Every finding on record at Lake Charles Care Center

Based on record review and interviews the facility failed to maintain complete and accurate medical records for 5 (#11, #12, #24, #29, #50) of 5 (#11, #12, #24, #29, #50) residents reviewed with catheters out of a sample of 36 residents. Findings: A review of the facility's policy titled, Charting and Documentation that was revised on 3/2025, read in part, All services provided to the resident, progress toward the care plan goals. shall be documented in the resident's medical record. The record shall facilitate communications between the interdisciplinary team regarding the resident .condition and response to care .Examples of what may be documented in resident's record: a. objective observations .c. treatment or services performed .3. Documentation in the medical record will be objective, complete and accurate . A review of the facility's policy titled, Output Measuring and Recording that was revised on 10/2020, read in part, The purpose of this procedure is to accurately determine the amount of Urine that a resident excretes in a 24 hour period 7. Record the time and output was measured The following information should be recorded .in the residents medical record .Signature and time of the person recording data. Resident #11A review Resident #11's medical record revealed an admission date of 01/06/2026 with diagnoses that included, but not limited to: cirrhosis of the liver and anxiety disorder. A review of Resident #11's tasks to be completed revealed a task to be completed and documented that read as follows: catheter care and output every shift. A review of Resident #11's POC (Point of Care) documentation for the month of May 2026 revealed no recorded outputs on the day shift for dates of: 05/06/2026, 05/09/2026, 05/10/2026, 05/11/2026, 05/18/2026, 05/19/2026, 05/20/2026, 05/21/2026, 05/24/2026, 05/28/2026, and 05/29/2026. There were no recorded outputs on the night shift for the dates of: 05/14/2026, 05/22/2026, and 05/30/2026. Continued review of POC documentation for June 2026 revealed no recorded outputs on the day shift on the dates of: 06/03/2026, 06/04/2026 and there were no recorded outputs on the night shift for the dates of 06/02/2026, and 06/06/2026. Resident #12A review Resident #12's medical record revealed an admission date of 04/01/2021 with diagnoses that included, but not limited to: chronic obstructive pulmonary disease and bladder neck dysfunction. A review of Resident #12's tasks to be completed revealed a task to be completed and documented that read as follows: catheter care and output every shift. A review of Resident #12's POC (Point of Care) documentation for the month of May 2026 revealed no recorded outputs on the day shift for dates of: 05/01/2026, 05/02/2026, 05/03/2026, 05/08/2026, 05/09/2026, 05/10/2026, 05/12/2026, 05/13/2026, 05/14/2026, 05/16/2026, and 05/18/2026, 05/19/2026, 05/23/2026, 05/24/2026, 05/26/2026, 05/27/2026, 05/28/2026, 05/29/2026, 05/30/2026, 05/31/2026. There were no recorded outputs on the night shift for the dates of: 05/22/2026, and 05/31/2026. Continued review of POC documentation for June 2026 revealed no recorded outputs on the day shift on the dates of: 06/01/2026, 06/03/2026, 06/04/2026, 06/05/2026 and there were no recorded outputs on the night shift for the dates of 06/02/2026, and 06/06/2026. Resident #24A review Resident #24's medical record revealed an admission date of 05/31/2025 with diagnoses that included, but not limited to: paraplegia and neuromuscular dysfunction of the bladder. A review of Resident #24's tasks to be completed revealed a task to be completed and documented that read as follows: catheter care and output every shift. A review of Resident #24's POC documentation for the month of May 2026 revealed no recorded outputs on the day shift for dates of: 05/18/2026, 05/19/2026, 05/20/2026, 05/21/2026, 05/27/2026, and 05/28/2026. There were no recorded outputs on the night shift for the dates of: 05/06/2026, 05/14/2026, 05/16/2026, 05/19/2026, 05/22/2026, 05/29/2026, 05/30/2026, and 05/31/2026. Continued review of POC documentation for June 2026 revealed no recorded outputs on the day shift on the dates of: 06/03/2026, 06/05/2026, 06/07/2026 and there were no recorded outputs on the night shift for the dates of 06/01/2026, 06/02/2026, 06/03/2026, 06/04/2026, 06/05/2026, 06/06/2026, and 06/07/2026. On 06/10/2026 at 1:45 p.m., an interview was conducted with S6ADON. S6ADON stated that the CNAs (certified nurse's assistants) are responsible for monitoring and documenting resident catheter outputs at the end of every shift. She also stated it is the responsibility of the CNA supervisor to ensure this was being done. An observation was made of the above residents' recorded catheter outputs for the month of May 2026 and June 2026. She confirmed that there were multiple days of missing data and confirmed it should have been complete. On 06/10/2026 at 2:45 p.m., an interview was conducted with S8DON. S8DON confirmed the catheter output should have been documented in each residents POC at the end of the staffs' shifts. She stated she had just learned this was not being done and should have been. Resident #29 A review of Resident #29's electronic records revealed she was admitted to the facility on [DATE] with diagnoses not limited to, Parkinson's disease, urinary tract infection, retention of urine, dementia, and neuromuscular dysfunction of bladder. A review of Resident #29's Task Description read in part, Catheter Care and Output, C.N.A. (Certified Nursing Assistant) every shift every 12 hours. A review of Resident #29's Documentation Survey Report for Catheter Care and Output for the month of June 2026 revealed no documentation for the day shift on the dates of: 06/01/2026 and 06/07/2026. There was no documentation for the night shifts on the dates of 06/01/2026, 06/02/2026, 06/05/2026, 06/06/2026, 06/07/2026, and 06/09/2026. Continued review of documentations for May 2026 revealed no documentation for the day shift on the dates of 05/01/2026, 05/02/2026, 05/03/2026, 05/04/2026, 05/05/2026, 05/06/2026, 05/09/2026, 05/09/2026, 05/11/2026, 05/12/2026, 05/13/2026, 05/20/2026, and 05/24/2026. There was no documentation for the night shift on the dates of: 05/08/2026, 05/08/2026, 05/11/2026, 05/12/2026, 05/13/2026, 05/16/2026, 05/18/2026, 05/19/2026, 05/21/2026, 05/27/2026, 05/28/2026, and 05/31/2026. On 06/10/2026 at 7:55 a.m., an interview was conducted with S7CNA who confirmed Resident #29 had a Foley catheter. She stated the CNAs were to empty the Residents Foley every shift and document the amount as required by the Care Plan Task. On 06/10/2026 at 12:05 p.m., a review of Resident #29's Care Plan, Document survey Report and CNA's Task with S6ADON. She confirmed that the CNAs' were not consistently documenting the resident output in the Documentation Survey Report. She stated the CNAs were to empty the residents' Foley bag and document the findings in the Document Survey Report as required by the Resident's Care Plan Task. On 06/10/2026 at 2:31 p.m., an interview was conducted with S2MDS who confirmed anytime a resident has a Foley, It is put in the Residents Care Plan Task Manager. The CNA's are to empty the urine out of the Foley and measure the urine, then document these findings every shift in the Document Survey Report. Resident #50 A review of Resident #50's electronic record revealed she was admitted on [DATE] with diagnosis not limited to, Hospice with end of life diagnosis of end stage heart disease, Retention of Urine, and Dementia. Record review of Resident #50's Care Plan, under Task Description read in part, Catheter Care and Output, C.N.A. (Certified Nursing Assistant) Every shift every 12 hours. A review of Resident #50's Documentation Survey Report for Catheter Care and Output For the month of June 2026. Revealed no documentation for the day shift on the dates of: 06/01/2026 and 06/05/2026. There were no documentation for the Nights shift on the dates of 06/01/2026, 06/02/2026, 06/05/2026, 06/06/2026, 06/07/2026, and 06/09/2026. Continued review of documentations for May 2026 revealed no documentation for the day shift of 05/05/2026, 05/06/2026, 05/09/2026, 05/14/2026, 05/17/2026, and 05/26/2026. There was no documentation for the night shift on the dates of 05/12/2026, 05/15/2026, 05/16/2026, 05/17/2026, 05/19/2026, 05/27/2026, 05/28/2026, and 05/31/2026. On 06/10/2026 at 10:23 a.m., S10.CNA confirmed Resident #50 had a Foley Catheter. She stated the CNAs were to empty her Foley every shift and document the findings in the computer as required by the Care Plan Task. On 06/10/2026 at 12:05 p.m., a review of Resident #50's Care Plan, Document survey Report and CNA's Task with S6ADON. She confirmed that the CNA's were not consistently documenting the resident output in the Documentation Survey Report. She stated the CNAs were to empty the residents Foley bag and document the findings in the Document Survey Report as required by the Resident's Care Plan Task. On 06/10/2026 at 2:31 p.m., an interview was conducted with S2MDS who confirmed anytime a resident had a Foley, It is put in the Residents Care Plan Task Manager. The CNAs are to empty the urine out of the Foley and measure the urine, then document these findings every shift in the Document Survey Report.

Based on record review, observations, and interviews the provider failed to store all drugs and biologicals under proper temperature controls. This had the potential to affect the census of 14 residents who resided on the Memory Care Unit.Findings:Record review of the facility's policy titled, Medication Labeling and Storage read in part, The Facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. A review of the USP (United States Pharmacopeia) temperatures revealed medications should be stored in temperatures between 68 - 77 degrees.On 06/09/2026 at 5:10 p.m., an observation with S13LPN of the Memory Care Unit's medication storage room revealed a 3 tier shelf with containers of medication on each shelf. At this time S13LPN stated these medications were for the residents on the memory care unit. S13LPN confirmed the stated room temperature was uncomfortably warm. S13LPN stated she worked on the unit since 01/2026 and the room had been this warm since then.A review of medication labels for random medications from the shelves was conducted with S13LPN. The labels for Ipratropium Bromide 0.5 mg and Albuterol Sulfate 3 milligrams Inhalation Solution read storage conditions: Protect from Light. Store at 68-77 Degrees Fahrenheit. See USP Control Room Temperatures. The label for Donepezil Hydrochloride tablets read: Store in temperatures at 68-77 Degree Fahrenheit. S13LPN confirmed the labels required the room temperature to be between 68 - 77 degrees.On 06/10/2026 at 9:05 a.m., an observation with S14MS of the Memory Care Unit medication room. He stated it was extremely warm in the storage room and that the room needed some kind of ventilation. At this time S14MS with his facility thermal temperature gun, obtained temperatures from the ceiling that was 88 degrees, the back wall 83 degrees, right wall was 82 degrees, the floor was 81 degrees, left wall 85 degree, and back of the shelves was 83 degrees. He stated they needed some vents and circulation in this room. On 06/10/2026 at 9:33 a.m., an interview with S8DON who confirmed she had removed all the medications from the Memory Care Unit medication storage room yesterday (06/09/2026). She stated the medication had been stored in that closet for at least one year. When asked if she thought this room was too warm to store medication, she refused to answer.

Based on observations and interviews the facility failed to maintain a clean and comfortable environment for 1 (#24) of 2 (#7, #24) sampled residents sampled for environment. Findings: A review of Resident #24 record revealed an admission date of 05/30/2025 with diagnoses that included, but were not limited to, paraplegia, polyneuropathy, and acute infarction of the spinal cord. On 06/08/2026 at 12:26 p.m., an observation of Resident #24's air conditioning (AC) unit revealed a thick layer of dust covering the front face unit vents. On 06/09/2026 at 9:15 a.m., a second observation of Resident #24's air conditioning unit revealed the thick layer of dust remained, covering the front face unit vents. On 06/10/2026 at 1:30 p.m., a concurrent observation and interview was conducted with S4HSK. S4HSK confirmed that cleaning the AC unit front face vents was included in the housekeepers' daily room cleaning duties. S4HSK observed Resident #24's AC unit, stated it appeared that it hadn't been cleaned in a while, and confirmed it should be cleaned daily, but had not been.On 06/10/2026 at 1:42 p.m., a concurrent observation and interview was conducted with S5HSKS. S5HSKS confirmed that the AC unit face vents should be wiped down daily and that there should be no dust on the vents. She observed Resident #24's AC unit and confirmed the unit was dirty.

Based on record review and interview the facility failed to complete a significant change MDS (Minimum Data Set) assessment no later than 14 days after determining there was a significant change in 1 (#107) resident's status out of 36 sampled residents reviewed.Findings:Review of Resident #107's EMR (Electronic Medical Record) revealed an admission date 01/05/2026 and was admitted with diagnoses that included dementia, anxiety, diabetes mellitus II and peripheral vascular disease.Further review of Resident #107's EMR revealed a physician's order dated 05/22/2026 that read admit to hospice, call hospice for any med changes, before transfer to another facility at time of death.A review of Resident #107's Significant Change MDS Assessment with an ARD (Assessment Reference Date) of 06/04/2026 was identified with a status of in-progress. Section F was incomplete and the assessment was not signed by an RN (Registered Nurse) within 14 days after the significant change was determined on 05/22/2026. On 06/10/2026 at 12:15 p.m., a concurrent record review and interview was conducted with S2MDS. S2MDS reviewed Resident #107's MDS assessment with an ARD of 06/04/2026 and confirmed the MDS assessment was not completed. S2MDS stated she was not aware the significant change MDS should have been completed within 14 days after the determination date. On 06/10/2026 at 1:05 p.m., an interview was conducted with S1RNDR. S1RNDR reviewed the RAI (Required Assessment Summary) for a Significant Change She confirmed a Significant Change MDS assessment should be completed upon the determination date of the significant change plus 14 days. S1RNDR further confirmed that a Significant Change MDS assessment should have been completed for Resident #107 by 06/04/2026 and was not completed.

Based on record reviews and interview, the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 1 (#13) out of 1 residents' records reviewed.Findings: Review of Resident #13's EMR (Electronic Medical Record) revealed an admission date of 06/15/2023 with diagnosis not limited to schizoaffective disorder, bipolar disorder, and delirium. Review of Resident #13's EMR revealed a PASRR (Pre-admission Screening and Resident Review) Level II determination date 02/11/2026 indicating the individual had a serious mental illness and was recommended for nursing home admission. Review of Resident #13's Significant Change MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) 02/20/2026 revealed a question that asked if the resident was evaluated by PASRR and was answered no. On 06/09/2026 at 3:12 p.m., a group interview was conducted with S2MDS and S3MDS. S2MDS reviewed Resident #13's PASRR status and confirmed the PASRR Level II status was dated 02/11/2026. S2MDS then viewed Resident #13's MDS assessment dated [DATE] and confirmed that the question regarding if the resident had been evaluated by PASRR had been incorrectly indicated.

Based on observations, record review and interviews the provider failed to carry out activities of daily living (ADL) for 1 (#9) of 2 (#5, #9) residents reviewed for ADL's out of a sample of 36 residents.Findings: Record review of the facilities policy titled, Activities of Daily Living (ADL's) Supporting with a revision date of 03/2025 read in part, Residents who are unable to carry out ADL independently will receive the services necessary to maintain good grooming .Appropriate care and services will be provided for residents who are unable to carry out ADL's independently .in accordance with the plan of care. Including appropriate support and assistance with: a. Hygiene (Grooming) Record review of Resident #9's electronic record revealed he was admitted to the facility on [DATE]. He had diagnosis not limited to, Chronic Pain, Insomnia, Renal Dialysis, Chronic Kidney Disease Stage 4, and Quadriplegia. The resident's quarterly Minimum Data Set assessment dated [DATE] revealed he had a Brief Interview of Mental Status was 15. Meaning he was cognitively intact.Record review of Resident #9's Care Plan read, Self-care deficit related to, needs assistance with ADL's, decreased mobility, diagnosis of functional quadriplegia. Resident will be clean.and well-groomed daily this quarter. Assist with ADL's as need (C.N.A (Certified Nursing Assistant)). Personal Hygiene-Dependent Shave as needed (C.N.A.).Record review of Resident #9's Documentation Survey Notes from the facility for June 2026 revealed he was bathed on 06/06/20206 and 06/08/2026.On 06/08/2026 at 2:38 p.m., an observation revealed Resident #9's facial hair was overgrown. At this time the resident stated he would like to be shaved daily. On 06/09/2026 at 9:58 a.m., an observation revealed Resident #9's facial hair remained overgrown. Resident #9 stated he wanted to be shaved daily. He stated he asked the CNA to shave him this morning and she told him she would shave him this evening. On 06/10/2026 at 7:55 a.m., an observation revealed Resident #9's facial hair was still overgrown. The resident stated he would like to be shaved. On 06/10/2026 10:50 a.m., S12CNA observed and confirmed Resident #9's hair on his face was overgrown. She stated he was to be bathed on Tuesdays, Thursdays and Saturdays and the CNAs were to shower and shave him on these days. On 06/10/2026 at 11:05 a.m., S6ADON confirmed Resident#9 could express his needs and if he wanted to be shaved, the CNA should shave him. At this time she reviewed Resident #9's care plan and stated he was dependent on staff for all his ADL's. She stated the CNA's were to shave him when they shower him.

