up to 90". In an interview on [DATE] at 8:20 AM, LPN #13 stated that she did not inform the attending physician of Resident #101's vital signs or low BGL. LPN #13 stated Resident #101 was asleep most of the night. LPN #13 stated she started Resident #101 on oxygen at around 1:00 AM on [DATE] after being made aware of the low SaO2 reading. LPN #13 stated that Resident #101's SaO2 reading was 88% before starting oxygen. When asked, LPN #13 stated she did a full assessment, to include listening to lung sounds, of Resident #101 during the morning at around 1:00 AM, but agreed that it was not documented anywhere. Review of the facility's Cedar Unit 24 hour report (document used to pass important information about residents from shift to shift) dated [DATE] failed to reveal any mention of Resident #101's low BGL, SaO2 or of Resident #101's new requirement for Oxygen or low blood pressure. In an interview on [DATE] at 1:27 PM, day shift Registered Nurse (RN) #18 stated she was not made aware of Resident #101's recent decrease in SaO2 levels, and the new requirement of oxygen. When asked, RN #18 stated "Yes" if a resident has a BGL of 35, a decrease in blood pressure that Resident #101 experienced, the physician should be notified. In an interview on [DATE] at 3:20 PM, Physician #17 stated per expectation and facility policy, he should have been notified of Resident #101's low BGL, low blood pressure and change in breathing status. Physician #17 stated he did not remember receiving a call from LPN #13. In an interview on [DATE] at 12:15 PM, float nurse (nurse that is not assigned a patient, and helps where needed) RN #9 stated that on [DATE] at about 12:15, a Certified Nursing Assistant (CNA) came to her stating Resident #101 was SaO2 level was dropping. RN #9 stated she went to Resident #101's room. RN #9 stated Resident #101 was lethargic, was having difficulty breathing and could hear crackles (abnormal breath sounds that imply an accumulation of fluid in the lungs) without the use of a stethoscope. RN #9 stated Resident #101's oxygen flow was increased to 5 Liters, and Resident #101 still had a low SaO2 of 87%. RN #9 stated the physician was immediately notified of Resident #101's situation, and an order to send Resident #101 to the hospital was attained. When asked, RN #9 stated, "Yes" the physician should have been notified of the original findings of Resident #9's low BGL, low blood pressure and change in breathing status. In an interview on [DATE] at 3:20 PM, Director of Nursing (DON) #2 stated she did not know why LPN #13 did not notify the physicaion of Resident #101's change in condition. DON #2 stated LPN #13 should have notified the physican of Resident #101's change in condition. ( )

Based on interview and record review, the facility failed to notify the physician of an acute change in condition in 3 of 5 sampled residents (#101, 102 and 105) reviewed for an acute change of condition, in a total sample of 5 residents resulting in a delay in treatment after Resident #101 and 102 were noted to have abnormal blood glucose levels (BGL) and Resident #105 experienced a [MEDICAL CONDITION]. Findings Include: According to the Mayo Clinic Website (http://www.mayoclinic.com/health/[MEDICAL CONDITION]/DS ), High blood sugar ([MEDICAL CONDITION]) affects people who have diabetes...It's important to treat [MEDICAL CONDITION], because if left untreated, [MEDICAL CONDITION] can become severe and lead to serious complications requiring emergency [MEDICAL CONDITION] doesn't cause symptoms until glucose values are significantly elevated - above 200 milligrams per deciliter (mg/dL). Review of the Facility's Blood Glucose Testing Policy dated July 1, 2008 revealed "If patient results are less then 70 (mg/dL) or greater than 400 (mg/dL)...and patient is asymptomatic repeat the test and notify the Physician of the results immediately. If patient is symptomatic notify Physician immediately and document in chart. Review of the Facility's Standing Orders (physician orders) revised 10/19/13 revealed, "If Blood sugar is less than 70 (mg/dL), proceed to [DIAGNOSES REDACTED] instruction, Institute protocol, and then notify physician. Notify Physician if great then 400 (mg/dL), for further instructions. Resident #101 Review of the Admission Record dated 9/27/13 revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Diabetic Flow Record revealed on 11/15/13 at 8:00 pm Resident #101's Blood Glucose Level (BGL) was 516 (mg/dL). Review of Resident #101's medical chart failed to reveal documentation that the resident's physician was notified of the abnormal BGL. Resident #102 Review of the Admission Record dated 9/3/13 revealed Resident #102 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 11/12/13 at 6:00 am revealed, "Resident drowsy, speech clear...Bld sugar (BGL) 53 (mg/dL), instant glucose tube po (orally) given at this time...6:20 am BS (BGL) 65 (mg/dL), more alert. Review of the medical record revealed that the resident's physician was not notified of the resident's abnormal BGL until 8:00 am by Clinical Care Coordinator (CCC) #6. Review of the Facility's Plan of Correction dated 11/1/13 revealed, "The CCC/designee will audit documentation on residents with a change in condition to assure the physician has been notified of changes in condition and interventions are in place. Immediate corrective action for any identified concern(s) will result in 1:1 education for the nurse. During an interview on 11/26/13 at 2:08 pm, CCC #6 stated that there was no 1:1 education provided to the nurse that failed to notify the physician of Resident #102's low BGL. Resident #105 Review of the Admission Record dated 9/27/13 revealed Resident #105 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Facility's "[MEDICAL CONDITION], NURSING MANAGEMENT OF" Policy dated 7/1/08 revealed, "Notify physician of resident's condition." Review of the Facility's