Based on observations, policy review, and interviews, the facility failed to maintain professional standards for food service safety by failing to: 1. Label and date food items in the kitchen refrigerator and freezer, 2. Keep a food item in a proper storage container after opening, 3. Maintain cleanliness of floor, walls, and equipment in the kitchen, 4. Remove dented cans from the dry storage area, 5. Wear proper hair restraints in the kitchen, and 6. Label and date food items in the unit refrigerators. The facility's census was 123. Findings: A review of the facility's policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices with a last review date of 03/13/2025, read in part, Policy Statement: Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation .12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. A review of the facility's policy titled Food Receiving and Storage with a last review date of 03/13/2025, read in part, Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices. Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated, 7. Refrigerated foods are labeled and dated so they are used prior to expiration, frozen, or discarded. Foods and Snack Kept on Nursing Units 2. All foods belonging to residents are labeled with the resident's name, and dated. A review of the facility's policy titled Foods Brought by Family/Visitors with a last review date of 03/13/2025, read in part, Policy Statement: Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Policy Interpretation and Implemenation.1. Family members and visitors are asked to inform nursing staff when foods are brought for a resident. 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. On 05/12/2025 at 8:20 a.m., an initial tour of the kitchen was made with S3DM (Dietary Manager). The following were identified: 1. Dry storage- 1 can of diced pears and 1 can of lemon pudding, both dented on the rim. 2. Walk in cooler- 1 bag of sliced pepperoni, open, and not dated or placed in a sealed container. 3. Walk in freezer- a. Dirt and debris noted on the floors under shelving. b. Bag of sealed hot dog weaners not dated. 4. Stand up cooler- 8 bowls of reported pureed bread not labeled or dated. 5. Oil and food debris noted on the sides of the fryer as well as the side of the adjacent oven and wall. S3DM confirmed all findings. On 05/12/2025 at 11:05 a.m., an observation and interview was conducted with S3DM of S5DA (Dietary Aid) and S6DC (Dietary Cook). S5DA was observed with facial hair on his chin not covered with a facial hair restraint. S6DC was observed with his side burns out of his facial hair restraint. S3DM confirmed that both S5DA and S6DC's facial hair should have been covered with a facial hair restraint. On 05/12/2025 at 2:10 p.m., an observation of the Unit A Refrigerator and the Unit B Refrigerator, and an interview was conducted with S7ADON (Assistant Director of Nursing.) The following were identified. 1. Unit A Refrigerator a. 3 breakfast sausage biscuits, not dated b. 1 plastic container of corn, not dated c. 1 cake square, not dated 2. Unit B Refrigerator a. 1 container of macaroni and cheese, not labeled or dated b. Sliced cheese, not labeled or dated c. Container of baked chicken, not labeled or dated d. 1 Rotisserie chicken, not labeled or dated e. 2 mangos, not labeled or dated f. 1 bag of grapes, not labeled or dated g. Sliced watermelon, not labeled or dated S7ADON confirmed all findings. On 05/13/2025 at 3:34 p.m., an interview was conducted with S8DON (Director of Nursing) and S7ADON. S8DON confirmed that all food items in the Unit A and Unit B refrigerators should have been labeled and dated per facility policy.

Based on observation, interview, and recipe review, the facility failed to follow the recipe in order to meet the nutritional needs of the residents as evidenced by kitchen staff failing to use the appropriate recipe to prepare pureed food items. This deficient practice had the potential to contribute to decreased intake, altered nutritional needs, and weight loss for the 14 residents who consumed pureed diets. Findings: A review of the facility's policy Preparation of Puree Food, with a last review date of 03/13/2025, revealed in part: Policy Statement: To ensure all residents requiring a puree texture diet receive meals that are safe, nutritious, palatable, and meet individual dietary needs. Preparation: 2. Use standardized recipes to ensure nutritional adequacy. Review of the recipe [NAME] Pureed Instant Mix revealed in part, 2 1/2 (half) cups of rice mix and 2 quarts of boiled water were required for 15 servings. Review of the recipe for Pureed Beans [NAME] Northern Dry Ham Buffet, revealed in part, 5 lbs (pounds) and 10 oz (ounces) of Beans [NAME] Northern Dry Ham Buffet and 1 cup of milk or appropriate liquid were required for 15 servings. The number of portions served should equal the same number of portions pureed. Review of the recipe for Parslied Carrots, revealed in part, 1 3/4 quarts of carrot sliced parslied and 1 cup of milk or appropriate liquid were required for 15 servings. The number of portions served should equal the same number of portions pureed. On 05/12/2025 at 10:30 a.m., an observation of S2DC (Dietary Cook) preparing pureed foods was conducted. S2DC prepared instant pureed rice without using a measuring container for the rice mixture or boiled water. S2DC prepared pureed Beans [NAME] Northern Dry Ham Buffet, ham and beans separately, without use of a measuring container for the ham. S2DC prepared pureed Parslied Carrots, using 2 (4 cup) containers of carrots. On 05/12/2025 at 12:20 p.m., an interview and review of pureed recipes was conducted with S2DC (Dietary Cook). S2DC stated that she was unsure how to use the pureed menus including measuring the quantities indicated. She confirmed that she should have measured the ingredients for the pureed rice and did not use the recipe to measure the required amount of Parslied Carrots. She stated that she eyeballed it when determining quantities. She also confirmed that she should have pureed the beans and ham together with the indicated measurements per the recipe for pureed Beans [NAME] Northern Dry Ham Buffet. On 05/12/2025 at 12:30 p.m., and interview was conducted with S3DM (Dietary Manager). S3DM confirmed that the pureed recipes should be followed including required measurements when preparing pureed food items. On 05/12/2025 at 2:00 p.m., a phone interview was conducted with S4RD (Registered Dietician). S4DM confirmed that pureed recipes should be utilized to prepare pureed food items.

Based on observations and interviews, the facility failed to provide a sanitary and comfortable environment for the residents. This had the potential to affect the 123 Resident that reside in the facility. Findings: On 05/12/2025 at 1:22 p.m., an observation in Resident #113's room revealed her Pacemakers Communication Device was laying on the floor by the headboard and was covered by dust. Under the resident #113 and her roommate's bed and along the wall, near the two beds' headboard, was a white substance, dust and particles. On 05/13/2025 at 3:51 p.m., an observation with S9LPN (Licensed Practical Nurse) in Resident #113's room confirmed her Pacemakers Communication Device was covered by dust and the floor under her and her roommate's bed and along the wall was covered with a white substance, dusty and particles On 05/14/2025 at 9:33 a.m., an observation of Rooms A, B, C, D and E with S10CN (Charge Nurse) confirmed under along the wall by the head boards and under the beds were covered with dust and particles. On 05/14/2025 at 9:44 a.m., an observation in rooms #A, B, C, D and E with S11HKS (House Keeping Supervisor) confirmed that in these rooms the house keeper did not clean along the wall near the headboards and under the beds. She stated the house keepers are to move the beds from the wall and clean under them daily. At 10:00 a.m., an observation with S11HKS, she also confirmed that in Resident #75's room his fan was covered with lint. She stated it was the house keeper's job to clean the resident's fan of lint.

Based on observation, interviews, and record reviews, the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards for 1 (#272) of 1 resident investigated for respiratory care out of a total of 42 sampled residents, by failing to ensure that the resident's oxygen humidifier or tubing was labeled with a date. Findings: A review of the facility's policy titled Oxygen Administration with a review date of March 2025, read in part: Purpose. The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. General Guidelines: 1. Pre-filled water reservoir packs used in respiratory therapy must be dated when opened and discarded every 7 days, or when the water level becomes low. Resident #272 was admitted to the facility on [DATE] with diagnoses including: senile generation of brain, cerebral infarction and congestive heart failure. A review of the physician's orders revealed an order written on 05/05/2025 for O2 (oxygen) per (delivered by) NC (nasal cannula) at 2 l/min (liters per minute) continuous. On 05/12/2025 at 9:30 a.m., Resident #272 was observed receiving oxygen per NC at 2 liters. An observation of the oxygen tubing revealed the tubing and humidifier were not labeled with a date. On 05/12/2025 at 12:30 p.m., a second observation of Resident #272's oxygen tubing revealed the tubing still did not contain a date of initiation. On 05/12/2025 at 12:52 p.m., an observation and interview was conducted with S1LPN (Licensed Practical Nurse), of Resident #272 oxygen set-up. S1LPN confirmed the oxygen tubing and humidifier container were not labeled with the date and should have been.

Based on observation, record review and interviews, the facility failed to implement the comprehensive person-centered care plan for 1 (#90) of 42 sampled residents as evidenced by staff failing to ensure Resident #90's bed was in the lowest position. The facility had a census of 123 residents. Findings: Review of Resident #90's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Bipolar Disorder, Unspecified, Schizoaffective Disorder (Bipolar Type), Schizoaffective Disorder (Depressive Type) and Anxiety Disorder. Review of Resident #90's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/27/2025 revealed she had a BIMS (Brief Interview for Mental Status) of 04, indicating she was severely, cognitively impaired. Review of Resident #90's Care Plan Report included a Focus of Potential for falls related to history of falls, decreased mobility, medication effects and confusion. This focus included an intervention dated 02/06/2025 that read in part, ensure bed in lowest position at all times. On 05/14/2025 at 08:35 a.m., Resident #90 was observed in her room lying in bed. Her bed was not in the lowest position. At this time, an interview and observation was conducted with S13CNA (Certified Nursing Assistant). S13CNA stated she had just fed Resident #90 and had put her bed up and had not lowered it to the lowest position. She confirmed that Resident #90's bed was not in the lowest position and should have been. On 05/14/2025 at 08:40 a.m., an interview was conducted with S12LPN (Licensed Practical Nurse). She stated that Resident #90's bed should be in the lowest position at all times due to multiple falls.

Based on observation, interview, and record review, the facility failed to follow the recipe in order to meet the nutritional needs of the residents as evidenced by kitchen staff failing to: 1) Use the appropriate recipe to prepare a pureed food item 2) Ensure the appropriate sized scoops were used to serve pureed and non-mechanically altered foods. This deficient practice had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss for the 15 residents who consumed pureed diets and the 113 residents that consumed non mechanically altered meals from the kitchen. 128 residents consumed meals from the facility's kitchen. Findings: On 05/08/2024, a review of the facility's policy Kitchen Weights and Measures,, with a last review date of 01/2024, revealed in part: Policy Statement: Food services staff will be trained in proper use of cooking and serving measurements to maintain portion control. Policy Interpretation and Implementation: 1. Cook and Food Services staff will be trained in weights and measures, volume and weights, appropriate utensil use, and food can sizes. 6. Staff will be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators (e.g., color-coded) on utensils will be prominently displayed for reference. 1. Review of the recipe for pureed butter rice revealed whole milk was the required liquid to be used. Review of the recipe for pureed instant rice revealed water was the required liquid to be used. On 05/06/2024 at 10:15 a.m., an observation of S4DC preparing pureed foods was performed. S4DC prepared a container of butter rice utilizing the recipe for pureed instant rice instead of pureed butter rice. S4DC used water instead of the required liquid of milk. On 05/08/2024 at 10:30 a.m. an interview with S6RD was conducted. The menu for pureed butter rice was reviewed. She confirmed that the butter rice prepared on 05/06/2024 should have been pureed with milk and not water. 2. Review of recipes for 05/06/2024 food items revealed the following listed the utensils required for correct sized portions: White beans and ham- 6 oz (ounce) spoodle Steamed rice - #8 dipper (4oz) Mixed vegetables (substituted for green beans) - #8 scoop (4oz) Pureed mixed vegetables (substituted for green beans) - #12 scoop (2 2/3 oz) Pureed white beans and ham- 6 oz spoodle Pureed rice- #8 scoop (4oz) On 05/06/2024 at 11:07 a.m., an observation was made of the kitchen staff serving meal trays. An interview with S5DS was conducted. S5DS provided menus of each food item served at this mealtime. Individual menus were reviewed, which indicated specific serving utensils to be used. The following utensils were used instead of the utensils listed on each recipe. White beans and ham- #8 gray scoop (4oz) Steamed rice- #12 [NAME] scoop (2 2/3 oz) Mixed vegetables (substituted for green beans) used - Red slotted scoop (2 oz) Pureed mixed vegetables (substituted for green beans) - #16 Blue scoop (2 oz) Pureed white beans and ham- Red scoop (2 oz) Pureed rice- #16 Blue scoop (2 oz) Review of recipe for 05/07/2024 food item revealed the following utensils required for correct sized portions: Bell Pepper Casserole -6 oz spoodle On 05/07/2024 at 11:30 a.m. an observation of the meal service was performed with S6RD. S6RD provided menus of each food item served at this mealtime. Individual menus were reviewed which indicated specific serving utensil to be used. The following utensils were used compared to the indicated utensils listed on each menu. Bell pepper casserole with tomatoes- #8 grey scoop (4oz) Bell pepper casserole without tomatoes - #8 grey scoop (4oz) On 05/06/2024 at 02:44 p.m., a phone interview with S6RD was conducted. She reported that recipes are used on an as needed basis for preparation of food or reviewed at the time of a new menu cycle. Kitchen staff have a book with recipes that they can refer to for measurements, but they are familiar with what serving utensil to use for preparation and what scoops to use for serving. She stated the sign for scoop measurements is located on the steam table. She further stated that S7PM and/or S5DS were responsible for monitoring the scoops used in serving food. On 05/07/2024 at 11:45 a.m., an interview was conducted with S5DS and S4DC. Both confirmed that the scoops used to serve the two bell pepper casseroles on 05/07/2024 were not the appropriate size as listed on the recipe. On 05/08/2024 at 10:30 a.m., a face to face interview with S6RD was conducted during which the surveyor observations of the incorrect utensil size use on 05/06/2024 and 05/07/2024 were discussed. S6RD confirmed that appropriate sized serving utensils were not used for those two days during lunch meal service. She stated that the serving sizes were inadequate. The scoop sign posted on the kitchen bulletin board was reviewed with S6RD, and she verified that this was the sign the staff should utilize for proper serving utensils. On 05/08/2024 at 03:00 p.m., an interview with S7PM was conducted. S7PM reported that she had been working at the facility for two years. She stated she or the S5DS are responsible for ensuring the correct serving scoops were being used.

Based on record review and interview, the facility failed to ensure the facility-wide assessment included a detailed review of facility Cuban population's ethnic, cultural, and/or preferred language factors that may potentially affect the care provided by the facility. This deficient practice affected 1 resident (#61) with a potential to affect a census of 127 residents currently residing in the facility. Findings: On 05/08/2024, a review of the facility's policy, Facility Assessment, with a revision date of 01/25/2024 revealed in part, the following: Policy Statement: A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our resident during day-to-day operations . Policy Interpretation and Implementation: . 3. The facility assessment includes a detailed review of the resident population. This part of the assessment includes: d. Religious, ethnic or cultural factors that affect the delivery of care and services, such as: . (4) Language translation requirements. Review of the Facility assessment dated [DATE] with an assessment date of 01/18/2024 failed to identify any resident population of Cuban descent, Spanish as a preferred language nor the use of an interpreter. Review of Resident #61's record revealed he was admitted to the facility on [DATE] with diagnoses that included Coronary Artery Disease, Hypertension, and Diabetes Mellitus. Review of Resident #61's MDS (Minimal Data Set) dated 03/27/2024, Section N revealed ethnicity of Cuban and the preferred language of Spanish. On 05/08/2024 at 10:00 a.m., a review of the facility's assessment was conducted with S1ADM (Administrator). He confirmed that Resident #61 was Cuban and his preferred language was Spanish. He also confirmed that the facility's assessment failed to include any ethnic, cultural factors, or language perforation that affected the delivery of his care.

Based on observation, interviews, and record review the facility failed to ensure that a resident's enteral feeding was properly labeled for 1 (#71) out of 1 (#71) resident investigated for tube feeding. This deficient practice had the potential to affect the 4 residents in the facility who received tube feedings. Findings: On 05/08/2024, a review of the facility's policy titled Enteral Feedings-Safety Precautions, with a reviewed date of 01/25/2024, read in part .Preventing errors in administration 2. On the formula label document initials, date and time the formula was hung. A review of Resident #71's clinical record revealed an admitted [DATE] with diagnoses that included Dysphagia Following Cerebral Infarction and Encounter for Attention to Gastrostomy. A review of Resident #71's current Physician's Orders revealed a diet order for Enteral feed of Isosource (formula) 1.5 at 57 ml /hr. (milliliters per hour) continuously. On 05/06/2024 at 11:23 a.m., an observation of Resident #71's enteral feeding delivery system revealed a disposable enteral feeding bag containing a light brown liquid infusing at 57 ml/hr. The disposable bag contained no label with the contents of the bag, the date and time, the contents were placed in the bag, nor the initials of who initiated the feeding. On 05/06/2024 at 11:23 a.m., during an interview and observation of Resident #71's enteral feeding delivery system with S3LPN (Licensed Practical Nurse), she confirmed the disposable bag did not have a label indicating the contents of the bag. She stated the bag should have a label with the date, time, contents of the bag, and initials of the nurse that completed the task. She reported the enteral feedings for Resident #71 were changed on the night shift. On 05/07/2024 at 1:55 p.m., an interview was conducted with S8DON (Director of Nursing). She confirmed disposable enteral feeding bags should be dated, timed, initialed, and labeled with the contents of the bag when the bag was prepared for the resident.

Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for use of antibiotics for 1 (#11) of 63 sampled residents whose records were reviewed. The deficient practice had the potential to affect a facility census of 127 residents. Findings: A review of Resident #11's EMR (Electronic Medical Record) revealed an admitted [DATE] with diagnoses that included Encephalopathy and Urinary Tract Infection. A review of resident #11's MAR (Medication Administration Record) for April 2024 revealed she received Xifaxan (an antibiotic) from 04/12/2024 through 04/30/2024. Further review of resident #11's medical record revealed a Discharge MDS with an ARD (Assessment Reference Date) of 04/24/2024, read in part .Section N. Medications .High Risk Drug Classes Use and Indication .antibiotics was not indicated. On 05/07/24 at 1:30 p.m., an interview was conducted with S2MDS (Minimal Data Set). S2MDS confirmed Resident #11 received an antibiotic during the timeframe of 04/12/2024 through 04/30/2024. She reviewed the referenced MDS, confirmed the antibiotics were not indicated and should have been.

Based on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had an accurate (PASARR) Pre-admission Screening and Resident Review Level I and/or Level II for 1 (#92) of 5 (#1, #13, #37, #64, #92) residents reviewed for PASAAR screening. Findings: Review of the facility's policy titled Admission Criteria read in part: 7. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MS, ID or RD. b. If the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative serves he or she needs, and whether placement in the facility is appropriate. Review of Resident #92's clinical record revealed he was admitted on [DATE] with diagnoses that include: Essential Hypertension, Alcohol Dependence, Major Depressive Disorder, Anxiety Disorder, and Paranoid Schizophrenia. Review of Resident #92's admission MDS (Minimum Data Set) assessment, dated 03/22/2023, revealed a BIMS (Brief Interview for Mental Status) of 14 indicating intact cognition, and a diagnosis of Schizophrenia. Resident #92's admission MDS, dated [DATE], also revealed a diagnosis of Schizophrenia. Review of Resident #92's care plan in part: Focus; Alteration in behavior related to diagnosis of Anxiety, Diagnosis of Schizophrenia, and Diagnosis of Alcohol Dependence. Further review revealed no plan to receive PASARR Level II services. Review of Resident #92's PASARR, dated 02/18/2021, revealed it was completed by the resident's previous facility and did not reflect his current psychiatric diagnoses. Section III Mental Illness section revealed a question that read, Do you suspect the applicant has, or has the applicant ever been diagnosed as having a mental illness? The response checked was, no, indicating the resident did not have a mental illness. The OBH-PASRR (Office of Behavioral Health Preadmission Screening and Resident Review), dated 06/03/2021, determination results revealed Level II not required, diagnosis of MDD (Major Depressive Disorder) and Anxiety. No behavioral health claims. Further review revealed Schizophrenia was not listed as a diagnosis. On 04/25/23 at 4:41 p.m., an interview was conducted with S5SSD, who was responsible for PASARR screening, and she agreed that the PASARR was not accurate because it did not reflect Resident #92's diagnosis of Schizophrenia on admission. She also confirmed that a Level II should have been done for Resident #92 when he was admitted on [DATE] with the diagnosis of Schizophrenia.

Based on record reviews and staff interviews, the facility failed to accurately code the residents' Minimum Data Set (MDS) assessments for 2(#89, #123) out of 38 sampled residents. This deficient practice had the potential to affect a census of 129. Findings: Resident #89 Resident #89 was admitted on [DATE] with diagnoses that included in part: Cerebrovascular Disease, Alzheimer's Disease, Anorexia, and Mild Protein-Calorie Malnutrition. A review of Resident #89's Minimum Data Set (MDS) Annual Assessment with an Assessment Reference Date (ARD) of 04/05/2023, read in part under Section K-Swallowing/nutritional Status for weight loss revealed the resident was coded as 0 which indicated No loss of 5% or more in the last month or loss of 10% or more in last 6 months. A review of Resident #89's progress notes revealed a Nutritional Status note written by on 04/11/23 that read, in part: Current weight is 128.4 pounds (lbs.) from 4/5/23 . Weight loss triggers: 5.0% change (Comparison weight 03/01/23, 136.2 lbs., -5.7%, -7.8 lbs.) .and 10% change (Comparison weight 11/2/22, 147.4 lbs., -12.9%, -19 lbs.). On 04/25/23 at 1:38 p.m., an interview and record review was conducted with S4MDS. She reviewed Resident #89's weights and progress notes and confirmed that Resident #89 had a weight loss of 5.7% in the last month and a weight loss of 12.9% in the last six months. S4MDS reviewed Resident #89's Annual MDS, with an ARD of 04/05/2023, and confirmed his weight loss status indicated no weight loss. 41868 Resident #123 A review of Resident #123's medical record revealed he admitted to the facility on [DATE] and discharged on [DATE]. Resident #123's nursing progress note, dated 03/03/2023 at 3:51 p.m., indicated he had discharged to his home. A review of the Facility Transfer Log for March 2023 revealed Resident #123's location of transfer on 03/03/2023 was home. A review of Resident #123's Discharge Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 03/03/2023 revealed a planned discharge, return not anticipated assessment was completed. Section A-Identification Information, A2100 Discharge Status was coded 03, indicating acute hospital. On 04/26/2023 at 8:40 a.m., an interview and record review was conducted with S3MDS Nurse. She confirmed that Resident #123 was discharged from the facility on 03/03/2023 to his home. S3MDS reviewed Resident #123's Discharge MDS, with an ARD of 03/03/2023, and confirmed his discharge status indicated he was discharged to an acute hospital instead of the community (private home).

Based on record reviews, observations, and interviews, the facility failed to ensure medication was properly stored and not available for improper resident use as evidenced by medication left unattended at the resident bedside for 4 (#7, #8, #9, #10) of 15 sampled residents. Findings: Review of the facility's policy, Storage of Medication, revealed in part: the facility shall store all drugs in a safe, secure and orderly manner. Resident #7 Resident #7 was admitted on [DATE] with diagnoses that included Hypertension, Anxiety, Depression, Chronic Pain, Anemia, Malnutrition, Cerebral Vascular Accident and Peripheral Vascular Disease. Review of Resident #7's Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) was 13 which indicated that he was cognitively intact. Review of Resident #7's physician orders summary report dated December 2022 revealed the following medication orders: Percocet 7.5/325mg (milligrams) orally every 8 hours as needed for pain Aspirin enteric coated 81 mg orally (po) daily Buspirone 10 mg give 2 tab po TID (3 times a day) Eliquis 5 mg po BID (twice a day) Gabapentin 300mg po TID Lipitor 20 mg po QHS (every night at bedtime) Norvasc 10mg po daily Plavix 75mg po daily Super B-complex po daily Thera M 1 tablet po daily Trazodone 50mg give 1/2 tablet QHS Zoloft 100mg po daily On 12/05/22 at 10:43 a.m., an observation of resident #7' in his room, revealed he was lying in bed with a bottle of Debrox ear wash solution and a blub syringed observed on the bedside. An interview was conducted with Resident #7 and he stated that someone, had given it to him, to help with his ears. Resident #7 was unable to recall who had placed the Debrox ear solution at his bedside. On 12/05/22 at 10:50 a.m., an interview was conducted at Resident #7 bedside with S2LPN (Licensed Practical Nurse), she confirmed with surveyor, resident #7 had a bottle of Debrox ear solution with a bulb syringe at the bedside. She also confirmed the resident did not have an order for Debrox ear wash and no medication should be left at a resident's bedside. Resident #8 Resident #8 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Urinary Tract Infection, Depression, Dementia, Alcoholism, Bi-polar, Anemia and Atrial-fibrillation. Review of Resident #8's MDS, dated [DATE], revealed the resident #8's BIMS was 15 which indicated that he was cognitively intact. Review of Resident #8's physician orders summary report dated December 2022 revealed in part, the following medications: Flonase suspension 50mcg (micrograms) 2 sprays in both nostrils daily for allergic rhinitis On 12/05/22 at 10:45 a.m., an observation and interview with resident #8 revealed a bottle Flonase nasal spray on the bedside table with the resident's name on the bottle. Resident #8 reported she had taken it earlier today and the nurse had not come back to pick it up. Resident #8 stated the nurse left the medication for her to self-administer the Flonase spray. On 12/05/22 at 10:50 a.m., an interview was conducted at resident's bedside, with S2LPN. S2LPN confirmed with surveyor, the Flonase nasal spray was left at Resident #8's bedside and confirmed no medication should be left at a resident's bedside. Resident #9 Resident #9 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Anxiety and Gastroesophageal Reflux Disease. Review of Resident #9's MDS, dated [DATE], revealed the resident's BIMS was 13, which indicated that she was cognitively intact. Review of Resident #9's physician orders summary report for December 2022 revealed in part, the following medications: Budesonide Suspension 0.5mg/2ml (milliliter) 1 vial BID, rinse mouth after use On 12/05/22 at 10:46 a.m., an observation and interview with Resident #9 revealed, a closed bullet of Budesonide solution 0.5mg/2ml was on the bedside table. Resident #9 stated that she does her nebulizer when she wants so the nurse will leave the medication at the bedside for use when she is ready to take the breathing treatment. On 12/05/22 at 10:50 a.m., an interview was conducted at Resident #9's bedside with S2LPN. S2LPN confirmed the medication vial of Budesonide solution for inhalation treatment was left on the bedside table for the resident to self-administrator when Resident #9 was ready for breathing treatment. S2LPN confirmed medication should not be left at the resident's bedside. Resident #10 Resident #10 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease, Nephrostomy tube, and Hypertension. On 12/05/22 at 11:20 a.m., an observation made of resident #10's bedside table revealed a medication box labeled as lidocaine 2.5% (percent) & prilocaine 2.5% cream. On 12/05/22 at 11:30 a.m., during an interview conducted at Resident #10's bedside S3LPN confirmed the medication on Resident #10's bedside table should not be left unattended in the room.

Based on record review and interview, the facility failed to develop and implement a baseline care plan for Resident #10 that included the instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care within 48 hours of the resident's admission. This deficient practice was identified for 1 (#10) of 15 sampled residents. Findings: Resident #10 was admitted on [DATE] with diagnoses that included End Stage Renal Disease, Hypertension, Nephrostomy tube Status/Post Cholecystectomy and Chronic Obstructive Pulmonary Disease. Review of Resident #10's electronic clinical record revealed that a baseline care plan was not developed. On 12/05/22 at 2:30 p.m., during an interview S1MDS confirmed that a baseline care plan was not developed and that one should have been done within 48 hours of admission.

Based on record reviews and interviews, the facility failed to discontinue a resident's medications upon readmission to the facility; and administering those medications which caused a significant medication error for one (#1) out of 5 (#1-#5) sampled residents. This deficient practice resulted in an actual harm for Resident #1 on 7/26/2022, when Resident #1 experienced a syncopal episode, was slumped over in the wheelchair, was non-responsive and clammy with a blood pressure of 121/45 and a heartrate of 35. Resident #1 was administered two different diuretic medications, which were supposed to be discontinued, for 5 days. The administration of the diuretics was a contributing factor to the resident having the syncopal episode and being admitted to the hospital where he was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident #1's medical record revealed he had readmitted to the facility from a local long-term acute care hospital on 7/21/2022. A review of Resident #1's discharge medication reconciliation order form dated 7/21/2022 from ____ Specialty hospital revealed no order of any diuretic medications. Resident #1's facility's order summary report dated 7/21/2022 included the following orders: (1) [MEDICATION(S)] ER (extended release) 12 hour 500 mg (milligrams). Give one capsule by mouth two times a day. (drug classification: diuretic) (2) [MEDICATION(S)] tablet 20-mg. Give 1 tablet by mouth one time a day. (drug classification: diuretic) A review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1 twice daily at 8:00 a.m. and 8:00 p.m. from 7/22/22 through 7/26/22. [MEDICATION(S)] was administered to Resident #1 daily at 8:00 a.m. from 7/22/22 through 7/26/22. A review of Resident #1's nursing progress notes from 7/26/2022 at 1:20 p.m. read in part, Brought to nurse by therapy department. Slumped in wheelchair. Non-responsive, clammy, pale. BP (blood pressure) 121/45, HR (heartrate) 35. Transferred to bed. Dr.___ making rounds orders to send to _____ hospital. A review Resident #1's local hospital records, with an admitted [DATE], revealed Resident #1 was admitted to a local hospital after a syncopal episode with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital progress note stated, discontinued diuretics which he received at NH (nursing home). Had been discontinued before in hospital and not sure why they were restarted A review of Medication Deviation Report, dated 7/27/22, revealed in part, Medication was administered after order was given to discontinue. Outcome of deviation: Resident admitted to hospital with acute [CONDITION(S)]/dehydration. Investigative findings: Discovered by Dr.___ while resident was in the hospital. Purpose of medication: diuretic. Condition of the resident, stable. Any adverse drug reaction? Yes, was admitted inpatient to the hospital. Resident no longer resided in the facility. On 9/8/2022 at 10:30 a.m., an interview was conducted with S1DON (Director of Nursing). She stated a resident's discharge medication orders are received from the hospital, and the orders are entered in the facility computer system by S2LPN (Licensed practical nurse) or another charge nurse on duty. Once in the computer, an order summary and medication administration documentation record is printed out. S1DON confirmed the discharge medication orders did not indicated the two medications, [MEDICATION(S)] and [MEDICATION(S)], were ordered. She confirmed the order summary and medication administration documentation record contained orders for [MEDICATION(S)] and [MEDICATION(S)]. S1DON verbalized S3MD (Medical Director) had called the day after Resident #1's hospital admission to question if resident had received any diuretics, in which she informed him, yes he had. S3MD informed her Resident was not supposed to be on any diuretics and requested a medication deviation report be completed. On 9/8/2022 at 11:20 a.m., an interview was conducted with S1DON and S2LPN, both verbalized the medications [MEDICATION(S)] and [MEDICATION(S)] were overlooked while imputing new orders and discontinuing previous orders for Resident #1's orders in the computer system. On 9/8/2022 at 12:30 p.m., a telephone interview was conducted with S3MD, who verbalized he was Resident #1's physician at the facility and while in the local hospital for admitted [DATE]. He stated he was attempting to pinpoint the reason for Resident #1's dehydration after admission to the hospital. Resident #1 had previously taken diuretics, but they were discontinued during his last hospitalization . He called the facility to inquire about Resident's medication and was told he had received 5 days of diuretics. S3MD verbalized the use of diuretics was a contributing factor in Resident #1 becoming weak, and having altered mental status that caused him to be admitted to the hospital for 6 days.

Based on observations, record reviews and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for 1 (#96) of 2 residents (#12, #96) reviewed for falls out of 32 residents reviewed in the initial pool. An actual harm occurred on 1/31/19 at 4:15 a.m., when Resident #96, was being given incontinent care while in bed with the assistance of one Certified Nursing Assistant (CNA). The resident, who required two person assistance, fell out of the bed onto the floor which resulted in a three inch laceration across her forehead. Hospital records indicated Cervical Fractures at C1 and C2, and fractures of her right tibia, fibula, and femur. The facility implemented corrective actions prior to the State Agency's Investigation on 4/7/19; thus, it was determined to be a Past Noncompliance citation. Findings: Resident #96 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident also had a [MEDICAL CONDITION] of the left lower extremity. Review of the resident's Minimum Data Set ((MDS) dated [DATE] indicated: A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed . self-performance extensive assist and support two plus persons physical assist. Further review of the MDS revealed the resident was cognitively intact. Review of an investigative report for resident #96 dated 1/31/19 indicated that at 4:15 a.m., S13LPN (Licensed Practical Nurse) was called to the resident's room and found the resident lying on the floor on her stomach on the left side of the bed. There was a three inch laceration noted on the resident's forehead. The resident was sent to a local hospital by ambulance. Review of a written statement from S10CNA which indicated while she was changing the resident, the resident was complaining of itching and wanted S10CNA to wipe her real good. After wiping the front area, S10CNA turned the resident and could not reach her back, so she pushed her a little to touch the area and one leg fell off of the bed. S10CNA went to catch the resident's leg and her whole body slid down with her. The resident fell off the opposite side of the bed from which S10CNA was standing. Review of a nursing note dated 1/31/19 at 8:30 a.m., revealed addendum Bed was not in lowest position d/t (due to) patient care being provided at the time. Review of Resident #96's follow-up x-ray report dated 3/13/19 included the following findings: Sub-acute [MEDICAL CONDITION] femur. Postoperative changes of the left hip. Reduction of [MEDICAL CONDITION] femoral neck via 3 reduction screws; [MEDICAL CONDITION] tibia and fibula. status [REDACTED]. Review of a Computerized Tomography (CT) Scan dated 4/8/19 indicated no detrimental change with interval improvement/healing of the C2 and C1 fractures previously noted. Further record review revealed the resident required hospitalization and surgery for [REDACTED]. Review of the resident's MDS (Minimum Data Set) dated 3/15/19, following the fall and hospitalization indicated: Section G: A. Bed mobility; Self-performance Total Dependence, Support two plus person physical assist. Further review of the MDS revealed the resident was cognitively intact. The resident's MDS dated [DATE] also indicated Bed mobility total dependence two person assist. Further review of the MDS revealed the resident was cognitively intact. An observation and interview of the resident on 4/8/19 at 10:33 a.m., was conducted. Resident #96 was in bed and had a neck brace in place. When spoken to, the resident requested that this surveyor move towards the end of the bed so she could make eye contact as her neck brace prevented her from moving her head very much. The resident verbalized she had fallen out of the bed when S10CNA was giving her incontinent care, that she was supposed to have two CNAs help, but only S10CNA came in the room to help her that time. The resident stated S10CNA did not pull her over enough in the bed to change her and when she turned her to the side, the CNA pushed her and she fell out of the bed. During an interview with S12CNA on 4/8/19 at 10:50 a.m., she stated the resident was a two person assist for incontinent care. At this time, S12CNA also stated the resident needed extensive two person assist with incontinent care. During an interview on 4/9/19 at 12:13 p.m., S14LPN stated the resident is a two person assist for toileting and repositioning/bed mobility, and further verified that the resident had been a two person assist prior to her fall and fracture on 1/31/19. On 4/9/19 at 1:55 p.m., S3ADON (Assistant Director of Nursing) stated Resident #96 has always been a 2 person assist for bed mobility, and peri-care and S12CNA decided on her own to not get assistance to help with the resident the night of the fall. On 4/10/19 at 6:00 a.m., during a telephone interview, S13LPN stated she was working when Resident #96 fell out of bed. She verified S10CNA attempted to give care to the resident by herself and the resident's leg went over the bed and she fell on the floor. On 4/9/19 at 3:03 p.m., S1Administrator stated he was aware of the incident with resident #96, and the seriousness of the incident and the result to the resident. S1Administrator further stated the facility immediately began taking corrective action following the fall and injury. On 4/10/19 at 3:33 p.m., S2DON stated their immediate Plan of Correction was to terminate S10CNA. Then they began in-servicing all staff on two person assist with residents. Their Quality Assurance Performance Improvement (QAPI) included evaluating residents to ensure all residents needing two person assist with incontinent care and turning and repositioning were receiving that level of care. They also randomly selected ten residents a week to observe care and monitor for four weeks, which was completed late March/early April. QAPI for the issue will continue quarterly. Throughout the survey of dates 4/7/19 through 4/10/19, 11 staff members were interviewed on two person assistance with turning and repositioning. Observations were made of staff showing surveyors turning and repositioning residents. Throughout the survey dates of 4/7/19 through 4/10/19, 2 records of 2 residents identified as further investigations for falls in the facility were reviewed. The facility immediately implemented the following actions to correct the deficient practice on 1/31/19: 1. S10CNA Certified Nursing Assistant was terminated. 2. Nursing staff were in-serviced on the proper position/repositioning care to ensure resident's entire body remains on mattress. 3. Once Resident #96 returns to the facility, she will have the assistance of two staff members while receiving incontinent care, turning and repositioning. 4. Audit of residents will be completed to determine those residents that may require two staff members to assist with to reduce the reoccurrence. 5. Ten residents per week for 4 weeks will be chosen to observe and monitor staff. 6. Quality Assurance and Performance protocol was implemented at the same time of the plan of correction, on 1/31/19, the date of the incident. A root cause was identified and a plan of correction was immediately implemented. According to records presented, the Plan of Completion, including the four weeks of observation of residents determined to need two person assist ended 4/4/19. QAPI will continue to be address quarterly to ensure safety with assistance.