Plan of Correction dated 11/1/13 revealed, "The facility has adopted Interact III change in condition Cards and Care Paths...documentation has been adopted by the facility for notifying the physician of a change in condition. Review of the facility Interact Version 3.0 tool dated 2011 Signs and Symptoms section revealed, [MEDICAL CONDITION] activity that is self-limited in the past 24 hours in a resident with known [MEDICAL CONDITION] activity should be communicated to the physician in an "non-immediate" manner. Review of the Nurses Notes dated 11/2/13 at 9:35 am revealed, "Resident (up) in WC (wheelchair) experiencing [MEDICAL CONDITION] 1-2 minutes. Pupils dilated resident twitching extremities. Review of the medical record failed to reveal that the resident's physician was notified of the resident suffering a [MEDICAL CONDITION]. During an interview on 11/26/13 at 11:50 am, Director of Nursing (DON) #2 stated that Resident #105 has a history of [MEDICAL CONDITION], and this was "probably why" the physician was not notified. DON #2 was unable to provide any documentation that Resident #105's physician was notified of the [MEDICAL CONDITION] Resident #105 suffered. ( )

This citation pertains to MI 749. Based on interview and record review, the facility failed to provide care that met professional standards to immediately assess and monitor a resident with an acute change in condition and notify the physician of any abnormal vital signs in 1 of 3 sampled residents (#101) reviewed for an acute change of condition, in a total sample of 3 residents resulting in delayed evaluation and treatment after Resident #101 was noted to have abnormal blood glucose levels, abnormal vital signs and a change in respiratory status. Resident #101 subsequently died . Findings include: Review of the Admission Record in the medical record dated [DATE] revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE] to the Cedar Unit. Review of a Hospital's Physician Discharge Summary dated [DATE] revealed Resident #101 was admitted with severe back pain due to spinal stenosis and under went back surgery on [DATE], developed septic shock (a potentially lethal drop in blood pressure), and was transferred to the intensive care unit. Resident #101 was discharged from the hospital on [DATE]. Review of the Hospital's After Visit Summary dated [DATE] revealed Resident #101 had [DIAGNOSES REDACTED]. Review of the Hospital's Discharge Summary dated [DATE] revealed Resident #101 was admitted from the facility to the Intensive Care Unit on [DATE] with a [DIAGNOSES REDACTED]. According to Fundamentals of Nursing (Potter and Perry, 6 th edition, 2005), acceptable vital signs for adults include the following: Respirations: ,[DATE] breathes per minute; average blood pressure: 120 (systolic)/80 (diastolic) mm Hg (millimeter of mercury, unit of pressure). According to Fundamentals of Nursing (Kozier, Erb, Blais and Wilkinson, 5th edition, 1995), [MEDICAL CONDITION] is an abnormally low blood pressure below 100 mmHg systolic. "Because blood pressure can vary considerably among individuals, it is important for the nurse to know a specific client's baseline blood pressure. For example, if a client's usual blood pressure is ,[DATE] mmHg and it is assessed...to be ,[DATE] mm Hg, this drop in pressure must be reported". According to Fundamentals of Nursing (Kozier, Erb, Blais and Wilkinson, 5th edition, 1995), An acceptable arterial blood oxygen saturation, or SaO2 (amount of oxygen in the blood) is 95%-100%. According to the Mayo Clinic Website (http://www.mayoclinic.com/health/diabetic-[DIAGNOSES REDACTED]/DS ), [DIAGNOSES REDACTED] (low blood sugar) is defined as a blood glucose level (BGL) below 70 milligrams per deciliter (mg/dL). [DIAGNOSES REDACTED] can lead to [MEDICAL CONDITION] and loss of consciousness and is considered a medical emergency. Review of the Facility's Change of Condition - Resident Physician/NP Notification Policy dated [DATE] revealed the attending physician or physician on call should be notified of acute conditions, which include "Change in vital signs...Significant change in mental or psychosocial status...Significant oxygen saturation level change...Other conditions as deemed necessary". Review of the Facility's Blood Pressure Measurement Policy dated [DATE] revealed after taking resident's blood pressure, the measurement should be recorded and compared to baseline if available, and notify supervisor and physician of abnormal findings or symptoms immediately. Review of the Facility's Blood Glucose Testing Policy dated [DATE] revealed "If patient results are less then 70 (mg/dL) or greater than 400 (mg/dL)...and patient is asymptomatic repeat the test and notify the Physician of the results immediately. If patient is symptomatic notify Physician immediately and document in chart. Review of the Facility's [DIAGNOSES REDACTED] (insulin shock) Policy dated [DATE] revealed if resident's BGL was below 40, this was considered a medical emergency, if the resident was conscious was to be given glucose gel by mouth or [MEDICATION NAME] by injection, and then notify the physician for further orders. Review of the Facility's Standing Orders (physician orders) revised [DATE] revealed, "Call Blood sugars (BGL) to Physician less then 70 or great then 400..." Review of Resident #101's Vital Sign Flow Sheet dated [DATE], [DATE] and [DATE] revealed the following blood pressures and SaO2 results: [DATE] (untimed) ,[DATE] no value [DATE] (11p-7a) ,[DATE] 90% (room air) [DATE] (7a-3p) ,[DATE] 89% (room air) [DATE] (3p-11p) ,[DATE] 93% ,[DATE] [DATE] (11p-7a) ,[DATE] 92% (2 liters of oxygen) [DATE] (7a-3p) ,[DATE] 83% ,[DATE] In an interview on [DATE] at 10:17 AM, Certified Nursing Assistant (CNA) #5 stated that vital signs for Resident #101 were assessed at around 12:00 am on [DATE]. This surveyor provided CNA #5 the Vital Sign Flow Sheet to confirm what