Based on record review and interviews, the facility failed to provide the respiratory care needed for treatment of [REDACTED].#1) of 7 residents (#1,#2, #6, #7, #8, #9, #10) requiring treatment of [REDACTED]. This failure resulted in an Immediate Jeopardy situation on 4/28/2017 at 7:40 PM when resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident's admission orders [REDACTED]. Nursing staff never placed the [MEDICAL CONDITION] machine on the resident from 4/28/17 at 7:40 PM until 5/1/17 at 10:45 PM. On 5/1/17 documentation revealed the resident's O2 saturation dropped to 90% at 3:00 PM and continued to drop that evening where documentation revealed an O2 saturation of 82% at 9:20 PM. The resident was transferred to the local hospital with an O2 saturation of 82% at 10:45 PM. Resident #1 was intubated and placed in the ICU (intensive care unit) at the local hospital. The facility administrator was notified of the Immediate Jeopardy on 5/17/2017 at 10:00 AM. A Plan of Removal for the Immediate Jeopardy situation was accepted 05/19/17 at 10:17 AM. The plan included: A. Steps taken to remove the cause of Immediate Jeopardy - Providing [MEDICAL CONDITION] per physician's orders [REDACTED]. Cause: Failure to provide the [MEDICAL CONDITION] per physician's orders [REDACTED]. 1. On 5/1/17 at 11:10 PM, _______ (Resident #1) was removed from Immediate Jeopardy and discharged from ________(the facility) to a __________(name of hospital) in Lake Charles, Louisiana. 2. Director of Nursing or designee will review all inquiries for admission to determine needs for prescribed respiratory equipment. The Director of Nursing or designee will visually confirm that all prescribed equipment is on-site at the facility prior to allowing patients to be admitted to the facility. 3. The Administrator will approve patients for admission to the facility on ce all respiratory equipment prescribed by a physician is received in the facility. 4. Patient's nurse will verify all physician orders [REDACTED]. In the event that an order cannot be followed, the patient's nurse will immediately notify the Physician, Director of Nursing and / or Administrator. Patient's nurse will document the response and instruction provided. 5. Staff training and education completed on 5/18/2017 with RN and LPN staff regarding [MEDICAL CONDITION] and [MEDICAL CONDITION] application, usage, and equipment availability. Emphasis placed on proper notification of the Physician, Director of Nursing and / or Administrator if a physician's orders [REDACTED]. Evidence of staff training attached to this plan of removal. 6. Director of Nursing or designee will perform a daily review beginning 5/18/2017 of all prescribed [MEDICAL CONDITION] and [MEDICAL CONDITION] equipment to confirm physician orders [REDACTED]. Daily review to continue for 60 days to confirm substantial compliance. After the 60-day period, weekly audits will continue on an ongoing basis to maintain substantial compliance. B. Steps taken to remove the cause of Immediate Jeopardy - Provide proper notification of the physician following patient decline. 1. Staff training and education completed on 5/18/2017 with RN and LPN staff regarding the clinical decline in patient status and the required physician notification. Emphasis placed on the immediate urgency of timely notification following a patient's decline in status and the requirement to document the response and instruction provided by the physician. Evidence of staff training attached to this plan of removal. 2. All current residents with a prescribed [MEDICAL CONDITION] and [MEDICAL CONDITION] equipment were assessed for their current status of oxygen saturation on 5/18/17. All results were determined to be within normal limits and properly documented in the patient's charts. All current [MEDICAL CONDITION] and [MEDICAL CONDITION] units were assessed and found to be in proper working order. Evidence of resident audit of oxygen saturation attached to this plan of removal. 3. The Medical Director was contacted on 5/18/17 for clarification on the providing the proper parameters for physician notification of oxygen saturation levels. 4. Beginning 5/19/2017, Director of Nursing or designee will perform a daily review of patient transfers to emergency room due to a decline in status. Verification of timely notification of physician will be assessed and addressed as needed. Daily review will continue on an ongoing basis to ensure substantial compliance. The immediate jeopardy was removed for resident #1 when she was transferred to the local hospital however, the deficient practice remains at a level of harm for Resident #1. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of hospital [MEDICAL CONDITION] progress notes and physician progress notes [REDACTED]. The resident also had a history of [REDACTED]. She had used a [MEDICAL CONDITION] at home but was started on [MEDICAL CONDITION] during hospital stay. Resident required intubation from 4/21 to 4/23/17. After the ventilator was removed, the resident remained in the hospital until 4/28/17 with stable O2 saturation levels between 96 - 100% according to progress notes. Review of Resident #1's nursing home admission orders [REDACTED]. Review of the facility Nurses Notes dated 4/28/2017 - 5/1/2017 revealed the following narratives: 4/28/2017 at 7:40 PM and signed by S5LPN: admitted Resident #1. Vitals: 147/90, 98.2, 97, 20 / weight 316 pounds Put Resident #1 on O2 at 3 Liters nasal cannula. Uses [MEDICAL CONDITION]. States she wants to use her own. Will notify family to please bring hers on 4/29/2017. On 4/29/2017 at 12:30 AM and signed by S8LPN: Vitals: 139/77, 97, 18, 96.8 02 at 3 Liters nasal cannula On 4/29/2017 at 10:30 AM and signed by S7LPN: 02 saturation 97% 02 at 3 Liters nasal cannula On 4/30/2017, no notes were entered by the staff. On 5/1/2017 at 3:00 PM and signed by S5LPN: 02 saturation 90 % 02 at 3 Liters nasal cannula On 5/1/2017 at 7:00 PM and signed by S5LPN: Vitals: 107/56, 96.8, 94, 18 02 saturation 86% 02 at 3 Liters nasal cannula On 5/1/2017 at 8:00 PM and signed by S5LPN: [MEDICAL CONDITION] put to use. Cannot get O2. Put O2 cannula in mouth to assist with 02 sat. 02 saturation 86%. On 5/1/2017 at 9:20 PM and signed by S5LPN: O2 saturation 82% with [MEDICAL CONDITION]. O2 per nasal cannula On 5/1/2017 at 10:00 PM and signed by S5LPN: Called Dr. ___ about not being able to get O2 saturation up. Send to local hospital for care. Written by S5LPN on 5/1/2017 at 10:40 PM: Telephoned local ambulance service for transfer to local hospital emergency room . On 5/1/2017 at 10:42 PM and signed by S5LPN: Called local hospital emergency room . Informed that Resident #1 was being transferred to emergency room for evaluation of O2 saturation being 82% and being so lethargic. On 5/17/17 at 2:43 PM, an interview with concurrent document review was conducted with S2DON during which time she confirmed the narrative notes recorded by S5LPN regarding Resident #1's respiratory status throughout the evening of 5/1/17. S2DON stated she would have notified the physician at 3:00 PM, 5/1/17, when Resident #1's O2 sat reached 90%. She stated the physician should have been notified at that time and certainly under the circumstances that transpired over the following hours (from 3:00 PM to 10:00 PM) resulting in the respiratory compromise of Resident #1 that required transport by ambulance to a local acute care hospital, and later reportedly required intubation for dependent ventilation. During this same interview, S2DON stated that the nurses have been educated on when to notify the physician. She could not provide a specific policy with parameters on when to notify the physician. A review of page 2 of the Hospital Consultation Report dated 5/2/17, indicated that the resident was transferred to a local hospital emergency room where she was intubated for hypercapnic [MEDICAL CONDITION], secondary to a combination of OSA (obstructive sleep apnea syndrome)/OHS (obesity hypoventilatio[DIAGNOSES REDACTED])/PNA (pneumonia) and noncompliance with [MEDICAL CONDITION] at the nursing home and newly diagnosed acute on chronic diastolic and systolic [MEDICAL CONDITION] as assessed by the local hospital's physician. During an interview with S5LPN on 5/16/2017 at 2:30 PM, she confirmed that she worked the 2 PM - 10 PM shift and admitted Resident #1 to the facility at 7:40 PM on 4/28/2017. She stated that she did not use the [MEDICAL CONDITION] machine on the Resident that evening. She stated she tried to put the [MEDICAL CONDITION] on Resident #1 when she returned on 5/1/2017 and the mask did not fit. S5 LPN stated she did not notify physician that the [MEDICAL CONDITION] mask did not fit. In an interview conducted on 5/16/2017 at 3:23 PM, S2DON confirmed Resident #1 arrived via local ambulance service from a local hospital. S2DON was not at the facility on 4/28/2017. Upon her return on 5/2/2017, her investigation into the incident revealed the following: S2DON stated she was told that S1Administrator took the [MEDICAL CONDITION] to a local durable medical equipment supplier and had them put the ordered settings in the machine. Upon return it was discovered that the medium mask did not fit; upon surveyor inquiry as to whether or not any effort was made to acquire a mask that would fit, she responded no. When asked if any effort was made on 4/28/2017, 4/29/2017, 4/30/2017 or 5/1/2017 to acquire a mask that fit so that the Resident could use the [MEDICAL CONDITION], S2DON responded no. She stated that she investigated the incident on 5/2/2017 after Resident #1 had been sent to the hospital. After interviewing all of the staff that was responsible for the Resident's care from 4/28/2017 - 5/1/2017, she stated that they confirmed they did not use the [MEDICAL CONDITION] ordered for Resident #1 during her stay at this facility because the mask did not fit. At 10:38 AM on 5/17/2017, S3ADON confirmed that on the morning of 4/28/2017 she reviewed and evaluated the physician's orders [REDACTED].#1 was eligible to be admitted to the facility. Review of the Physician Admission and Order Form dated 4/27/2017 revealed a primary [DIAGNOSES REDACTED]. On the physician's orders [REDACTED]. S3ADON confirmed that she went to the office of S6Marketing Director before 5:30 PM on 4/28/2017 and retrieved the [MEDICAL CONDITION] machine with attached bag, then brought it to the assigned room for Resident #1. When asked if the [MEDICAL CONDITION] machine had a mask, S3ADON stated that the [MEDICAL CONDITION] machine had a bag with the tubing, but no mask. The facility provided a Philips Respironics, [MEDICAL CONDITION] Auto Bi-Flex which delivers positive airway pressure therapy for the treatment of [REDACTED]. It is for use in the home or hospital /institutional environment. When set in the Auto Bi-level therapy mode, the system will monitor your breathing as you sleep and automatically adjust the pressure to meet your needs. During an interview on 5/17/2017 at 11:07 AM, S1Administrator stated that he took the [MEDICAL CONDITION] to a local durable medical equipment supplier to input the ordered settings in sometime that after noon. He returned with the [MEDICAL CONDITION] machine which had an attached bag and placed it on the desk of S6Marketing Director. He stated that S6Marketing Director gave the programmed [MEDICAL CONDITION] and attached bag to S3ADON sometime before 5:30 PM. During an interview with S2 DON on 5/17/17 at 12:05 PM she stated all of her staff knows the difference between [MEDICAL CONDITION] and [MEDICAL CONDITION] and have had training in usage. She was unable to provide any documentation of staff training and qualification on usage of [MEDICAL CONDITION] or [MEDICAL CONDITION]. At that time, she stated that the facility did not have a policy and procedure on [MEDICAL CONDITION] machine usage. During an interview on 5/17/2017 at 12:45 PM, S6Marketing Director stated she worked admissions and received the admissions paperwork with the [MEDICAL CONDITION] order, the [MEDICAL CONDITION] settings and mask size for Resident #1 on 4/28/2017. She gave a copy of the admission orders [REDACTED]. She also gave a copy of the admission order with the [MEDICAL CONDITION] settings and mask size to S1Administrator around noon. She verified that S1Administrator left some time after noon to bring the [MEDICAL CONDITION] to be programmed and put the [MEDICAL CONDITION] machine with a bag attached on her desk when he returned. The programmed [MEDICAL CONDITION] with the bag attached was given to S3ADON before she left at 5:30 PM for the day. On 5/17/2017 at 2:43 PM S2DON revealed that she had been misinformed about the mask not fitting and after questioning S3ADON, it was revealed that there was not a mask for the [MEDICAL CONDITION] machine in Resident #1's room from 4/29/2017 - 5/1/2017. On 5/17/2017 at 4:00 PM during a telephone interview, S4MedDir was asked if there would have been a different outcome if the resident had been on [MEDICAL CONDITION] from admission to the facility on [DATE] until sent to a local hospital emergency roiagnom on [DATE]. S4MedDir stated, that he did want to make it clear that he had not physically seen the resident, but had reviewed all of the daily progress notes that the local hospital sent to him. A telephone interview on 5/18/2017 at 1:15 PM with S7LPN confirmed that she was the nurse for Resident #1 from 6 AM - 10 PM on 4/29/2017 and 4/30/2017 at the facility. She stated that she did see a physician's orders [REDACTED].#1's room, so she did not put Resident #1 on the machine. She stated she used Resident #1's [MEDICAL CONDITION] machine that the family brought from home on 4/30/2017 When asked if the family had brought Resident #1's [MEDICAL CONDITION] machine S7LPN asked if there was a difference between the [MEDICAL CONDITION] machine and a [MEDICAL CONDITION] machine. According to hospital records the resident had been on a [MEDICAL CONDITION] at home and not a [MEDICAL CONDITION]. During a telephone interview on 5/18/2017 at 2:10 pm, S8LPN confirmed she was the nurse working 10 PM to 6 AM shift with Resident #1. She stated she never saw a physician's orders [REDACTED].#1's room.

Based on interview and record review, the facility failed to promptly notify the physician regarding Resident #1's change in medical status when the resident's O2 saturation began to drop for 1 resident (#1) of 7 residents (#1, #2, #6, #7, #8, #9, #10) requiring treatment of [REDACTED]. This failure resulted in an Immediate Jeopardy situation on 4/28/17 at 7:40 PM for Resident #1, with [DIAGNOSES REDACTED]. The resident's admission orders [REDACTED]. Nursing staff never placed the [MEDICAL CONDITION] machine on the resident from 4/28/17 at 7:40 PM until 5/1/17 at 10:45 PM. On 5/01/17 documentation revealed the resident's O2 saturation dropped to 90% at 3:00 PM and continued to drop that evening where documentation revealed an O2 saturation of 82% at 9:20 PM. The resident was transferred to a local hospital with an O2 saturation of 82% at 10:45 PM. Resident #1 was intubated and placed in the Intensive Care Unit (ICU) at the local hospital. The facility administrator was notified of the Immediate Jeopardy on 5/17/17 at 10:00 AM. A Plan of Removal for the Immediate Jeopardy situation was accepted 05/19/17 at 10:17 AM. The plan included: A. Steps taken to remove the cause of Immediate Jeopardy - Providing [MEDICAL CONDITION] per physician's orders [REDACTED]. Cause: Failure to provide the [MEDICAL CONDITION] per physician's orders [REDACTED]. 1. On 5/1/17 at 11:10 PM, _______ (Resident #1) was removed from Immediate Jeopardy and discharged from ________(the facility) to a __________(name of hospital) in Lake Charles, Louisiana. 2. Director of Nursing or designee will review all inquiries for admission to determine needs for prescribed respiratory equipment. The Director of Nursing or designee will visually confirm that all prescribed equipment is on-site at the facility prior to allowing patients to be admitted to the facility. 3. The Administrator will approve patients for admission to the facility on ce all respiratory equipment prescribed by a physician is received in the facility. 4. Patient's nurse will verify all physician orders [REDACTED]. In the event that an order cannot be followed, the patient's nurse will immediately notify the Physician, Director of Nursing and / or Administrator. Patient's nurse will document the response and instruction provided. 5. Staff training and education completed on 5/18/2017 with RN and LPN staff regarding [MEDICAL CONDITION] and [MEDICAL CONDITION] application, usage, and equipment availability. Emphasis placed on proper #notification of the Physician, Director of Nursing and / or Administrator if a physician's orders [REDACTED]. Evidence of staff training attached to this plan of removal. 6. Director of Nursing or designee will perform a daily review beginning 5/18/2017 of all prescribed [MEDICAL CONDITION] and [MEDICAL CONDITION] equipment to confirm physician orders [REDACTED]. Daily review to continue for 60 days to confirm substantial compliance. After the 60-day period, weekly audits will continue on an ongoing basis to maintain substantial compliance. B. Steps taken to remove the cause of Immediate Jeopardy - Provide proper notification of the physician following patient decline. 1. Staff training and education completed on 5/18/2017 with RN and LPN staff regarding the clinical decline in patient status and the required physician notification. Emphasis placed on the immediate urgency of timely notification following a patient's decline in status and the requirement to document the response and instruction provided by the physician. Evidence of staff training attached to this plan of removal. 2. All current residents with a prescribed [MEDICAL CONDITION] and [MEDICAL CONDITION] equipment were assessed for their current status of oxygen saturation on 5/18/17. All results were determined to be within normal limits and properly documented in the patient's charts. All current [MEDICAL CONDITION] and [MEDICAL CONDITION] units were assessed and found to be in proper working order. Evidence of resident audit of oxygen saturation attached to this plan of removal. 3. The Medical Director was contacted on 5/18/17 for clarification on the providing the proper parameters for physician notification of oxygen saturation levels. 4. Beginning 5/19/2017, Director of Nursing or designee will perform a daily review of patient transfers to emergency room due to a decline in status. Verification of timely notification of physician will be assessed and addressed as needed. Daily review will continue on an ongoing basis to ensure substantial compliance. The immediate jeopardy was removed for Resident #1 when she was transferred to the local hospital, however the deficient practice remains at a level of harm for Resident #1. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Nurses Notes dated 4/28/2017 - 5/1/2017 revealed the following narratives: 4/28/2017 at 7:40 PM and signed by S5LPN: admitted Resident #1. Vitals: 147/90, 98.2, 97, 20 / weight 316 pounds Put Resident #1 on O2 at 3 Liters nasal cannula. Uses [MEDICAL CONDITION]. States she wants to use her own. Will notify family to please bring hers on 4/29/2017. On 4/29/2017 at 12:30 AM and signed by S8LPN: Vitals: 139/77, 97, 18, 96.8 02 at 3 Liters nasal cannula On 4/29/2017 at 10:30 AM and signed by S7LPN: 02 saturation 97% 02 at 3 Liters nasal cannula On 4/30/2017, no notes were entered by the staff. On 5/1/2017 at 3:00 PM and signed by S5LPN: 02 saturation 90 % 02 at 3 Liters nasal cannula On 5/1/2017 at 7:00 PM and signed by S5LPN: Vitals: 107/56, 96.8, 94, 18 02 saturation 86% 02 at 3 Liters nasal cannula On 5/1/2017 at 8:00 PM and signed by S5LPN: [MEDICAL CONDITION] put to use. Cannot get O2. Put O2 cannula in mouth to assist with 02 sat. 02 saturation 86%. On 5/1/2017 at 9:20 PM and signed by S5LPN: O2 saturation 82% with [MEDICAL CONDITION]. O2 per nasal cannula On 5/1/2017 at 10:00 PM and signed by S5LPN: Called Dr. ___ about not being able to get O2 saturation up. Send to local hospital for care. Written by S5LPN on 5/1/2017 at 10:40 PM: Telephoned local ambulance service for transfer to local hospital emergency room . On 5/1/2017 at 10:42 PM and signed by S5LPN: Called local hospital emergency room . Informed that Resident #1 was being transferred to emergency room for evaluation of O2 saturation being 82% and being so lethargic. In an interview conducted on 5/16/2017 at 3:23 PM, S2DON confirmed Resident #1 arrived via local ambulance service from a local hospital. S2DON was not at the facility on 4/28/2017. Upon her return on 5/2/2017, her investigation into the incident revealed the following: S2DON stated she was told that S1Administrator took the [MEDICAL CONDITION] to a local durable medical equipment supplier and had them put the ordered settings in the machine. Upon return it was discovered that the medium mask did not fit When asked if any effort was made on 4/28/2017, 4/29/2017, 4/30/2017 or 5/1/2017 to acquire a mask that fit so that the Resident could use the [MEDICAL CONDITION], S2DON responded no. She stated that she investigated the incident on 5/2/2017 after Resident #1 had been sent to the hospital. After interviewing all of the staff that was responsible for the Resident's care from 4/28/2017 - 5/1/2017, she stated that they confirmed they did not use the [MEDICAL CONDITION] ordered for Resident #1 during her stay at this facility because the mask did not fit. On 05/17/17 at 2:43 PM, an interview with concurrent document review was conducted with S2DON during which time she confirmed the narrative notes recorded by S5LPN regarding Resident #1's respiratory status throughout the evening of 05/01/17. S2DON stated she would have notified the physician at 3:00 PM, 05/01/17, when Resident #1's O² sat reached 90%. She stated the physician should have been notified at that time and certainly under the circumstances that transpired over the following hours (from 3:00 PM to 10:00 PM) resulting in the respiratory compromise of Resident #1 that required transport by ambulance to a local acute care hospital, and later reportedly required intubation for dependent ventilation. On 05/17/17 at 3:00 PM, an interview with concurrent document review was conducted with S5LPN during which time she confirmed her narrative notes regarding Resident #1's respiratory status throughout the evening of 05/01/17. Furthermore, S5LPN verified she did not notify the physician between the hours of 3:00 PM and 10:00 PM, when she reported Resident #1's O² sat steadily declined, with the assistance of 3 liters O² delivered via nasal cannula, from 90% to 82%, in addition to the symptomatic reports indicating Resident #1 was lethargic.

Based on observation, interview and record review the facility failed to assure that the resident who enters the facility without pressure sores does not develop pressure sores and the resident who has pressure sores receives necessary treatment and services to promote healing for one resident (Resident #192) out of 5 residents (#26, #30, #56, #95, #192) who were investigated for pressure ulcers out of 26 residents with pressure ulcers as reported by the facility per the Form 672, 13 of which were developed in the facility. This deficient practice resulted in actual harm when Resident #192 entered the facility on 4-25-16 with no pressure ulcers identified on the initial nursing assessment and developed a deep tissue injury to the left heel on 4-28-16 measuring 4.9 centimeters (cm) by 6 cm. The facility did not have any documentation of monitoring measures such as floating of the heels and use of heel protectors after the pressure ulcer was identified. The pressure ulcer progressed to a Stage 3 pressure ulcer on 5-2-16. Observations on 5-24-16 and 5-25-16 revealed that the heels were not floated and there were no heel protectors in place. Treatment was changed on 5-23-16 because the wound was not progressing and developed foul-smelling, purulent drainage and required consult of wound care specialists on 5-26-16. The resident reported that she experienced pulsating pain to the heel. This deficient practice had the potential to affect the 113 residents reported by the facility on the form 672 as being in a chair all or most of the time. Findings; Resident #192 Record review revealed the Resident was admitted to the facility from the behavioral hospital on 4-25-16 with [DIAGNOSES REDACTED]. The review of the admission nursing assessment revealed that the resident's skin looked good and the only concern noted was [MEDICAL CONDITION] to both feet. The Braden scale for predicting pressure sore risk was completed by S12LPN, Case Manager on 4-25-16 and the resident was assessed as being at moderate risk for pressure sore development with a score of 14. The review of the interim plan of care dated 4-25-16 revealed that Resident #192 was at risk for impaired skin integrity related to impaired mobility, use of anti-anxiety/antidepressant medications, and required assistance for repositioning and transfers. There were interventions listed which included provision of a pressure relieving mattress, encourage resident to get out of bed, reposition frequently to relieve pressure, and provide staff icon to alert them of residents at a high risk for developing pressure ulcers. Further review revealed nurses' treatment notes dated 4-28-16 written by S5LPN (Licensed Practical Nurse), treatment nurse, which indicated that staff informed her that the resident had an area noted to the left heel. The area was assessed by S1DON (Director of Nursing) and was purple in color and measured 4.9 cm x 6.0 cm. The physician and family were notified and an order was obtained for [MEDICATION NAME] to the area every other day. The review of the interim careplan revealed that the problem of DTI (deep tissue injury) to the left heel was added to the careplan on 4-28-16 and the only interventions listed were to provide wound care as ordered and to notify the MD (Medical Doctor) of worsening or non-healing. The treatment record indicated that the treatment was for [MEDICATION NAME] to Stage 3 on the left heel on 5-2-16. The physician's assessment dated [DATE] was reviewed and there was documentation that the resident had a Stage 3 wound to the left heel which was dressed. The physician had also written for wound care and to elevate the left foot off of the bed. There was no documentation to support that the order to elevate the left foot was put on the physician's orders [REDACTED]. There was no documentation of an assessment to the wound until 5-4-16, when the wound was assessed as a Stage 3 which measured 4.9 cm x 6 cm (centimeters) with no exudate, no odor, and with black/brown eschar. Further review disclosed that on 5-10-16 S5LPN, treatment nurse documented on the nurse's treatment notes that the physician was notified of a [MEDICATION NAME] allergy and the treatment was changed to Santyl to the Stage 3 pressure ulcer on the left heel. The wound was assessed again on 5-11-16 and it measured 4.5 cm x 6.4 cm with serosanguineous exudate with slight odor and no change was documented under response to treatment. The assessment on 5-18-16 indicated that the pressure ulcer was 4.3 cm x 6.2 cm with no exudate and improved was marked under response to treatment. The nurse's treatment note dated 5-23-16 showed that the physician was notified that the wound was not progressing with current treatment and had foul-smelling, purulent drainage and the order was changed to Mesalt to the left heel. The review of the assessment dated [DATE] revealed that the Stage 3 pressure ulcer was 6 cm x 6 cm with slight odor and the wound had deteriorated. The review of the careplan dated 5-5-16 revealed that the problem with the heel began on 4-28-16 and a heel protector was to be on the left foot while in bed. An observation was made of wound care on 5-24-16 at 9:10 a.m. with S5LPN treatment nurse. When the room was entered, the resident was lying in bed and she did not have a heel protector in place, the left heel was flat on the bed and was not elevated and there was no heel protector visible in the room at that time. Another observation was made on 5-24-16 at 9:45 a.m. and the resident's heels were flat on the bed and there were no heel protectors in place. An interview was held with S33 CNA (Certified Nursing Assistant) on 5-24-16 at 9:55 a.m. and she stated she was caring for Resident #192. She stated that she thought she had wounds, but was not sure where. She said that she does have to be turned every 2 hours, but did not think she had any extra things to remember about her care. Another observation was done on 5-24-16 at 3:45 p.m. and the resident was asleep in the bed, her heels were resting on the bed and were not floated and there were no heel protectors in place. An interview was held with S34 CNA on 5-24-16 at 3:45 p.m. and she stated that she usually worked weekend doubles and she was not familiar with the resident. She stated she would have to ask the nurse about her needs. An observation was done on 5-25-16 at 6:30 a.m. and the resident was in the bed with her heels flat on the bed and no heel protectors were in place. S35 CNA verified the above observation. S13LPN, ADON (Assistant Director of Nursing) also verified that the heels were flat on the bed with no heel protectors in place on 5-25-16 at 6:45 a.m. S13LPN, ADON found a heel protector in a drawer in the room. S33 CNA was again interviewed on 5-25-16 at 6:50 a.m. and she stated that she was not aware that Resident #192 was to have heel protectors in place. An interview was held with S5LPN, treatment nurse on 5-25-16 at 8:15 a.m. She stated that there was no documentation to show that the resident's heels were uploaded. She stated that she did not need a physician's orders [REDACTED]. She stated that when the wound was assessed as a Stage 3, the opened area was very small. She stated that at that point, she did not realize there were no heel protectors in place and she never noticed that the heels were not floated. She stated that on 5-11-16, she got an order for [REDACTED]. An interview was held with S1DON on 5-25-16 at 8:20 a.m. and she stated that she had assessed the area on the left heel on 4-28-16 and it was purple and soft. She stated that from her assessment she did expect this area to open up. S1DON said that the admitting nurse did not identify any issues with skin on 4-25-16. She also stated that the heel protectors and the floating of the heels should have been on the monitoring sheets and verified they were not, but said that the nurse should know about this from verbal communication. An interview was held with S25LPN on 5-25-16 at 9:20 a.m. and she stated that she was not aware before today that Resident #192 was to have heel protectors on when she was in the bed. An interview was held with Resident #192 on 5-25-16 at 9:20 a.m. and she stated that she did experience pain to the heel and it was a pulsating pain, sometimes worse than other times. She stated that she did experience pain when the dressing was changed on the heel. The treatment note of 5-23-16 had documentation that the area on the heel had foul-smelling and purulent drainage with new treatment orders obtained. There was no documentation that the facility was monitoring the measures such as floating the heels (which was physician's orders [REDACTED]. The review of the assessment done on 5-25-16 revealed that the area was 6 cm x 6 cm with slight odor and had deteriorated.