Resident #101's vital signs were after measurement. CNA #5 stated Resident #101's Blood Pressure was ,[DATE], CNA #5 stated she could not remember what the SaO2 level was, but did remember that it was below 90%. CNA #5 stated she immediately went and told Licensed Practical Nurse (LPN) #13 of these findings. CNA #5 stated that LPN #13 put oxygen on Resident #101, and had CNA #5 re-check the SaO2 level. CNA #5 stated after re-checking Resident #101's SaO2, it was measured at 92%. CNA #5 stated she did not write the original SaO2 reading down per direction from LPN #13. CNA #5 stated she was unaware of the physician being notified of Resident #101's vital signs and condition. Review of Resident #101's medical record failed to reveal any mention of oxygen being started by LPN #13, or Resident #101's original SaO2 reading. Review of the medical record also failed to reveal documentation that the attending physician was notified of this change in condition. Review of the Nurse's Notes dated [DATE] at 7:30 AM and written by LPN #13 revealed at 6:00 AM Resident #101's BGL was 35. "Res (Resident) conscious but lethargic, oral instant glucose administered". The note revealed at 6:10 AM Resident #101's BGL was 50 "then Quickly droped (sic) again to 37. [MEDICATION NAME] injection was administered sub Q (injected with a syringe) 15 min (minutes) later (no change) in BS (Blood Glucose Level)...A 2nd dose of [MEDICATION NAME] was administered...came up to 90". In an interview on [DATE] at 8:20 AM, LPN #13 stated that she did not inform the attending physician of Resident #101's vital signs or low BGL. LPN #13 stated Resident #101 was asleep most of the night. LPN #13 stated she started Resident #101 on oxygen at around 1:00 AM on [DATE] after being made aware of the low SaO2 reading. LPN #13 stated that Resident #101's SaO2 reading was 88% before starting oxygen. When asked, LPN #13 stated she did a full assessment, to include listening to lung sounds, of Resident #101 during the morning at around 1:00 AM, but agreed that it was not documented anywhere. Review of the facility's Cedar Unit 24 hour report (document used to pass important information about residents from shift to shift) dated [DATE] failed to reveal any mention of Resident #101's low BGL, SaO2 or of Resident #101's new requirement for Oxygen or low blood pressure. In an interview on [DATE] at 1:27 PM, day shift Registered Nurse (RN) #18 stated she was not made aware of Resident #101's recent decrease in SaO2 levels, and the new requirement of oxygen. When asked, RN #18 stated "Yes" if a resident has a BGL of 35, a decrease in blood pressure that Resident #101 experienced, the physician should be notified. In an interview on [DATE] at 3:20 PM, Physician #17 stated per expectation and facility policy, he should have been notified of Resident #101's low BGL, low blood pressure and change in breathing status. Physician #17 stated he did not remember receiving a call from LPN #13. In an interview on [DATE] at 12:15 PM, float nurse (nurse that is not assigned a patient, and helps where needed) RN #9 stated that on [DATE] at about 12:15, a Certified Nursing Assistant (CNA) came to her stating Resident #101 was SaO2 level was dropping. RN #9 stated she went to Resident #101's room. RN #9 stated Resident #101 was lethargic, was having difficulty breathing and could hear crackles (abnormal breath sounds that imply an accumulation of fluid in the lungs) without the use of a stethoscope. RN #9 stated Resident #101's oxygen flow was increased to 5 Liters, and Resident #101 still had a low SaO2 of 87%. RN #9 stated the physician was immediately notified of Resident #101's situation, and an order to send Resident #101 to the hospital was attained. When asked, RN #9 stated, "Yes" the physician should have been notified of the original findings of Resident #9's low BGL, low blood pressure and change in breathing status. In an interview on [DATE] at 3:20 PM, Director of Nursing (DON) #2 stated she did not know why LPN #13 did not notify the physician of Resident #101's change in condition. DON #2 stated LPN #13 should have notified the physician of Resident #101's change in condition. ( )

Based on interview and record review, the facility failed to provide care that met professional standards to notify the physician of a resident with an acute change in condition in 3 of 5 sampled residents (#101, 102 and 105) reviewed for an acute change of condition, in a total sample of 5 residents resulting in a delay in treatment after Resident #101 and 102 were noted to have abnormal blood glucose levels (BGL) and Resident #105 experienced a [MEDICAL CONDITION]. Findings include: According to the Mayo Clinic Website (http://www.mayoclinic.com/health/[MEDICAL CONDITION]/DS ), High blood sugar ([MEDICAL CONDITION]) affects people who have diabetes...It's important to treat [MEDICAL CONDITION], because if left untreated, [MEDICAL CONDITION] can become severe and lead to serious complications requiring emergency [MEDICAL CONDITION] doesn't cause symptoms until glucose values are significantly elevated - above 200 milligrams per deciliter (mg/dL). Review of the Facility's Blood Glucose Testing Policy dated July 1, 2008 revealed "If patient results are less then 70 (mg/dL) or greater than 400 (mg/dL)...and patient is asymptomatic repeat the test and notify the Physician of the results immediately. If patient is symptomatic notify Physician immediately and document in chart. Review of the Facility's Standing Orders (physician orders) revised 10/19/13 revealed, "If Blood sugar is less than 70 (mg/dL), proceed to [DIAGNOSES REDACTED] instruction. Institute protocol, and then notify physician. Notify Physician if great then 400 (mg/dL), for further instructions. Resident #101 Review of the Admission Record dated 9/27/13 revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Diabetic Flow Record