Based on interview, medical record review, and a review of the resident's personal diary, the facility failed for 1 (#4) out of 7 sampled residents reviewed for pain management to: (1) obtain this resident's prescribed pain medication and anti anxiety medication until five days after admission to the facility; (2) recognize and implement other non medicinal interventions to assist the resident in relieving his pain and anxiety; (3) document accurate and on going assessments of the resident's pain and anxiety level. The resident experienced actual harm when he had inadequate pain control and anxiety for five consecutive days. (4) The facility also failed to assess and monitor 1 (#3) resident following the administration of an antipsychotic out of 7 sampled residents and 1 random sampled resident. This deficient practice had the potential to affect 5 residents who reside in the facility and have orders for anti-psychotic medications according to the number provided by S1RN. Findings: Resident #4 was admitted from his home by his personal physician on 8/26/11 at 4: 00 p.m. with multiple [DIAGNOSES REDACTED]. An interview was conducted with resident #4 on 9/20/11 at 3:30 p.m. He stated he had "chronic" back and leg pain, and had been on pain medication, "[MEDICATION NAME]" for a long time. He stated he had problems with his pain for about a week when he first got here because he was not getting his prescribed pain medicine or nerve medicine because the facility did not have it. He stated he was told by his nurses that they needed a "hard script" for these medications, his personal doctor had not provided them with the script and he had not been evaluated by the facility doctor so this doctor would not give him a prescription. He stated he came to the facility on a Friday and he did not get his pain medicine or his nerve medicine for the entire weekend. He further stated they were giving him extra strength Tylenol and it did not relieve his pain. He stated he also didn't sleep well at night and sometimes he had to have therapy in his room because he hurt too bad to go to therapy. When asked if the staff came in regularly to ask him about his pain he said "they do now." He further stated when he would tell them he was hurting they would just keep telling him they needed a hard script to get his medicine. He stated his wife had a fight with one of the nurses who told his wife she did not think the pain med was needed. He stated it was very upsetting to him and because he didn't get his nerve medicine either, he felt even worse. During an interview of S2DON on 9/20/11 at 5:30 p.m., she stated the facility procedure for potential new admissions was to review the resident's medical records and complete an assessment at his/her home prior to admission to determine their eligibility for the nursing home. She further stated S4, Administrator, the assigned ADON and herself met after the medical record review and home assessment were completed to determine if a resident's needs could be met and what items were needed prior to the resident's admission to the facility. She stated, the admissions coordinator was notified if other documents or equipment was needed prior to the resident's admission to the facility. S5ADON was present at this interview and confirmed that she had done a home visit with resident #4 prior to his admission to the facility. S2DON stated there was no formal documentation of this home visit. The resident's medical records were reviewed. A fax cover letter for receipt of home health documents was dated 8/25/11. These home health documents and other hospitalization records had multiple entries about the resident ' s depression, [MEDICAL CONDITION] disorder and his pain level assessments of 6-8. The Statement of Medical Status dated 8/19/11 revealed resident #4's medication regime included [MEDICATION NAME] 1 mg three (3) times per day and [MEDICATION NAME] 10/650 mg every 6 hours. A review of the speech therapy evaluation on 8/29/11 revealed the resident was an "I" (independent) in all areas of language and communication abilities, was able to follow multi step commands without difficulty, had mild problem solving difficulties and moderate memory problems. During an interview of S7LPN on 9/21/11 at 11:30 a.m., she stated resident #4 had no difficulties communicating his needs. Subsequent interviews with S8LPN, and CNA's S9, S10, and S11 conducted on 9/21/11 between 2:10 p.m. and 2:45 p.m. confirmed resident #4 could easily communicate his needs. The physician orders [REDACTED].; and [MEDICATION NAME] 1 mg - po tid. The September, 2011 physician orders [REDACTED]. A review of the Nurse's Notes revealed the resident arrived to the facility at 5:00 p.m. on 8/26/11. There was no documentation of the resident's pain level for this time period. It also read: "mood is content." This note was signed by S8LPN. The admission nursing evaluation also done by S8LPN at 5:00 p.m. revealed under the section "pain" - frequency- there was an "X" marked for frequently; intensity was marked as an "8" on a scale of 0 (none) - 10 (worst). A review of the resident's MAR for August had no indication of pain relief medication being given to the resident for this "8" pain. The next nurse s notes entry of 6:00 p.m. by S8LPN read: "Denies pain at this time." Further review of the medical records revealed a pain evaluation had been completed by S8LPN on 8/26/11. There was no documentation of the time of this evaluation. In the section titled "Pain Profile" under "Past Pain Interventions" there was a checkmark at "E" for prescribed medications. There was a check mark at "N" for over - the- counter medications and also an "N" for non-med interventions. According to this form' s key, these responses indicated prescribed medications were the only pain intervention resident #4 verbalized to be effective in this evaluation. Further nurse's note review indicated S8LPN had called resident #4's admitting physician regarding "hard scripts for residents narcs " ...The notes also read an alternative physician had phoned back. This Nurse's note entry dated 8/26/11 at 7:00 pm also read that this physician's response was, "He will have to wait until Monday when (name of admitting physician) can clarify orders." Further review of the nurse's notes by S8LPN for 8/26/11 revealed the resident had been administered the over - the- counter medication Tylenol at 7:45 p.m. for the resident's complaint of back pain rated by the resident as a "6" on a scale of 0-10. The PRN Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" 4 " and not a "6 " . The nurse's notes for this time period indicated the resident was administered Tylenol at 12:00 a.m. for general pain and again at 5:00 a.m. for the resident's complaint of back pain. This note further read: 'Res states "Are my meds here." Explained to resident awaiting hard script from (admitting physician's name) ' Further review of the resident's nurse's notes revealed no documentation of an assessment of the resident's pain or lack of pain from this 5:00 a.m.entry until an entry of 10-6 on 8/29/11 which read: 0 c/o pain.' Resident #4's pain status was not documented again until 8/30/11 in the 9:00 p.m. note. It read: "Resident's wife phoned regarding arrival of pain medication. She was told the medications were in and will be administered at the next scheduled time. Wife becomes upset. This nurse explained the importance of keeping the medication on the scheduled time." The entry at 9:15 p.m. read: " Resident notified that pain medication will be given at the next scheduled time " ... The entry at 11:15 p.m. read ... " c/o back pain, medicated for pain ... " The MAR indicated [REDACTED]. A review of the MAR indicated [REDACTED]#4 ' s prescribed pain medication was not administered until 5 days after it was ordered. Further review of the nurse's notes read that the resident received pain medication at 8:00 a.m. with his "routine am meds." This was 11 hours after the resident's wife had been informed his pain medication was in. The MAR indicated [REDACTED]. On 9/21/11 at 1:30 p.m. resident was again interviewed after reviewing the medical record. He again stated he would tell the nurses that the Tylenol didn't work and they would just tell him they could not get his prescribed medicine because no hard script. He stated the pain was mostly in his back and leg and was about a " 7-8." When asked what the pain was like, he stated it was an aching shooting pain. He stated the staff didn't try to help him reposition or offer any other assistance to relieve his pain just kept telling him he could not get his ordered medications until his doctor sent what was needed. He stated "I was really upset especially because I didn't get my nerve medicine either." Said my wife kept a notebook. The resident gave this surveyor verbal consent to review his bedside diary. There were multiple entries from the date of admission to this survey. It read: 8/28 - not doing well at all;8/29 - no pain medication yet. An interview was conducted with resident #4's wife on 9/21/11 at 1:40 p.m. She stated she had tried to intervene with the facility about her husband's pain. She stated he was always in pain, was nervous and had really had a rough time until they had they obtained his medicine. She stated that one of the nurses had told her that she did not think her husband was having pain. She further stated she had been concerned about complaining because her husband was afraid he would be treated differently. She also stated she had kept a diary to help when friends came to visit. She stated she had made some notes about her husband in the diary. She stated her husband had a history of [REDACTED]. When asked , if anyone from the facility had come to their home to evaluate her husband before he was admitted to the nursing home, she stated "No." She further stated that she had offered to go to the physician's office to get the "hard script" that she was told was needed to get her husband's pain and nerve medicine but was told no. She further stated after her husband had gone for the entire weekend without his medication, she was told by the nurses that the facility doctor was more easily accessible than a "regular" doctor, so we changed. A review of documents confirmed a physician change request had been completed. This request was dated 8/30/11, 4 days after the resident ' s admission to the facility. She further stated she had become very upset when her husband had called her in pain and told her his medicine had come in and they did not want to give it to him. She stated the nurse told her he could not get his around the clock medicine because it needed to stay on the scheduled time it was supposed to be given. The review of the Nurse's notes confirmed the resident's wife had been told this on 8/30/11 at 9:00 p.m. During an interview of S8LPN on 9/21/11 at 2:10 p.m. she confirmed she had worked the Friday evening when the resident was admitted ,and again on the following Monday. She confirmed resident #4 did not get his [MEDICATION NAME] or [MEDICATION NAME] on any of those dates because they could not get the medication filled. She further stated she had not notified the charge nurse or asked her to assist with obtaining the resident's medication because she had called the resident's physician who informed her he would not send a "hard script" for this resident because he did not know the resident. She confirmed the physician had told her it would have to wait until Monday and ordered Tylenol prn for his pain. She stated she did not call the Medical Director to get a hard script. She further stated she did not think the resident was in pain because he did not complain. When asked what the resident's pain level was throughout her shift, she stated she had not asked and once again stated he did not complain of pain. When asked what the resident's mood was like, she stated she could not recall any problems. When asked what type of behavior monitoring tool was being used for the resident, she did not answer. Upon review of the resident's record, she confirmed no monitoring tool was evident for the month of August, 2011. During an interview of S11CNA on 9/21/11 at 2:45 p.m., she stated she had worked the weekend when resident #4 was admitted . She stated he would not outwardly tell you he had pain. She further stated he moaned when he moved in bed and if you asked him if he was in pain, he would say "yes." She further stated she would tell the nurse if the resident was hurting. She also stated he would occasionally get confused, and didn't talk very much when he first came in. Stated he seemed like he was scared at first. A review of the staffing schedule indicated S11CNA had worked with resident #4 on the evening shift on Sunday, 8/28/11. An interview was conducted with S12LPN on 9/21/11 at 3:00 p.m. She confirmed she had worked the first weekend resident #4 was in the facility and had not given him his [MEDICATION NAME] or [MEDICATION NAME] as ordered because they were not available. She stated she had not notified the charge nurse of the situation nor had she contacted the DON or any other facility administrator to assist with getting the resident's medications. She stated she had not called the Medical Director either. She stated she had not asked the resident what his pain level was, and further stated "he wasn't complaining of pain to me." Further interview was conducted with S2DON on 9/21/11 at 10:55 a.m. When asked how the facility assures the resident has what is needed prior to admission to the facility, she again stated administrative staff met, and reviewed medical records including the Statement of Medical Status. She stated the family was responsible for getting a "hard script" from the doctor if the resident was coming from home. She stated usually the admission coordinator took care of this. She further stated if a resident showed up without the needed script, a call would be made to the admitting physician and he could fax a script to the pharmacy to get the medication and send the "hard script" to the facility. S6, Admissions coordinator stated at 11:10 a.m. on 9/21/11 that she "never" instructed a family member to get a "hard script " and further stated she would call the physician and she would go pick up the prescription. She stated that she did not remember trying to get a hard script for resident #4, and also stated she kept no documentation of her interventions as admissions coordinator. On 9/21/11 at 1:10 p.m., the medical record of resident #4 was reviewed with S2DON. She stated she had not been notified that the medications of [MEDICATION NAME] and [MEDICATION NAME] for resident #4 were not available. She stated she should have been notified. She further stated the LPN should have notified the charge nurse if there was a problem obtaining the resident's medications. She confirmed the medical director was not called to intervene when the resident's physician would not provide the necessary prescription. On 9/21/11 at 3:30 p.m., S2DON confirmed resident #4 should not have been admitted to this facility on 8/26/11 without the availability of [MEDICATION NAME] or [MEDICATION NAME]. She further stated since he was coming from home and not another medical facility, his admission should have been delayed to assure his medication needs could be met. (4) Resident #3: A record review revealed this resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nurse documented that the resident seemed a little agitated and anxious. The nurse administered [MEDICATION NAME] to the resident and documented the resident tolerated it well. A policy was requested from S2 DON for the use of this medication and at this time on 9-21-2011 at 10:45 a.m., S2 was interviewed and she stated a PRN [MEDICAL CONDITION] medication flow record should be completed when the medication was given. She reviewed the record and stated she was unable to find one that had been documented when the [MEDICATION NAME] was given 9-5-2011. S1RN provided a copy of the PRN [MEDICAL CONDITION] Medication Flow Record and the record showed that the pre-administration assessment of the resident should include an attempt to eliminate any physiologic causes for the behavior, an attempt to eliminate any environmental causes, an attempt to counteract the resident's behavior and if the physician had approved the [MEDICAL CONDITION] medication interventions. There was no documentation to show this had been done. The [MEDICAL CONDITION] Medication Flow Record also showed for post-administration assessment that vital signs and behaviors were to be documented after 15 minutes, 30 minutes, 1 hour and 2 hours. There was no documentation of vital signs until 1 hour and 40 minutes after the [MEDICATION NAME] was given, however, the resident was having [MEDICAL CONDITION] at that time and ended up going to the hospital for evaluation. During a telephone interview on 9-21-2011 at 10:50 a.m. with staff S3LPN, the nurse who administered the [MEDICATION NAME], she stated she gave [MEDICATION NAME] to this resident, however, she did not document on a [MEDICAL CONDITION] Drug Monitoring Form used for assessment as ordered by the physician. No documentation was found in the record that she assessed this resident prior to the administration of [MEDICATION NAME] nor that she assessed the resident's condition after the [MEDICATION NAME] was administered.

Based on interview, and record review, the facility failed to provide care and services for residents to meet their highest practical well-being. Based upon the Louisiana Revised Statutes, Section 961 of Chapter 11 reads: A Licensed Practical Nurse must practice practical nursing in accordance with the standards normally expected... This would include assessing the residents needs and being an advocate for the resident until they reach their highest practical well-being. The facility failed: (1) to implement and document consistent, accurate assessments of the pain and behavioral status of 1 (#4) out of 7 sampled residents reviewed for pain management. This resident experienced actual harm when the facility failed to recognize the resident's pain and anxiety and when the facility failed to provide appropriate interventions to minimize the resident's uncontrolled pain and anxiety for a period of 4 consecutive days. Findings: Resident #4 was admitted on Friday, 8/26/11 at 4:00 p.m. with multiple [DIAGNOSES REDACTED]. An interview was conducted with resident #4 on 9/20/11 at 3:30 p.m. He stated he had " chronic " back and leg pain, and had been on pain medication, " [MEDICATION NAME] " for a long time. He stated he had problems with his pain for about a week when he first got here because he was not getting his prescribed pain medicine or nerve medicine because the facility did not have it. He stated he came to the facility on a Friday and he did not get his pain medicine or his nerve medicine for the entire weekend. He further stated they were giving him extra strength Tylenol and it did not relieve his pain. He stated he also didn't sleep well at night and sometimes he had to have therapy in his room because he hurt too bad to go to therapy. When asked if the staff came in regularly to ask him about his pain he said " they do now. " He stated his wife had a fight with one of the nurses who told his wife she did not think the pain medicine was needed. He stated it was very upsetting to him and because he didn't get his nerve medicine either, he felt even worse. The medical records for resident #4 were reviewed. A review of the residents Statement of Medical Necessity dated 8/19/11 revealed resident #4's medication regime that included [MEDICATION NAME] 1 mg three (3) times per day and [MEDICATION NAME] 10/650 mg every 6 hours. The physician orders [REDACTED].; and [MEDICATION NAME] 1 mg - po tid. The September, 2011 physician orders [REDACTED]. A review of the Nurse's Notes revealed the resident arrived to the facility at 5:00 p.m. on 8/26/11. There was no documentation of the resident's pain level for this time period. It also read: "mood is content." This note was signed by S8LPN. The admission nursing evaluation also done by S8LPN at 5:00 p.m. revealed under the section "pain" - frequency- there was an " X " marked for frequently; intensity was marked as an "8" on a scale of 0 (none) - 10 (worst). Further review of the medical records revealed a pain evaluation had been completed by S8LPN on 8/26/11. There was no documentation of the time of this evaluation. In the section titled "Pain Profile" under "Past Pain Interventions" there was a checkmark at "E" for prescribed medications. There was a check mark at "N" for over - the- counter medications and also a "N" for non-med interventions. According to this form's key, these responses indicated prescribed medications were the only pain intervention resident #4 verbalized to be effective in this evaluation. The next nurse's notes entry of 6:00 p.m. by S8LPN read: "Denies pain at this time." Further nurse's note review indicated S8LPN had called resident #4's admitting physician regarding "hard scripts for residents narcs" ...This Nurse's note entry dated 8/26/11 at 7:00 pm also read that this physician's response was, "He will have to wait until Monday when (name of admitting physician) can clarify orders." Further review of the nurse's notes by S8LPN for 8/26/11 revealed the resident had been administered the over the-counter medication Tylenol at 7:45 p.m. for the resident's complaint of back pain rated by the resident as a "6" on a scale of 0-10. The PRN Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"4" and not a "6". When the resident was administered Tylenol again at 5:00 a.m.on 8/27/11 the nurse's note note read: 'Res states "Are my meds here." Explained to resident awaiting hard script from (admitting physician's name). Further review of the resident's nurse's notes revealed no documentation of an assessment of the resident's pain or lack of pain from this 5:00 a.m. entry until an entry of 10-6 on 8/29/11 which read: "0 c/o pain." Resident #4's pain status was not documented again until 8/30/11 in the 9:00 p.m. note. It read: "Resident's wife phoned regarding arrival of pain medication. She was told the medications were in and will be administered at the next scheduled time. Wife becomes upset. This nurse explained the importance of keeping the medication on the scheduled time." The entry at 9:15 p.m. read: "Resident notified that pain medication will be given at the next scheduled time" ... The entry at 11:15 p.m. read ... "c/o back pain, medicated for pain ..." The MAR indicated [REDACTED]. During an interview of S8LPN on 9/21/11 at 2:10 p.m. she confirmed she had worked the Friday evening when the resident was admitted ,and again on the following Monday. She confirmed resident #4 did not get his [MEDICATION NAME] or [MEDICATION NAME] on any of those dates. She stated she had obtained an order for [REDACTED]. She further stated she did not think the resident was in pain because he did not complain. When asked what the resident's pain level was throughout her shift, she stated she had not asked and once again stated he did not complain of pain. When asked what the resident's mood was like, she stated she could not recall any problems. When asked what type of behavior monitoring tool was being used for the resident, she did not answer. Upon review of the resident's record, she confirmed no monitoring tool was evident for the month of August, 2011. During an interview of S11CNA on 9/21/11 at 2:45 p.m., she stated she had worked the weekend when resident #4 was admitted . She stated he would not outwardly tell you he had pain. She further stated he moaned when he moved in bed and if you asked him if he was in pain, he would say "yes ". She also stated he would occasionally get confused, and didn't talk very much when he first came in. She stated he seemed like he was scared at first. A review of the staffing schedule indicated S11CNA had worked with resident #4 on the evening shift on Sunday, 8/28/11. An interview was conducted with S12LPN on 9/21/11 at 3:00 p.m. She confirmed she had worked the first weekend resident #4 was in the facility and had not given him his [MEDICATION NAME] or [MEDICATION NAME]. She stated she had not asked the resident what his pain level was, and further stated "he wasn't complaining of pain to me ". On 9/21/11 at 1:30 p.m. resident was again interviewed. He again stated he would tell the nurses that the Tylenol didn't work and they would just tell him they could not get his prescribed medicine because there was no hard script. He stated the pain was mostly in his back and leg and was about a "7-8" When asked what the pain was like, he stated it was an aching shooting pain. He stated the staff didn't try to help him reposition or offer any other assistance to relieve his pain, just kept telling him he could not get his ordered medications until his doctor sent what was needed. He stated "I was really upset especially because I didn't get my nerve medicine either." He said my wife kept a notebook. The resident gave this surveyor verbal consent to review his bedside diary. There were multiple entries from the date of admission to this survey. It read: 8/28- not doing well at all; 8/29 - no pain medication yet. An interview was conducted with resident #4's wife on 9/21/11 at 1:40 p.m. She stated he was always in pain, was nervous and had really had a rough time until they had they obtained his medicine. She stated that one of the nurses had told her that she did not think her husband was having pain. She stated her husband had a history of [REDACTED]. She further stated that after her husband had gone for the entire weekend without his medication. She further stated she had become very upset when her husband had called her in pain and told her his medicine had come in and they did not want to give it to him. She stated the nurse told her he could not get his around the clock medicine because it needed to stay on the scheduled time it was supposed to be given. The review of the Nurse's notes confirmed the resident's wife had been told this on 8/30/11 at 9:00 p.m.

Based on observation, record review and interview,the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents by failing to: 1. Ensure the use of an appropriate/safe device for ambulation/mobility, and 2. Ensure adequate supervision during ambulation. for one resident (#183) out of 4 residents reviewed for accidents and hazards, out of a total sample of 46. This deficient practice caused actual harm to resident #183 when the nursing staff failed to competently identify the safety risk of resident #183 using a walker for ambulation to a local center for dialysis treatment when the resident was using the walker following his dialysis treatment, and when staff failed to adequately supervise the resident with a one person assist. The resident fell . This fall ultimately resulted in the resident being hospitalized for [REDACTED]. The resident was hospitalized from [DATE] to 8/6/11, returning with orders to use an immobilizer on his right knee/leg. Findings: Resident #183 was admitted to the nursing home on 6/23/11 with [DIAGNOSES REDACTED]. The resident also presented with dementia, Hypertensive [DIAGNOSES REDACTED], Chronic Obstructive Pulmonary Disease, Anemia, Benign prostatic hypertrophy, elevated prostate specific antigen and Chronic hypertension. The resident received dialysis on Monday, Wednesday and Friday. Resident #183 also had an abnormality of gait, difficulty walking and had recently received a session of chemotherapy. Review of the Falls and Fall Risk Managing policy indicated ... based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes, to try to prevent the resident from falling, and try to minimize complications from falls. According to the resident ' s care plan, he was at high risk for falls on admission. Review of the resident's care plan revealed a problem listed was Potential for falls/injury r/t weakness/dialysis... Review of a nurses ' note dated 8/1/11 revealed the resident left the facility at 8:00 a.m. in stable condition going to the dialysis center for dialysis treatment. There was no assessment completed indicating the use of a walker as appropriate or safe for the resident to use prior to and after dialysis treatments. Review of an incident and accident report dated 8/1/11 and timed 4:30 p.m., revealed the resident had a fall in the parking lot of the dialysis center while using a walker. During an Interview with S19Transportation/CNA, she stated she brought resident #183 to a local dialysis center for treatment. She indicated resident #183 usually used a wheelchair, but he used his walker that morning when he went for his dialysis treatment. She also commented resident #183 was always weak, especially after his dialysis treatment. She indicated following the resident 's dialysis treatments, the resident is brought to a waiting room until nursing home transportation arrives to pick him up. During an interview with resident #90, #183 ' s roommate on 8/18/11 at 9:30 a.m., he stated the accident happened on 8/1/11. He stated S18Transportation/CNA was putting him (#90) into the van to go home, when resident #183 fell . He further stated he was unsure why the staff did not make the resident use his wheelchair that day, as he usually did, but, the resident had used his walker that day. During an interview with S18Transportation/CNA on 8/17/11 at 4:15 p.m., she stated the resident was ambulating with a walker when he fell to his left side in the dialysis center parking lot, stating she could not get to him before he fell . She indicated she went into the building to get a wheelchair, went back outside, and a man nearby helped her to put the resident into the wheelchair. She then brought residents #183, and #90, back to the nursing home. During an interview with S22PT on 8/18/11 at 1:25 p.m., she stated the resident had been using a wheelchair prior to now, and she had requested the family take the walker home. She indicated, at this point, the resident mainly went from the bed to the chair with assistance because he was so weak. Although resident #183 was normally transported to dialysis via wheelchair related to his weakened physical condition, and numerous serious medical issues, there was no indication of any question or assessment by the nursing home staff to deem the walker as safe or appropriate for him to use on 8/1/11 to ambulate. During an interview with S2DON on 8/18/11 at 3:45 p.m., she stated the nurses do only a visual assessment of dialysis residents when they go to and come back from dialysis. On 8/17/11 the facility provided documentation of an inservice that was dated 8/2/11 which was to all staff:....When assisting residents for transport via van/bus please make sure that the resident is within arms reach of you or you are holding on th them. Some of our resident's are in an awakened state and require that extra support. Never leave your resident unattended. Your are to assist them from inside the building to van/bus. If an incident does occur you are to take the resident back in facility and report incident. Medical help may be needed. Reporting accidents/incidents in a timely manner makes a difference. Please note: Pay special attention to our residents that are coming from the hospital and dialysis, they are very compromised at this time.