revealed on 11/15/13 at 8:00 pm Resident #101's BGL was 516 (mg/dL). Review of Resident #101's medical chart failed to reveal documentation that the resident's physician was notified of the abnormal BGL. Resident #102 Review of the Admission Record dated 9/3/13 revealed Resident #102 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 11/12/13 at 6:00 am revealed, "Resident drowsy, speech clear...Bld sugar (BGL) 53 (mg/dL), instant glucose tube po (orally) given at this time...6:20 am BS (BGL) 65 (mg/dL), more alert. Review of the medical record revealed that the resident's physician was not notified of the resident's abnormal BGL until 8:00 am by Clinical Care Coordinator (CCC) #6. Review of the Facility's Plan of Correction dated 11/1/13 revealed, "The CCC/designee will audit documentation on residents with a change in condition to assure the physician has been notified of changes in condition and interventions are in place. Immediate corrective action for any identified concern(s) will result in 1:1 education for the nurse. During an interview on 11/26/13 at 2:08 pm, CCC #6 stated that there was no 1:1 education provided to the nurse that failed to notify the physician of Resident #102's low BGL. Resident #105 Review of the Admission Record dated 9/27/13 revealed Resident #105 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Facility's "[MEDICAL CONDITION], NURSING MANAGEMENT OF" Policy dated 7/1/08 revealed, "Notify physician of resident's condition" Review of the Facility's Plan of Correction dated 11/1/13 revealed, "The facility has adopted Interact III change in condition Cards and Care Paths...documentation has been adopted by the facility for notifying the physician of a change in condition. Review of the facility Interact Version 3.0 tool dated 2011 Signs and Symptoms section revealed, [MEDICAL CONDITION] activity that is self-limited in the past 24 hours in a resident with known [MEDICAL CONDITION] activity should be communicated to the physician in an "non-immediate" manner. Review of the Nurses Notes dated 11/2/13 at 9:35 am revealed, "Resident (up) in WC (wheelchair) experiencing [MEDICAL CONDITION] 1-2 minutes. Pupils dilated resident twitching extremities. Review of the medical record failed to reveal that the resident's physician was notified of the resident suffering a [MEDICAL CONDITION]. During an interview on 11/26/13 at 11:50 am, Director of Nursing (DON) #2 stated that Resident #105 has a history of [MEDICAL CONDITION], and this was "probably why" the physician was not notified. DON #2 was unable to provide any documentation that Resident #105's physician was notified of the [MEDICAL CONDITION] Resident #105 suffered. ( )

Based on interview and record review, the facility failed to immediately assess, monitor and contact the physician concerning a resident with an acute change in condition in 1 of 3 sampled residents (#101) reviewed for an acute change of condition, in a total sample of 3 residents resulting in a delay in treatment after Resident #101 was noted to have abnormal blood glucose levels, abnormal vital signs and a change in respiratory status. Resident #101 subsequently died . Findings Include: Review of the Admission Record in the medical record dated [DATE] revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE] to the Cedar Unit. Review of a Hospital's Physician Discharge Summary dated [DATE] revealed Resident #101 was admitted with severe back pain due to spinal stenosis and under went back surgery on [DATE], developed septic shock (a potentially lethal drop in blood pressure), and was transferred to the intensive care unit. Resident #101 was discharged from the hospital on [DATE]. Review of the Hospital's After Visit Summary dated [DATE] revealed Resident #101 had [DIAGNOSES REDACTED]. Review of the Hospital's Discharge Summary dated [DATE] revealed Resident #101 was admitted from the facility to the Intensive Care Unit on [DATE] with a [DIAGNOSES REDACTED]. According to Fundamentals of Nursing (Potter and Perry, 6 th edition, 2005), acceptable vital signs for adults include the following: Respirations: ,[DATE] breathes per minute; average blood pressure: 120 (systolic)/80 (diastolic) mm Hg (millimeter of mercury, unit of pressure). According to Fundamentals of Nursing (Kozier, Erb, Blais and Wilkinson, 5th edition, 1995), [MEDICAL CONDITION] is an abnormally low blood pressure below 100 mmHg systolic. "Because blood pressure can vary considerably among individuals, it is important for the nurse to know a specific client's baseline blood pressure. For example, if a client's usual blood pressure is ,[DATE] mmHg and it is assessed...to be ,[DATE] mm Hg, this drop in pressure must be reported". According to Fundamentals of Nursing (Kozier, Erb, Blais and Wilkinson, 5th edition, 1995), An acceptable arterial blood oxygen saturation, or SaO2 (amount of oxygen in the blood) is 95%-100%. According to the Mayo Clinic Website (http://www.mayoclinic.com/health/diabetic-[DIAGNOSES REDACTED]/DS ), [DIAGNOSES REDACTED] (low blood sugar) is defined as a blood glucose level (BGL) below 70 milligrams per deciliter (mg/dL). [DIAGNOSES REDACTED] can lead to [MEDICAL CONDITION] and loss of consciousness and is considered a medical emergency. Review of the Facility's Change of Condition - Resident Physician/NP Notification Policy dated [DATE] revealed the attending physician or physician on call should be notified of acute conditions, which include "Change in vital signs...Significant change in mental or psychosocial status...Significant oxygen saturation level change...Other conditions as deemed necessary". Review of the Facility's Blood Pressure Measurement Policy dated [DATE] revealed after taking resident's blood pressure, the measurement should be recorded and compared to baseline if available, and notify supervisor and physician of abnormal findings or symptoms immediately. Review of