Based on interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessment and plan of care for 2 of 3 [MEDICAL TREATMENT] residents reviewed out of a total facility [MEDICAL TREATMENT] population of 8 by failing to: 1. Accurately assess and intervene for resident #183's pain following a fall, which resulted in the resident being hospitalized for [REDACTED]. 2. Adequately assess for an appropriate assistive device for ambulation to and from [MEDICAL TREATMENT] treatment for [REDACTED]. 3. Adequately supervise and provide a one person assist as indicated in the resident's care plan, for resident #183 which resulted in a fall and a complete tear of his R ACL and bucket handle tear 1 of his R meniscus; 4. Wait for a licensed person to assess resident #183 following a fall and prior to moving him; 5. Obtain an agreement from the [MEDICAL TREATMENT] center and physician for clarification of the care of 2 residents (#183 and #90) before and after [MEDICAL TREATMENT] including medications which should and should not be given; and 6. Assessing 2 resident's (#183 and #90) prior to and after [MEDICAL TREATMENT] treatment. Findings: Resident #183 was admitted to the nursing home on 6/23/11 with [DIAGNOSES REDACTED]. He also presented with dementia, Hypertensive [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], elevated prostate specific [MEDICATION NAME] and Chronic hypertension. The resident received [MEDICAL TREATMENT] on Monday, Wednesday and Friday. Resident #183 also had an abnormality of his gait, difficulty walking and was in the process of receiving [MEDICAL CONDITION]. Review of the Falls and Fall Risk Managing policy indicated ... based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling, and try to minimize complications from falls. According to the resident 's care plan, he was at high risk for falls on admission. Review of an Incident and Accident report revealed on 8/1/11 at 4:30 p.m., resident #183 fell in the [MEDICAL TREATMENT] center parking lot following [MEDICAL TREATMENT] treatment, while using a walker to ambulate. 1. During an interview with S20LPN on 8/18/11 at 3:00 p.m. she verified the first time she addressed the resident's pain following the fall, was on 8/2/11, when the family, and doctor were here. She looked at the note on 8/1/11 and it stated the resident was not noted to be in pain, but there was no other documentation. When S16LPN was questioned about the assessment for resident #183 ' s pain, she showed the resident 's pain documentation sheet, stating this is where his pain is assessed and treated. The sheet provided was the PRN Medication Administration and Pain Assessment Record. This sheet indicated on 8/1/11 at 9:00 a.m., the resident was given [MEDICATION NAME] for anxiety and [MEDICATION NAME] 5/500 for knee pain. This was before the resident went to [MEDICAL TREATMENT]. It further indicated the resident was given [MEDICATION NAME] 5/500 and [MEDICATION NAME] 7.5 mg on the dates of 8/2/11; 8/7; 8/10; 8/11; 8/12/; 8/15/ and 8/16 around 9:00 a.m. Review of the nurse's notes dated from 8/1/11 at 5:00 p.m. to 8/2/11 at 8:00 a.m., did not reveal any assessment of pain. On 8/2/11 at 8:00 a.m., the nurse gave the resident a [MEDICATION NAME] for right knee pain (records showed she did this on a regular basis) . On 8/2/11 at 9:00 a.m., when the doctor was making rounds, he ordered a mobile x-ray to be done. At 11:30 a.m., ___ mobile was in the facility for the x-ray, but could not do it because the resident ' s leg would not extend (per later interview). On 8/2/11, a nurse's note, with no date, indicated the resident had called a family member complaining of pain. The nurse assessed the resident 's pain level at 8 on a scale from 1 -10. She obtained orders to send the resident to the hospital. There was no indication in the nurse's notes, the MAR indicated [REDACTED]. The next pain medication given to the resident by the facility was on 8/7/11 at 5:00 a.m. (following his return from the hospital on [DATE] at 12:30 a.m.). According to emergency room Orders (Physician Orders) the resident was admitted to the hospital following a fall which occurred on 8/1/11 related to intractable right knee pain. Review of a [MEDICAL TREATMENT] Discharge Form dated 8/3/11, the resident 's [DIAGNOSES REDACTED]. He returned to the facility on [DATE] with an immobilizer to the right leg. Following the incident, the resident is wheelchair/bed bound, and is scheduled to be evaluated for Physical Therapy on 8/22/11 in order to decide if the resident is capable of improving his Activities of Daily Living. 2. Review of a nurses ' note dated 8/1/11 revealed the resident left the facility at 8:00 a.m. in stable condition going to the [MEDICAL TREATMENT] for [MEDICAL TREATMENT] treatment. Although resident #183 was normally transported to [MEDICAL TREATMENT] via wheelchair related to his weakened physical condition, and numerous serious medical issues, there was no indication of any question or assessment by the nursing home indicating the walker would be safe for him to use on 8/1/11 to go to and back from the [MEDICAL TREATMENT] center for treatment. During an interview with S22PT on 8/18/11 at 1:25 p.m., she stated the resident had been using a wheelchair prior to now, and she had requested the family take the walker home. At this point the resident mainly went from the bed to the chair with assistance related to his weakness. During an Interview with S19Transportation/CNA, she stated she brought residents #183 and #90 to a local [MEDICAL TREATMENT] center for treatment. She indicated resident #183 usually used a wheelchair, but he used his walker that morning when he went to [MEDICAL TREATMENT]. He had his walker on 8/1/11 because the family had brought it to him. S19 stated, when she gets to the [MEDICAL TREATMENT] center she unloads each resident, and lets the center know the residents have arrived She stated she sometimes picked up the residents in the afternoon, depending on the schedule. She also commented resident #183 was always weak, especially after his [MEDICAL TREATMENT] treatment. She indicated following the resident 's [MEDICAL TREATMENT] treatment, the [MEDICAL TREATMENT] center puts them in a waiting room until transportation is there to pick them up. She further stated there is a bell system to use if anyone needs help, but no staff are in this area. During an interview with resident #90, #183 ' s roommate on 8/18/11 at 9:30 a.m., he stated the accident happened on 8/1/11. He stated S18Transportation/CNA was putting him in the van when resident #183 fell . He further stated he was unsure why the staff did not make the resident use his wheelchair, as he usually did, but, the resident had used his walker that day. 3. Review of the resident's care plan indicated a problem as a potential for Falls/Injury Risk r/t weakness/[MEDICAL TREATMENT]. Approaches indicated to transfer with 1 person assist due to weakness related to [MEDICAL TREATMENT]; ambulate with assist as needed. The plan also indicated falls on 8/1/11 and resident educated to be careful while ambulating with walker. Another fall was indicated 8/8/11, again with educate resident to call for assistance. Another problem listed was Potential for falls/injury r/t weakness/[MEDICAL TREATMENT]... fall on 8/1/11 and 8/8/11 On 8/1/11 the resident was educated to be careful while ambulating with walker and on 8/8/11.. therapy to eval and educate resident to call for assistance, educated staff to make sure call light is within reach. Transfer with 1 person assist related to weakness related to [MEDICAL TREATMENT]. During an interview with S18Transporation/CNA on 8/17/11 at 4:15 p.m., she stated the resident was ambulating with a walker and fell to his left side in the [MEDICAL TREATMENT] center parking lot before she could get to him to help him. She indicated she went into the building to get a wheelchair, went back outside, and a man nearby helped her to put the resident into the wheelchair. She then brought resident #183 back to the nursing home. The written witness statement from S18 indicated she was putting the safety belt on resident #90 (who was in a wheelchair), and when she looked up resident #183 had started walking to the van with his walker. S18 went to get him, but by the time she reached him, he had fallen on his left side. The statement indicated some young man assisted her and they put the resident in a wheelchair and S18 brought him back to the nursing home. 4. During an interview with S18Transportation/CNA on 8/17/11 at 4:30 p.m., she stated she had gone to pick up resident's #183 and #90 at the [MEDICAL TREATMENT] center on 8/1/11. She stated resident #90 was outside of the center and #183 was inside the building in the waiting room. She first went to assist resident #90 to the van, who was in a wheelchair, and put him into the van. When she looked up, she saw resident #183 ambulating towards the van with a walker. Before she could get to him, the resident fell to the right side, but landed on his left side. She stated when she picked him up from the ground the resident was very weak, but he did not say anything other than he was alright. She stated he was outside of the [MEDICAL TREATMENT] center on the sidewalk coming down, and a few feet from the van. She indicated he was usually in his wheelchair inside of the [MEDICAL TREATMENT] building when she goes to pick him up. A man who was leaving the center, assisted her to pick up resident #183. She had gone into the center to get a wheelchair, stating no [MEDICAL TREATMENT] staff was in that area of the [MEDICAL TREATMENT] center when she went in. She again verbalized, resident #183 was usually in his wheelchair, but that day, was using his walker. She indicated she had a cell phone, and called the nursing home when the accident happened, but no one answered the phone, but she wasn't sure what time it was, only that it was 2nd shift. During this interview, she stated she was unable to contact the nursing home, and there was no [MEDICAL TREATMENT] staff member to tell in the waiting room to tell about the fall. S18 also indicated she had left the resident alone after the fall when she went into the waiting room to find a wheelchair. Resident #90 was already in the van. When she arrived back at the nursing home, she told S16LPN of the accident, at which time she assumed she assessed the resident. 5. Review of the [MEDICAL CONDITION], Care of a Resident policy provided by the facility on 8/16/11 at 2:50 p.m. read the following: Policy Interpretation and Implementation #2. Education and training of staff includes, specifically: -a. the nature and clinical management of [MEDICAL CONDITION] -b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis -c. Signs and symptoms of worsening condition and/or complications of [MEDICAL CONDITION] -d. How to recognize and intervene in medical emergencies... -e. How to recognize and manage equipment failure or complications (according to the type of equipment used in the facility; -f. Timing and administration of medications, particularly those before and after [MEDICAL TREATMENT].... #3. Education and training of staff in the care of [MEDICAL CONDITION]/[MEDICAL TREATMENT] resident's may be managed by the contracted [MEDICAL TREATMENT] facility or by a clinician with special training in [MEDICAL CONDITION] and [MEDICAL TREATMENT] care. #4. Agreements between this facility and the contracted [MEDICAL CONDITION] facility include all aspects of how the resident's care will be managed, including: a. How the care plan will be developed and implemented; b. How information will be exchanged between the facilities... #5. The resident's comprehensive care plan will reflect the resident's needs related to [MEDICAL CONDITION]/[MEDICAL TREATMENT] care. During an interview with S1Administrator on 8/18/11 at 4:30 p.m., he verified the facility did not have an agreement, protocol or instructions with the local [MEDICAL TREATMENT] center for residents #183 or #90, where they were receiving [MEDICAL TREATMENT] treatment. 6. During an interview with S2DON, on 8/18/11 at 9:45 a.m., she stated the nurses do only a visual assessment of [MEDICAL TREATMENT] residents when they go to and come back from [MEDICAL TREATMENT]. No vitals are done and they do not communicate with the [MEDICAL TREATMENT] center unless there is a problem. Communication happens between the doctor at the center that makes rounds there, and then their nurse will call here if we need to know something. Review of a nurses ' note dated 8/1/11, written by S16LPN, indicated an assessment was completed when the resident was brought back to the nursing home following the fall. The note indicated the resident had no apparent injury; no pain noted and was able to move all extremities. During an interview with S16LPN on 8/18/11 at 3:05 p.m. she verified she cared for the two residents receiving [MEDICAL TREATMENT] (#183 and #90), who were brought to a local [MEDICAL TREATMENT] center for treatment on 8/1/11. She stated she took vitals when they came back, but said she did not write any down. She then went to S20LPN and they stated any vital signs taken would have been written on the sheet in the resident ' s charts. S20 stated she did not take vitals prior to a resident going to [MEDICAL TREATMENT]. Review of the vital sign and weight flow records indicated no blood pressures were written for residents #183 or #90 before and/or after each [MEDICAL TREATMENT] treatment. On 8/1/11, the day resident #183 fell , vital signs were taken after the resident returned to the facility and it had been reported he had fallen. Review of a nurses ' note dated 8/1/11 revealed resident #183 left the facility at 8:00 a.m. in stable condition going to the [MEDICAL TREATMENT] for [MEDICAL TREATMENT] treatment.