the Facility's Blood Glucose Testing Policy dated [DATE] revealed "If patient results are less then 70 (mg/dL) or greater than 400 (mg/dL)...and patient is asymptomatic repeat the test and notify the Physician of the results immediately. If patient is symptomatic notify Physician immediately and document in chart. Review of the Facility's [DIAGNOSES REDACTED] (insulin shock) Policy dated [DATE] revealed if resident's BGL was below 40, this was considered a medical emergency, if the resident was conscious was to be given glucose gel by mouth or [MEDICATION NAME] by injection, and then notify the physician for further orders. Review of the Facility's Standing Orders (physician orders) revised [DATE] revealed, "Call Blood sugars (BGL) to Physician less then 70 or great then 400..." Review of Resident #101's Vital Sign Flow Sheet dated [DATE], [DATE] and [DATE] revealed the following blood pressures and SaO2 results: [DATE] (untimed) ,[DATE] no value [DATE] (11p-7a) ,[DATE] 90% (room air) [DATE] (7a-3p) ,[DATE] 89% (room air) [DATE] (3p-11p) ,[DATE] 93% ,[DATE] [DATE] (11p-7a) ,[DATE] 92% (2 liters of oxygen) [DATE] (7a-3p) ,[DATE] 83% ,[DATE] In an interview on [DATE] at 10:17 AM, Certified Nursing Assistant (CNA) #5 stated that vital signs for Resident #101 were assessed at around 12:00 am on [DATE]. This surveyor provided CNA #5 the Vital Sign Flow Sheet to confirm what Resident #101's vital signs were after measurement. CNA #5 stated Resident #101's Blood Pressure was ,[DATE], CNA #5 stated she could not remember what the SaO2 level was, but did remember that it was below 90%. CNA #5 stated she immediately went and told Licensed Practical Nurse (LPN) #13 of these findings. CNA #5 stated that LPN #13 put oxygen on Resident #101, and had CNA #5 re-check the SaO2 level. CNA #5 stated after re-checking Resident #101's SaO2, it was measured at 92%. CNA #5 stated she did not write the original SaO2 reading down per direction from LPN #13. CNA #5 stated she was unaware of the physician being notified of Resident #101's vital signs and condition. Review of Resident #101's medical record failed to reveal any mention of oxygen being started by LPN #13, or Resident #101's original SaO2 reading. Review of the medical record also failed to reveal documentation that the attending physician was notified of this change in condition. Review of the Nurse's Notes dated [DATE] at 7:30 AM and written by LPN #13 revealed at 6:00 AM Resident #101's BGL was 35. "Res (Resident) conscious but lethargic, oral instant glucose administered". The note revealed at 6:10 AM Resident #101's BGL was 50 "then Quickly droped (sic) again to 37. [MEDICATION NAME] injection was administered sub Q (injected with a syringe) 15 min (minutes) later (no change) in BS (Blood Glucose Level)...A 2nd dose of [MEDICATION NAME] was administered...came up to 90". In an interview on [DATE] at 8:20 AM, LPN #13 stated that she did not inform the attending physician of Resident #101's vital signs or low BGL. LPN #13 stated Resident #101 was asleep most of the night. LPN #13 stated she started Resident #101 on oxygen at around 1:00 AM on [DATE] after being made aware of the low SaO2 reading. LPN #13 stated that Resident #101's SaO2 reading was 88% before starting oxygen. When asked, LPN #13 stated she did a full assessment, to include listening to lung sounds, of Resident #101 during the morning at around 1:00 AM, but agreed that it was not documented anywhere. Review of the facility's Cedar Unit 24 hour report (document used to pass important information about residents from shift to shift) dated [DATE] failed to reveal any mention of Resident #101's low BGL, SaO2 or of Resident #101's new requirement for Oxygen or low blood pressure. In an interview on [DATE] at 1:27 PM, day shift Registered Nurse (RN) #18 stated she was not made aware of Resident #101's recent decrease in SaO2 levels, and the new requirement of oxygen. When asked, RN #18 stated "Yes" if a resident has a BGL of 35, a decrease in blood pressure that Resident #101 experienced, the physician should be notified. In an interview on [DATE] at 3:20 PM, Physician #17 stated per expectation and facility policy, he should have been notified of Resident #101's low BGL, low blood pressure and change in breathing status. Physician #17 stated he did not remember receiving a call from LPN #13. In an interview on [DATE] at 12:15 PM, float nurse (nurse that is not assigned a patient, and helps where needed) RN #9 stated that on [DATE] at about 12:15, a Certified Nursing Assistant (CNA) came to her stating Resident #101 was SaO2 level was dropping. RN #9 stated she went to Resident #101's room. RN #9 stated Resident #101 was lethargic, was having difficulty breathing and could hear crackles (abnormal breath sounds that imply an accumulation of fluid in the lungs) without the use of a stethoscope. RN #9 stated Resident #101's oxygen flow was increased to 5 Liters, and Resident #101 still had a low SaO2 of 87%. RN #9 stated the physician was immediately notified of Resident #101's situation, and an order to send Resident #101 to the hospital was attained. When asked, RN #9 stated, "Yes" the physician should have been notified of the original findings of Resident #9's low BGL, low blood pressure and change in breathing status. In an interview on [DATE] at 3:20 PM, Director of Nursing (DON) #2 stated she did not know why LPN #13 did not notify the physician of Resident #101's change in condition. DON #2 stated LPN #13 should have notified the physician of Resident #101's change in condition. ( )