Based on observation, record review, policy review, and interviews the facility failed to perform comprehensive accurate assessments for 3 of 46 sampled residents. According to the Resident Census and Conditions on 8/15/11 there were 160 residents residing in the facility. The facility failed: (1) to assess for the use of the walker resulting in actual harm to the resident when he fell and sustained a complete tear R ACL and bucket handle tear at meniscus for 1 (#183) of 4 residents reviewed for falls; (2) to accurately and continuously assess for pain following a fall resulting in actual harm when he was hospitalized for [REDACTED]. (3) to assess pre and post [MEDICAL TREATMENT] for 1 (#183) of 3 residents reviewed for [MEDICAL TREATMENT]; (4) to accurately assess 1 (#10) of 4 residents reviewed for pressure sores by not identifying and/or monitoring the resident's left heel before the resident acquired a Stage II severity pressure ulcer. According to the Resident Census and Conditions of Residents form, dated 8/15/11, there were 7 residents with pressure sores and the total number of residents with pressure sores excluding Stage I, upon admission to the facility was 2; and (5) to assess the fingernails of 1 (#205) of 4 residents reviewed for grooming. Findings: Resident #183: The resident was admitted to the nursing home on 6/23/11 with [DIAGNOSES REDACTED]. He also presented with dementia, Hypertensive [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], elevated prostate specific [MEDICATION NAME] and Chronic hypertension. The resident received [MEDICAL TREATMENT] on Monday, Wednesday and Friday. Resident #183 also had an abnormality of gait, difficulty walking and was in the process of receiving [MEDICAL CONDITION]. Review of the Falls and Fall Risk Managing policy indicated ... based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling, and try to minimize complications from falls. According to the resident ' s care plan, he was at high risk for falls on admission. (1) Review of a nurse's note dated 8/1/11 revealed the resident left the facility at 8:00 a.m. in stable condition going to the [MEDICAL TREATMENT] center for [MEDICAL TREATMENT] treatment. Review of an incident and accident report dated 8/1/11 at 4:30 p.m, revealed the resident had a fall in the parking lot of the [MEDICAL TREATMENT] center. During an Interview with S19 Transportation/CNA, she stated she brought resident #183 and #90 to a local [MEDICAL TREATMENT] center for treatment. She indicated #183 usually used a wheelchair, but he used his walker that morning when he went to [MEDICAL TREATMENT]. He had his walker on 8/1/11 because the family had brought it to him. S19 stated, when she gets to the [MEDICAL TREATMENT] center she unloaded each resident, and let the center know the residents had arrived She stated she sometimes picked up the residents in the afternoon, depending on the schedule. She also commented resident #183 was always weak, especially after his [MEDICAL TREATMENT] treatment. She indicated following the resident 's [MEDICAL TREATMENT] treatment, the [MEDICAL TREATMENT] center puts them in a waiting room until transportation is there to pick them up. There is a bell system to use if anyone needs help, but no staff are in this area. During an interview with resident #90, #183 ' s roommate on 8/18/11 at 9:30 a.m., he stated the accident happened on 8/1/11. S18Transportation/CNA was putting him in the van when #183 fell . He was unsure why the staff did not make the resident use his wheelchair, as he usually did, but the resident had used his walker that day. During an interview with S18Transportation/CNA on 8/17/11 at 4:15 p.m., she stated the resident was ambulating with a walker and fell to his left side in the [MEDICAL TREATMENT] center parking lot before she could get near him. She indicated she went into the building to get a wheelchair, went back outside, and a man nearby helped her to put the resident into the wheelchair. She then brought resident #183 back to the nursing home. The written witness statement from S18 indicated she was putting the safety belt on resident #90 (who was in a wheelchair), and when she looked up resident #183 had started walking to the van with his walker. S18 went to get him, but by the time she reached him, he had fallen on his left side. The statement indicated some young man assisted her and they put the resident in a wheelchair and S18 brought him back to the nursing home. During an interview with S22PT on 8/18/11 at 1:25 p.m., she stated the resident had been using a wheelchair prior to now, and she had requested the family take the walker home. At this point the resident mainly went from the bed to the chair with assistance related to his weakness. Although resident #183 was normally transported to [MEDICAL TREATMENT] via wheelchair related to his weakened physical condition, and numerous serious medical issues, there was no indication of any question or assessment by the nursing home staff to deem the walker would be safe for him to use on 8/1/11. Review of a [MEDICAL TREATMENT] Discharge Form dated 8/3/11, the resident ' s [DIAGNOSES REDACTED]. (2) Review of a nurses ' note dated 8/1/11, written by S16LPN, indicated an assessment completed when the resident was brought back to the nursing home following the fall. The note indicated the resident had no apparent injury; no pain noted and was able to move all extremities. During an interview with S20LPN on 8/18/11at 3:00 p.m., she verified the first time she addressed the resident's pain following the fall, was on 8/2/11, when the family, and doctor were here. She looked at the note on 8/1/11 and it stated the resident was not noted to be in pain, but there was no other documentation. When S16LPN was questioned about the assessment for resident #183 ' s pain, she showed the resident ' s pain documentation sheet, stating this is where his pain is assessed and treated. The sheet provided was the PRN Medication Administration and Pain Assessment Record. This sheet indicated on 8/1/11 at 9:00 a.m., the resident was given [MEDICATION NAME] for anxiety and [MEDICATION NAME] 5/500 for knee pain. This was before the resident went to [MEDICAL TREATMENT]. It further indicated the resident was given [MEDICATION NAME] 5/500 and [MEDICATION NAME] 7.5 mg on the dates of 8/2/11; 8/7; 8/10; 8/11; 8/12/ 8/15/ and 8/16 around 9:00 a.m. Review of the nurses ' notes dated from 8/1/11 at 5 p.m. to 8/2/11 at 8 a.m., did not reveal any assessment of pain. On 8/2/11 at 8:00 a.m., the nurse gave the resident a [MEDICATION NAME] for right knee pain (records show she did this on a regular basis). On 8/2/11 at 9:00 a.m., when the doctor was making rounds, he ordered a mobile x-ray to be done. At 11:30 a.m. ___ mobile was in the facility for the x-ray, but could not do it because the resident ' s leg would not extend (per later interview). On 8/2/11, a nurse's note, with no date, indicated the resident had called a family member complaining of pain. The nurse assessed the resident 's pain level at 8 on a scale from 1 -10. She obtained orders to send the resident to the hospital. There was no indication in the nurses ' notes, the MAR indicated [REDACTED]. The next pain medication given to the resident by the facility was on 8/7/11 at 5:00 a.m. (following his return from the hospital on [DATE] at 12:30 a.m.). According to emergency room Orders (Physician Orders) the resident was admitted to the hospital following a fall which occurred on 8/1/11 related to intractable right knee pain. The resident was admitted to the hospital on [DATE] and returned to the facility on [DATE] with orders for a right knee/leg immoblizer. (3) During an interview with S16LPN on 8/18/11 at 3:05 p.m. she verified she cared for two residents receiving [MEDICAL TREATMENT] (#183 and #90), who were brought to a local [MEDICAL TREATMENT] center. She stated she took vitals when they came back, but said she did not write any down. She then went to S20LPN and they stated any vital signs taken would have been written on the sheet in the resident ' s charts. S20 stated she did not take vitals prior to a resident going to [MEDICAL TREATMENT]. Review of the vital sign and weight flow record indicated no blood pressure written for resident #183. Vital signs were noted in nurses ' notes for the following dates: 6:25 at 7 p.m 6/27 (no time) 6/23/11 at 4:30 (when having chest pains); 6/24/11 at 12 p.m., 7/23/11 at 10 a.m., and 7 p.m. 7/24/11 at 9:10 a.m. 7/9/11 at 3 p.m, 7/6/11 at 8 am and 5 p.m.; 7/4/11 at 6:30 p.m., 7/6/11 at 9:30 a.m. (resident was admitted at this time for acute coronary syndrome). And on 7/9/11 at 8 a.m., 7/15/11 at 8 p.m. 7/16/11 (no time), and 7/16/11 at 3 p.m. On 8/1/11, the day the resident fell , vital signs were taken after the resident returned to the facility and it had been reported he had fallen. During an interview with S2DON on 8/18/11 at 3:45 p.m., she stated the nurses do only a visual assessment of [MEDICAL TREATMENT] residents when they go to and come back from [MEDICAL TREATMENT]. No vitals are done and they do not communicate with __ __ [MEDICAL TREATMENT] Center unless there is a problem. Communication happens between the doctor at the center that makes rounds there, and then their nurse will call here if we need to know something. When S16LPN was questioned about the assessment for resident #183 ' s pain, she showed the resident ' s pain documentation sheet, stating this is where he pain is assessed and treated. The sheet provided was the PRN Medication Administration and Pain Assessment Record. This sheet indicated on 8/1/11 at 9 a.m., the resident was given [MEDICATION NAME] for anxiety and [MEDICATION NAME] 5/500 for knee pain. This was before the resident went to [MEDICAL TREATMENT]. Further indicated the resident was given [MEDICATION NAME] 5/500 and [MEDICATION NAME] 7.5 mg on the dates of 8/2/11; 8/7; 8/10; 8/11; 8/12/ 8/15/ and 8/16 and around 9 a.m. Review of the nurses ' notes dated from 8/1/11 at 5 p.m. to 8/2/11 at 8 a.m., did not reveal any assessment of pain. On 8/2/11 at 8 a.m., the nurse gave the resident a [MEDICATION NAME] for right knee pain (records show she did this on a regular basis) . On 8/2/11 at 9 a.m., when the doctor was making rounds, he ordered a mobile x-ray to be done. At 11:30 a.m. ___ mobile was in house for the x-ray, but could not do it because the resident ' s leg would not extend (per later interview). On 8/2/11, a nurses ' note, with no date, indicated the resident had called a family member complaining of pain. The nurse assessed the resident ' s pain level at 8 on a scale from 1 -10. She obtained orders to send the resident to the hospital. There was no indication in the nurses ' notes, the MAR indicated [REDACTED]. The next pain medication given to the resident by the facility was on 8/7/11 at 5 a.m. (following his return from the hospital on [DATE] at 0030. (4) Resident #10: Review of the Physician's Progress Notes, dated 6/7/11, stated Resident #10 was being evaluated for nursing home admission. Resident #10 had a history of [REDACTED]. In addition, the Physician's Progress Notes stated under the Assessment/Plan section that the [MEDICAL CONDITION] was going to be monitored and the plan was to elevate the Resident's legs ... The Physician had also documented that Resident #10 was appropriate for nursing home admission to assist with ADL's, medications, PT and OT. There was no mention of any wounds or skin condition problems. The Admission Nursing Evaluation form stated Resident #10 had dry skin and the right lower extremity had [MEDICAL CONDITION] on 6/10/11. There was no breakdown, no skin tears, and/or no skin discolorations observed on 6/10/11. The Braden scale for predicting pressure sore risk read a score of 18 on 6/10/11, which meant the Resident was at risk according to the total score key at the bottom of the sheet. A weekly body audit was done on 6/17/11 and there were no problems documented at this time. A wound assessment sheet, dated 6/20/11, read a pressure wound was located on the left heel measuring 5.5 cm x 5.5 cm. This was an acquired Stage II wound. The Pressure Ulcer Treatment policy stated a Stage II Pressure Ulcer was a 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 ... An interview with S4LPN/ADON revealed every resident had a Braden scale done by a floor Nurse upon admission to the facility followed by a weekly skin assessment done by S17LPN/Wound Care, when asked if the score on the Braden scale makes a difference of how often a resident was assessed on 8/19/11 at 12:20 p.m. On 8/19/11 at 12:24 p.m., S7LPN/Case Manager confirmed Resident #10 did not have any pressure wounds upon admission to the facility on [DATE] and she did not care plan the Resident for such. S7 also revealed S17LPN/Wound Care Nurse wrote Resident #10 had acquired the Stage II blister to the left heel on 6/20/11 and this was added to the Resident ' s accumulative [DIAGNOSES REDACTED]. (5) Resident #205: Resident #205 was observed on 8/16/11 at 9:00 a.m. with a thick brown substance under his fingernails and lengthy fingernails. The resident was very agitated during the interview but stated one of the ladies told me she was going to cut my nails yesterday and she never came back. His son stated during an interview on 8/16/11 at 9:33 a.m. he had brought his father some nail clippers. He also stated he had asked the staff to clip his father's nails previously to today, he could not recall the day, but stated staff had informed him that they would clip his nails. He then stated " I guess I will have to do this myself." He further stated he did not think his father's nails had been clipped since he had been in this facility. The resident was admitted on [DATE]. On further observation on 8/17/11 at 8:40 a.m., resident #205 was less agitated and more easily directed to questions asked. He again stated the staff told him they would clip his nails, because he was not supposed to clip his own nails, but they had not come back yet to do this. On 8/17/11 at 11:10 a.m. an interview was conducted with S12, Kitchen Supervisor. She stated she participated in QLR and monitored rooms 107 -109 daily. The Quality of Life Representative Report (QLR) for 8/16/11 was reviewed with S12. She stated she did not see anything unsatisfactory for resident #205 yesterday (8/16/11) and he was agitated today and she had not written his QLR assessment yet today. The documentation on the QLR of 8/16/11 read for "fingernails are clean and cut" - "I" which indicated according to the tool - satisfactory. On 8/17/11 at 11:50 a.m., an observation of resident #205 was made with S9LPN. She confirmed his nails were dirty and required trimming. She stated he was not a diabetic and his nails should have been done by either the shower aide or the regular CNA. When asked if the condition of the nails was part of her assessment, she stated "yes." She further stated she missed it and would get his nails clipped today even if she had to do it herself. An interview of S5LPN, Staff Development Coordinator was conducted on 8/17/11 at 12:00 p.m. She stated she was the CNA Supervisor.She confirmed the shower aide or the resident's CNA was responsible for looking at their assigned residents nails and clipping and cleaning the nails if needed and the resident was not a diabetic. The Nursing Assistant's Daily Care Record was reviewed with S5. It was observed that the date of 8/16/11 had no checkmarks for a shower or bedbath being given on that day. She stated this indicated it was not done. She further stated if the resident refused his care, the CNA was to notify his nurse. During an interview with S11CNA on 8/18/11 at 9:00 a.m.she stated she was supposed to look at the nails of her assigned residents and clean and cut them if it was needed.

Based on observation, record review and interview the Administration failed to utilize effective training methods and staff supervision to assure each resident maintained their highest practicable physical, mental, and psychosocial well-being by failing to: 1. Ensure staff were trained and competent on comprehensive assessments of [MEDICAL TREATMENT] residents and the [MEDICAL TREATMENT] residents' care prior to and following [MEDICAL TREATMENT] treatment, including the use of appropriate assistive devices (#183 and #90); 2. Ensure staff were trained and able to effectively assess a resident's condition following a fall, specifically pain (#183); 3. Ensure staff were trained to follow the resident's plan of care for 1 person assists to prevent accidents and falls, and appropriate policies and procedures to follow in the event of an accident or fall (#183);and 4. Obtain an agreement from all [MEDICAL TREATMENT] centers giving treatment to facility residents, in accordance with their corporate policy on [MEDICAL CONDITION]/[MEDICAL TREATMENT] and to ensure continuity of care for resident's with [MEDICAL CONDITION]/[MEDICAL TREATMENT] (#183 and #90). Resident #183 was caused actual harm when he was not adequately assessed for the use of a walker to be used to ambulate to and from [MEDICAL TREATMENT] treatment, and when a staff member did not follow his care plan and provide 1 person assist while using the walker. This resulted in the resident falling, which resulted in a complete tear of his R ACL and a bucket handle tear 1 of his R meniscus. He was hosptalized on [DATE] and returned to the facility on [DATE] with an immobilizer to the right leg. The staff also failed to adequately assess and intervene for the resident's pain following the resident's fall on 8/1/11 which resulted in the resident being hospitalized from [DATE] to 8/6/11 for intractable pain. Findings: Review of the resident's care plan revealed a problem listed as Potential for falls/injury r/t weakness/[MEDICAL TREATMENT]... fall on 8/1/11 and 8/8/11.... Transfer with 1 person assist related to weakness, related to [MEDICAL TREATMENT]. Further review of the resident's care plan indicated a problem as Potential for Risk r/t [MEDICAL CONDITION]/[MEDICAL TREATMENT]. Approaches included Monitor for s/sx of Uremia: severe nausea, confusion, [MEDICAL CONDITION], irregular heart rhythm, fluid in lungs...monitor vital signs, cardiac status and mental status. Review of resident #183's record revealed heart rhythm, lung assessment, vital signs, cardiac status and mental status had not been monitored before the resident left for [MEDICAL TREATMENT] or after he came back to the nursing home following [MEDICAL TREATMENT] treatment. During an interview with S16LPN on 8/18/11 at 3:05 p.m. she verified she cared for two residents receiving [MEDICAL TREATMENT] (#183 and #90), who were brought to a local [MEDICAL TREATMENT] center. She stated she took vitals when the residents would come back, but said she had not written any down. She then went to S20LPN and they agreed any vital signs taken would have been written on the sheet in the residents' charts. S20 stated she had not taken vitals prior to a resident going to [MEDICAL TREATMENT]. On 8/1/11, the day the resident fell , vital signs were noted after the resident returned to the facility after it had been reported the resident had fallen. During an interview with S2DON on 8/18/11 at 3:45 p.m., she stated the nurses do only a visual assessment of [MEDICAL TREATMENT] residents when they go to and come back from [MEDICAL TREATMENT]. No vitals are done at the nursing home prior to the residents going to the center for [MEDICAL TREATMENT]. During an Interview with S19Transportation/CNA, on 8/17/11 at 4:00 p.m., she stated she brought resident #183 and #90 to a local [MEDICAL TREATMENT] center for treatment. She indicated resident #183 usually used a wheelchair, but he used his walker that morning, when he went to [MEDICAL TREATMENT]. She also commented resident #183 was always weak, especially after his [MEDICAL TREATMENT] treatment. She indicated, following the residents' [MEDICAL TREATMENT] treatment, the residents' wait in a waiting room until facility transportation arrives to pick them up. During an interview with resident #90, #183 ' s roommate on 8/18/11 at 9:30 a.m., he stated S18Transportation/CNA was putting him in the van when #183 fell while trying to walk to the van with a walker after [MEDICAL TREATMENT] treatment. Resident #90 further stated he was unsure why the staff did not make the resident use his wheelchair, as he usually did, but the resident had used his walker that day. During an interview with S18Transportation/CNA on 8/17/11 at 4:15 p.m., she stated the resident was ambulating with a walker after [MEDICAL TREATMENT] treatment, and fell to his left side in the [MEDICAL TREATMENT] center parking lot before she could get near him. 2. During an interview with S20LPN on 8/18/11 at 3:00 p.m. she verified the first time she addressed the resident's pain following the fall, was on 8/2/11, when the family, and doctor were here. She looked at the note on 8/1/11 and it stated the resident was not noted to be in pain, but there was no other documentation. When S16LPN was questioned about the assessment for resident #183 ' s pain, she showed the resident ' s pain documentation sheet, stating this is where his pain is assessed and treated. The sheet provided was the PRN Medication Administration and Pain Assessment Record. This sheet indicated on 8/1/11 at 9:00 a.m., the resident was given [MEDICATION NAME] for anxiety and [MEDICATION NAME] 5/500 for knee pain. This was before the resident went to [MEDICAL TREATMENT]. Further review indicated the resident was given [MEDICATION NAME] 5/500 and [MEDICATION NAME] 7.5 mg on the dates of 8/2/11; 8/7; 8/10; 8/11; 8/12/ 8/15/ and 8/16 around 9:00 a.m. Review of the nurse's notes dated from 8/1/11 at 5:00 p.m. to 8/2/11 at 8:00 a.m., did not reveal any assessment of pain. On 8/2/11 at 8:00 a.m., the nurse gave the resident a [MEDICATION NAME] for right knee pain (records showed she did this on a regular basis) . On 8/2/11 at 9:00 a.m., when the doctor was making rounds, he ordered a mobile x-ray to be done. At 11:30 a.m. ___ mobile was in the facility for the x-ray, but could not do it because the resident's leg would not extend (per later interview). On 8/2/11, a nurse's note, with no date, indicated the resident had called a family member complaining of pain. The nurse assessed the resident ' s pain level at 8 on a scale from 1 -10. She obtained orders to send the resident to the hospital. There was no indication in the nurse's notes, the MAR indicated [REDACTED]. The next pain medication given to the resident by the facility was on 8/7/11 at 5:00 a.m. (following his return from the hospital on [DATE] at 12:30 a.m.). According to emergency room Orders (Physician Orders) the resident was admitted to the hospital following the fall on 8/1/11 related to intractable right knee pain. A review of a [MEDICAL TREATMENT] Discharge Form dated 8/3/11, revealed resident #183 had sustained a complete tear of his R ACL and a bucket handle tear 1 of his R meniscus. He returned to the facility on [DATE] with an immobilizer to the right leg. 3. During an interview with S18Transportation/CNA on 8/17/11 at 4:15 p.m. she stated, after resident #183 fell following [MEDICAL TREATMENT] treatment, she went into the [MEDICAL TREATMENT] center to get a wheelchair, and then went back outside to help him. She indicated a young man coming out of the center helped her to put resident #183 into the wheelchair. She then brought residents #183 and #90 back to the nursing home. The written witness statement from S18Transportation/CNA indicated on 8/1/11 at 4:35 p.m., she was putting the safety belt on resident #90 (who was in a wheelchair). When she looked up resident #183 had started walking to the van with his walker. She indicated she went to help him, but by the time she reached him, he had fallen on his left side. During an interview with S22PT on 8/18/11 at 1:25 p.m., she stated the resident had been using a wheelchair prior to the incident, and to her knowledge, the resident had not been assessed for the use of the walker. She further stated , the resident mainly went from the bed to the chair with assistance because of his weakness, and generally stayed in his room, except when he had an appointment or [MEDICAL TREATMENT]. Although resident #183 was normally transported to [MEDICAL TREATMENT] in a wheelchair related to his weakened physical condition, and numerous serious medical issues, there was no indication of any question or assessment by the nursing home staff to deem if the walker would be safe for the resident to use for ambulation to and from the [MEDICAL TREATMENT] center on 8/1/11. 4. Review of the [MEDICAL CONDITION], Care of a Resident with policy provided by the facility on 8/16/11 at 2:50 p.m. read the following: Policy Interpretation and Implementation #2. Education and training of staff includes, specifically: -a. the nature and clinical management of [MEDICAL CONDITION] -b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis -c. Signs and symptoms of worsening condition and/or complications of [MEDICAL CONDITION] -d. How to recognize and intervene in medical emergencies... -e. How to recognize and manage equipment failure or complications (according to the type of equipment used in the facility; -f. Timing and administration of medications, particularly those before and after [MEDICAL TREATMENT].... #3. Education and training of staff in the care of [MEDICAL CONDITION]/[MEDICAL TREATMENT] resident's may be managed by the contracted [MEDICAL TREATMENT] facility or by a clinician with special training in [MEDICAL CONDITION] and [MEDICAL TREATMENT] care. #4. Agreements between this facility and the contracted [MEDICAL CONDITION] facility include all aspects of how the resident's care will be managed, including: a. How the care plan will be developed and implemented; b. How information will be exchanged between the facilities... #5. The resident's comprehensive care plan will reflect the resident's needs related to [MEDICAL CONDITION]/[MEDICAL TREATMENT] care. During an interview with S1Administrator on 8/18/11 at 4:30 p.m., he verified the Administration had not obtained a written agreement, protocol or instructions from __ __ [MEDICAL TREATMENT] Center. Record review indicated resident's #183 and #90 were receiving [MEDICAL TREATMENT] treatment from this center along with one other resident living at the facility.