Based on interview and record review, the facility failed to immediately assess, monitor and contact the physician concerning a resident with an acute change in condition in 3 of 5 sampled residents (#101, 102 and 105) reviewed for an acute change of condition, in a total sample of 5 residents resulting in a delay in treatment after Resident #101 and 102 were noted to have abnormal blood glucose levels (BGL) and Resident #105 experienced a [MEDICAL CONDITION]. Findings Include: According to the Mayo Clinic Website (http://www.mayoclinic.com/health/[MEDICAL CONDITION]/DS ), High blood sugar ([MEDICAL CONDITION]) affects people who have diabetes...It's important to treat [MEDICAL CONDITION], because if left untreated, [MEDICAL CONDITION] can become severe and lead to serious complications requiring emergency [MEDICAL CONDITION] doesn't cause symptoms until glucose values are significantly elevated - above 200 milligrams per deciliter (mg/dL). Review of the Facility's Blood Glucose Testing Policy dated July 1, 2008 revealed "If patient results are less then 70 (mg/dL) or greater than 400 (mg/dL)...and patient is asymptomatic repeat the test and notify the Physician of the results immediately. If patient is symptomatic notify Physician immediately and document in chart. Review of the Facility's Standing Orders (physician orders) revised 10/19/13 revealed, "If Blood sugar is less than 70 (mg/dL), proceed to [DIAGNOSES REDACTED] instruction. Institute protocol, and then notify physician. Notify Physician if great then 400 (mg/dL), for further instructions. Resident #101 Review of the Admission Record dated 9/27/13 revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Diabetic Flow Record revealed on 11/15/13 at 8:00 pm Resident #101's BGL was 516 (mg/dL). Review of Resident #101's medical chart failed to reveal documentation that the resident's physician was notified of the abnormal BGL. Resident #102 Review of the Admission Record dated 9/3/13 revealed Resident #102 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 11/12/13 at 6:00 am revealed, "Resident drowsy, speech clear...Bld sugar (BGL) 53 (mg/dL), instant glucose tube po (orally) given at this time...6:20 am BS (BGL) 65 (mg/dL), more alert. Review of the medical record revealed that the resident's physician was not notified of the resident's abnormal BGL until 8:00 am by Clinical Care Coordinator (CCC) #6. Review of the Facility's Plan of Correction dated 11/1/13 revealed, "The CCC/designee will audit documentation on residents with a change in condition to assure the physician has been notified of changes in condition and interventions are in place. Immediate corrective action for any identified concern(s) will result in 1:1 education for the nurse. During an interview on 11/26/13 at 2:08 pm, CCC #6 stated that there was no 1:1 education provided to the nurse that failed to notify the physician of Resident #102's low BGL. Resident #105 Review of the Admission Record dated 9/27/13 revealed Resident #105 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Facility's "[MEDICAL CONDITION], NURSING MANAGEMENT OF" Policy dated 7/1/08 revealed, "Notify physician of resident's condition" Review of the Facility's Plan of Correction dated 11/1/13 revealed, "The facility has adopted Interact III change in condition Cards and Care Paths...documentation has been adopted by the facility for notifying the physician of a change in condition. Review of the facility Interact Version 3.0 tool dated 2011 Signs and Symptoms section revealed, [MEDICAL CONDITION] activity that is self-limited in the past 24 hours in a resident with known [MEDICAL CONDITION] activity should be communicated to the physician in an "non-immediate" manner. Review of the Nurses Notes dated 11/2/13 at 9:35 am revealed, "Resident (up) in WC (wheelchair) experiencing [MEDICAL CONDITION] 1-2 minutes. Pupils dilated resident twitching extremities. Review of the medical record failed to reveal that the resident's physician was notified of the resident suffering a [MEDICAL CONDITION]. During an interview on 11/26/13 at 11:50 am, Director of Nursing (DON) #2 stated that Resident #105 has a history of [MEDICAL CONDITION], and this was "probably why" the physician was not notified. DON #2 was unable to provide any documentation that Resident #105's physician was notified of the [MEDICAL CONDITION] Resident #105 suffered. ( )

BASED ON INTERVIEW AND CLOSED RECORD REVIEW, THE FACILITY FAILED TO MODIFY THE FALLS CARE PLAN TO PREVENT AN AVOIDABLE FALL FOR TWO RESIDENTS ( #20 ) OUT OF SEVEN RESIDENTS AND ONE OF TWO SUPPLEMENTAL RESIDENTS ( #23 ) REVIEWED FOR FALL'S FROM A TOTAL SAMPLE OF 20 RESIDENTS RESULTING IN AN IMMEDIATE JEOPARDY FOR RESIDENT # 20. RESIDENT #20 fell , SUSTAINED A CEREBRAL HEMORRHAGE (INTERNAL BLEEDING OF THE BRAIN ) AND CONSEQUENTLY died DUE TO THE COMPLICATIONS FROM THE PREVENTABLE FALL. THE FACILITY'S DEFICIENT PRACTICE REMAINED AT A POTENTIAL FOR MORE THAN MINIMAL HARM AT AN ISOLATED CASE FOR RESIDENT # 23 WHO fell AND SUSTAINED ABRASIONS ON THE TOP OF HIS HEAD. THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] WAS REMOVED ON [DATE] AT 11:00 AM WHEN THE FACILITY PROVIDED A CORRECTION PLAN. FINDINGS INCLUDE: ON [DATE] REVIEW OF RESIDENT #20'S CLOSED MEDICAL RECORD REFLECTED THE FOLLOWING: INSIDE THE FRONT COVER OF RESIDENT #20'S MEDICAL RECORD WAS A TRANSFER SHEET DATED [DATE]. IT SHOWED THE REASON FOR RESIDENT #20'S TRANSFER TO A HOSPITAL WAS THAT RESIDENT #20 WAS FOUND ON THE FLOOR, BLEEDING FROM HER HEAD AND WAS TAKEN TO THE HOSPITAL BY AMBULANCE. THIS INCIDENT TOOK PLACE ON [DATE]. THE FACILITY'S FACE SHEET PRINTED ON [DATE], REFLECTED RESIDENT #20 WAS AN [AGE] year OLD FEMALE INITIALLY admitted to the facility on [DATE] AND LAST readmitted [DATE]. HER [DIAGNOSES REDACTED]. A COMPREHENSIVE MINIMUM DATA SET (MDS) THAT IS AN ASSESSMENT AND CARE SCREENING TOOL, FOR RESIDENT # 20 WAS COMPLETED ON [DATE]. IT REFLECTED FOR THE COGNITIVE PATTERNS SECTION, A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) WAS DONE AND THE SCORE WAS A 7 OUT OF 15, MEANING THAT RESIDENT #20 HAD SEVERE COGNITIVE IMPAIRMENT. A CARE AREA ASSESSMENT (CAA) WORKSHEET WITH DATE OF [DATE] GENERATED FOR FALLS FROM THE COMPREHENSIVE ASSESSMENT REFLECTED UNDER ANALYSIS OF FINDINGS, FALLS ARE LISTED AS AN ACTUAL PROBLEM."THE RESIDENT TRIGGERED BECAUSE SHE NEEDS ASSISTANCE STANDING AND TRANSFERRING. THE RESIDENT DID HAVE A RECENT FALL WITH NO INJURIES. THE RESIDENT IS ASSISTED TO TRANSFER PRN (WHENEVER NECESSARY). THE RESIDENT DOES NOT WEAR NON SKID FOOTWEAR ... THE RESIDENT HAS BEEN EDUCATED ON HER CALL LIGHT AND IS ENCOURAGED TO USE IT FOR ASSISTANCE PRN (AS NEEDED). THE RESIDENT CAN OFTEN MAKE HER NEEDS KNOWN BUT DOES HAVE A COGNITIVE DEFICIT WITH A SLOW DECLINE ". A QUARTERLY MDS, dated [DATE], FOR RESIDENT #20 REFLECTED IN THE COGNITIVE PATTERNS SECTION, A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) WAS DONE AND SCORE IS A 4 OUT OF 15, MEANING THAT RESIDENT #23 HAS SEVERE COGNITIVE IMPAIRMENT. THERE WAS A DECLINE IN HER COGNITION. NURSE'S NOTES DATED [DATE] AT 11:10 PM REFLECTED THE FOLLOWING: "RESIDENT OBSERVED IN ROOM C-9 ON LEFT SIDE AGAINST THE WALL (WALL WITH WINDOW), WITH HEAD UP AGAINST TE BASEBOARD VENT AT 10:00 PM, BLOOD VISIBLE BENEATH HEAD COMING FROM POSTERIOR SCALP. PATIENT NOT MOVED, RESIDENT ABLE TO MOVE TOES AND HAS EQUAL GRIP STRENGTH IN HANDS, VITAL SIGNS BLOOD PRESSURE ,[DATE] (ACCORDING TO AMERICAN HEART ASSOCIATION NORMAL BLOOD PRESSURE ,[DATE]), TEMPERATURE 97.6, HEART RATE 118 (NORMAL HEART RATE ,[DATE]), RESPIRATORY RATE OF 24, BLOOD OXYGEN SATURATION OF 91%, PERRL (PUPILS EQUAL AND REACTIVE TO LIGHT). 911 CALLED AT 10:21 PM (APPROXIMATELY), EMS (EMERGENCY MEDICAL SERVICE) HERE AT 11:30 PM, RESIDENT LEFT FOR HOSPITAL AT 11:40 PM. ALARM NOT SOUNDING AT TIME OF OCCURRENCE. WORKING ALARM HAD BEEN UNCLIPPED PRIOR TO OCCURRENCE. RESIDENT OBSERVED UNCLIPPING ALARM THROUGHOUT SHIFT AND WAS FREQUENTLY REAPPLIED BY STAFF. NOTIFIED FAMILY AND LEFT MESSAGE. NO CHANGE IN LEVEL OF CONSCIOUSNESS AFTER OCCURRENCE. RESIDENT WAS ASK WHAT SHE WAS ATTEMPTING TO DO PRIOR TO FALL AND STATED THAT SHE NEEDED AN ASPRIN". A CARE PLAN WITH A DATE OF [DATE] LISTED A FOCUS WITH THE FOLLOWING DESCRIPTION: "I AM AT RISK FOR FALLS RELATED TO UNAWARE OF SAFETY NEEDS, DECONDITIONING, DEMENTIA, AND RECENT HOSPITAL STAY. I HAVE A HISTORY OF FALLS RELATED TRANSFERRING MYSELF WITHOUT STAFF ASSISTANCE WAS INITIATED ON [DATE]. FOR GOALS , IT LISTED, "I WILL NOT SUFFER ANY SIGNIFICANT INJURY RELATED TO FALLS THROUGH THE REVIEW DATED [DATE]". INTERVENTIONS INCLUDED, " I NEED TO BE EVALUATED FOR, AND SUPPLIED APPROPRIATE ADAPTIVE EQUIPMENT OR DEVICES AS NEEDED, RE-EVALUATE AS NEEDED FOR CONTINUED APPROPRIATENESS AND TO ENSURE LEAST RESTRICTIVE DEVICE OR RESTRAINT. I USE AN SENSOR ALARM TO BED AND WHEEL CHAIR, WANDERGUARD ELECTRONIC ALARM. ENSURE DEVICE IS IN PLACE AS NEEDED. ON [DATE] ADDED INTERVENTION INCLUDED, RESIDENT RE-EDUCATED ON USING THE CALL LIGHT. ON [DATE] ADDED INTERVENTION INCLUDED SELF LOCKING WHEELCHAIR. ON [DATE] AT 9:05 AM DURING AN INTERVIEW WITH ADMINISTRATOR (ADMIN), DIRECTOR OF NURSING (DON) AND UNIT MANAGER STAFF "A" IN THE ADMINISTRATORS OFFICE, THEY WERE ASKED FOR INFORMATION ABOUT THE [DATE] FALL. DON STATED, "RESIDENT TAKES ALARM OFF ALL THE TIME. IT WAS ON AT 10:00 PM. SHE TAKES IT OFF ALL THE TIME BECAUSE SHE LIKES TO BE INDEPENDENT". THEY WERE ASKED WHAT SAFETY MEASURES WERE IN PLACE AT THE TIME OF FALL. STAFF "A" STATED, "SHE HAD A TAB ALARM". THEY WERE ASKED IF THIS INCIDENT WAS REPORTED TO THE STATE AND THE ADMIN STATED, "SHE WAS admitted TO OUR FACILITY FROM ANOTHER NURSING HOME AND HAD SEVERAL FALLS THERE. I EXPECT SHE MAY FALL. I LOOK AT HER AS A RISK FOR FALLS. THEY TOILETED HER 20 MINUTES PRIOR (TO THE FALL) AND THEY FOUND HER NEXT TO HER BED. I READ THE INCIDENT REPORT A COUPLE OF TIMES AND I DON'T SEE WHERE THAT WAS A REPORTABLE INCIDENT". THEY WERE ASKED HOW MANY FALLS RESIDENT #20 HAD THIS YEAR, AND THE "DON" STATED, "THIS WAS THE FOURTH". THEY WERE ASKED AND PROVIDED THE HOSPITAL DOCUMENTATION, FALL OCCURRENCE REPORTS, INVESTIGATIONS AND NURSING DOCUMENTATION FOR THE PAST NINE MONTHS FOR RECORD REVIEW. THE FALL'S UNUSUAL OCCURRENCE REPORT'S AND NURSES NOTES REFLECTED THE FOLLOWING FALL INCIDENCES: FALL #1: DATED [DATE] FALL OCCURRED AT 1:15 PM, RESIDENT #20 WAS FOUND ON THE FLOOR IN FRONT OF HER ROOM. NURSES NOTE AT 2:00 PM "FOUND RESIDENT ON THE FLOOR LAYING ON HER LEFT SIDE NO INJURIES". FALL #2: DATED [DATE] FALL OCCURRED AT 3:05 AM IN RESIDENT ROOM, RESIDENT WAS FOUND SITTING ON THE FLOOR LEANING AGAINST BED. NURSES NOTE NOT PROVIDED. FALL #3: DATED [DATE] FALL OCCURRED AT 10:00 AM IN BATHROOM, RESIDENT OBSERVED CERTIFIED NURSING ASSISTANT (CNA) WENT TO ANSWER RESIDENT'S CALL LIGHT, FOUND RESIDENT ON BATHROOM FLOOR WITH HEAD UNDER TOILET. NURSES NOTE WITHOUT A TIME LISTED, "THIS NURSE CALLED TO RESIDENTS ROOM AFTER CNA FOUND RESIDENT ON BATHROOM WHEN ANSWERING CALL LIGHT. RESIDENT DENIES PAIN AT THIS TIME AND WHEN ASKED WHAT HAPPENED RESIDENT STATED, "I DON'T KNOW". FALL #4: DATED [DATE] FALL OCCURRED AT 1:40 PM IN BATHROOM, CERTIFIED NURSING ASSISTANT PUT RESIDENT ON THE TOILET, AND LEFT TO ANSWER A LIGHT AND RESIDENT GOT UP ON HER OWN. NURSES NOTES WITHOUT A TIME LISTED "OBSERVED ON FLOOR IN BATHROOM DOORWAY OF ROOM, CNA REPORTS THAT SHE HAD JUST PUT HER ON THE TOILET AND HAD GONE TO ANSWER ANOTHER LIGHT AND HEARD HER ALARM SOUNDING". FALL #5: DATED [DATE] FALL OCCURRED AT 10:00 PM IN RESIDENT'S ROOM, NURSING ASSISTANT REPORTED OBSERVED RESIDENT ON LEFT SIDE IN ROOM UP AGAINST THE WALL (WHERE THE WINDOW IS) WITH HEAD ELEVATED UP AGAINST BASEBOARD. THIS FALL PRECIPITATED THE TRANSFER TO THE HOSPITAL. A REVIEW OF THE HOSPITAL DOCUMENTATION DATED [DATE] FOR RESIDENT # 20 REFLECTED THE FOLLOWING: A DOCUMENT TITLED "PHYSICIAN DISCHARGE SUMMARY" LISTED ADMISSION AND DISCHARGE [DIAGNOSES REDACTED]. ON [DATE] AT APPROXIMATELY 9:50 AM IN CONFERENCE ROOM ADMINISTRATOR WAS ASKED WHERE RESIDENT # 20 WENT AFTER THE HOSPITAL AND ADMINISTRATOR REPORTED THAT RESIDENT # 20 WENT TO A HOSPICE HOUSE. WHEN ASKED IF RESIDENT #20 WAS SENT TO THE HOSPICE HOUSE AS A RESULT OF INJURIES FROM THE [DATE] FALL, THE ADMINISTRATOR STATED, "I ASSUME SO". [DATE] AT 10:20 AM DURING A TELEPHONE INTERVIEW WITH RESIDENT # 23'S DAUGHTER AND DURABLE POWER OF ATTORNEY WAS CONDUCTED. SHE WAS ASKED ABOUT RESIDENT #20 AND THE RESIDENTS DAUGHTER STATED, "MY MOTHER PASSED AWAY [DATE] AND IT WAS THE MOST AWFUL EXPERIENCE I HAVE HAD WITH DEATH. I LOST MY SON [AGE] years AGO FROM A CAR ACCIDENT AND MY HUSBAND TWO YEARS AGO FROM A HEART ATTACK. WATCHING HER (MOTHER) SUFFER AND STARVE TO DEATH SLOWLY WAS AWFUL". SHE WAS ASKED WHAT CAUSED RESIDENT #20 TO STOP EATING AND THE DAUGHTER STATED, "AFTER THE BRAIN BLEED MY MOTHER NEVER LEARNED HOW TO SWALLOW AGAIN AND MY MOTHER NEVER WANTED A FEEDING TUBE". ON [DATE] STAFF "A" WAS ASKED WHERE THE FALL RISK ASSESSMENT WERE KEPT IN THE CHART. STAFF "A " STATED, "WE DO THEM ONLY ON ADMISSION AND NOT AFTER EVERY FALL". ON [DATE] AT APPROXIMATELY 12:45 PM IN THE CONFERENCE ROOM DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING AND STAFF "A", THEY WERE ASKED IF THE [DATE] FALL WAS AVOIDABLE OR UNAVOIDABLE. STAFF "A" STATED, "IN MY PERSONAL OPINION IT WAS UNAVOIDABLE BECAUSE SHE WAS FIERCELY INDEPENDENT". STAFF "A" WAS ASKED IF OTHER SAFETY INTERVENTIONS WERE ATTEMPTED TO KEEP RESIDENT #20 INDEPENDENT AND PREVENT FALLS, STAFF "A" REPORTED THAT HE WAS NOT SURE BUT THAT HE THOUGHT RESIDENT WAS BEING SEEN PHYSICAL THERAPY. A REVIEW OF THE DOCUMENT TITLED "PT (PHYSICAL THERAPY ) EVALUATION AND PLAN OF TREATMENT" DATED [DATE], REFLECTED UNDER TREATMENT APPROACHES EVALUATION ONLY. THE DIRECTOR OF NURSING AND STAFF "A" WERE ASKED TO GO THROUGH EACH OF THE FALL UNUSUAL OCCURRENCE REPORTS, SHOW THE INVESTIGATION (AND OR ROOT CAUSE) OF EACH FALL AND ANY INTERVENTIONS ADDED TO THE CARE PLAN AFTER EACH FALL. STAFF "A" REPORTED ON EACH FALL THE FOLLOWING: [DATE] "I TALKED TO HER ABOUT USING THE CALL LIGHT". HOWEVER, RESIDENT #20 HAS BEEN assessed with [REDACTED]. [DATE] PHYSICAL THERAPY EVALUATION WAS SUGGESTED. UNCLEAR IF THERE WAS FOLLOW UP FOR THIS. [DATE] treatment of [REDACTED]. [DATE] NO INTERVENTIONS WERE GIVEN. THE [DATE] INDICATED ALARM WAS NOT SOUNDING AND STAFF WERE AWARE THAT SHE KEPT TAKING OFF THE ALARM AND STAFF WOULD REAPPLY. THIS WAS A PREVENTABLE FALL GIVEN THAT THE FALLS CARE PLAN OF [DATE] DID NOT HAVE RECENT INTERVENTIONS THAT INCLUDED ANY MODIFICATIONS RECOMMENDED FROM THE OCCURRENCE REPORTS. THE DATE FOR ALL THE INTERVENTIONS WAS [DATE]. THE CARE PLAN DID NOT APPEAR TO BE UPDATED OR MODIFIED AFTER EACH FALL INCIDENT; THERE WAS A TOTAL OF 5 FALLS. THE CORRECTION PLAN TO REMOVE THE IMMEDIATE JEOPARDY WAS ACCEPTED ON [DATE] AT 11:00 AM. THIS CONSISTED OF THE FOLLOWING: 1. THE FACILITY'S QUALITY ASSURANCE COMMITTEE MET TO REVIEW THE CURRENT CENTER'S FALL REDUCTION PROGRAM ( NRS-248A0 ). 2. THE NURSE MANAGEMENT TEAM WILL REVIEW ALL RESIDENTS FALL CARE PLANS AND RESIDENT CARE GUIDES. THIS WILL INCLUDE UTILIZING ROOT CAUSE ANALYSIS (STARTED IN JANUARY, 2013). 3. THE NURSE MANAGEMENT TEAM WAS INSERVICED ON POST FALL ROOT CAUSE ON [DATE]. 4. THE CENTER'S STAFF AND CONTRACTED EMPLOYEES WILL BE INSERVICED ON THE CENTERS FALL REDUCTION PROGRAM AND ROOT CAUSE ANALYSTS PROVIDED BY ADMINISTRATOR/DIRECTOR OF NURSING. 5. THE ADMINISTRATOR /DIRECTOR WILL REPORT TO THE QA COMMITTEE MONTHLY FOR RECOMMENDATION AND FOLLOW-UP. ( ) ACCORDING TO NURSES NOTES DATED [DATE] RESIDENT #23 WAS A [AGE] year OLD MALE, admitted to the facility on [DATE] AS A TRANSFER FROM ANOTHER FACILITY WITH A HISTORY OF RECURRENT FALLS. THIS SAME NURSES NOTE REFLECTED RESIDENT #23 HAD AN " ABRASION TO TOP OF HEAD FROM FALL AT ANOTHER FACILITY, RS (RESIDENT) HAS BED SENSOR AND UNDERCHAIR ALARM ". ACCORDING TO RESIDENT #23 ' S FACE SHEET RESIDENT #23 WAS discharged FROM THIS FACILITY ON [DATE]. THE FACILITY HAD NOTES FROM A HOSPITAL PHYSICIAN FAXED TO THE FACILITY DATED [DATE], WHICH REFLECTED RESIDENT #23 HAD FALLS, RECURRENT FALLS AND INCLUDED: + WELL KNOWN TO ME FROM PREVIOUS ADMITS + ESSENTIALLY AT BASELINE FOR WALKING WITH R/W (ROLLER WALKER) + MULTI FACTORIAL REASONS FOR FALLS: 1) LEFT HIP ... WITH MODERATE LIMP 2) B (BI LATERAL) LE (LOWER EXTREMITY) EDEMA + NUMB FEET 3) UNSAFE BEHAVIORS 4) UNSTEADY GAIT. THESE SAME NOTES FROM THE HOSPITAL PHYSICIAN REFLECTED RESIDENT #23 PREFERRED TO USE A 4 WHEELED WALKER BUT HAD POOR CONTROL WITH THIS AND HE RECOMMENDED HE USE A ROLLER WALKER (FRONT WHEELS ONLY) FOR MORE EFFECTIVE LOWER EXTREMITY SUPPORT AND ASSISTANCE. RESIDENT #23 ' S FALL CARE PLAN INITIATED [DATE] REFLECTED A NEED FOR " BILATERAL FLOOR MATS BY BED WHEN THE RESIDENT WAS IN BED". HOWEVER, THERE WAS NO MENTION OF A NEED FOR A FRONT WHEELED WALKER ON HIS FALL CARE PLAN. THE " UNUSUAL OCCURRENCE " REPORT DATED [DATE] REFLECTED RESIDENT #23 HAD BEEN OBSERVED LAYING ON THE FLOOR BY A NURSE AIDE AND THE SENSOR ALARM WAS ON BUT DID NOT SOUND. THE PHYSICAL ASSESSMENT SECTION OF RESIDENT #23 REFLECTED THERE WERE TWO ABRASIONS ON R (RIGHT) LEG ON PATELLA AND ONE SKIN TEAR ON THE RIGHT BACK. THE " UNUSUAL OCCURRENCE " REPORT DATED [DATE] ALSO REFLECTED UNDER " ITEMS WITNESSED AND IN PLACE AT TIME OF EVENT " THAT RESIDENT #23 WAS ABLE TO AMBULATE INDEPENDENTLY AND THE NEW INTERVENTIONS WERE NON-SKID FOOTWEAR (WHICH WAS ALREADY ON THE FALL CARE PLAN) BEDSIDE MAT (WHICH WAS ALREADY ON THE FALL CARE PLAN), CHAIR AND BED ALARM (WHICH WAS ON THE FALL CARE PLAN AND IN PLACE). THE " UNUSUAL OCCURRENCE " REPORT DATED [DATE] DID NOT ADDRESS WHY THE BED SENSOR WAS NOT SOUNDING. THE FACILITY DOCUMENTED ON ADMISSION AND WAS AWARE OF RESIDENT #23 ' S MOST RECENT FALL AND HIS HISTORY OF FALLS. HOWEVER, HIS FALL CARE PLAN WAS NOT FOLLOWED FOR BEDSIDE MATS AND HIS CARE PLAN WAS NOT INDIVIDUALIZED TO REFLECT HIS NEED/RECOMMENDATION FOR A FRONT WHEELED WALKER WHEN AMBULATING. THERE WERE NO PROVISIONS WHEN HE IS NOT TO AMBULATE INDEPENDENTLY. THE FALL OF [DATE] WAS PREVENTABLE. ( )