Every finding on record at Lake Emory Post Acute Care

Based on observations, record reviews, interviews, and policy review, the facility failed to provide adequate supervision and maintain an environment free from accidental hazards for one (1) of two (2) residents reviewed for falls (Resident (R)15). R15 had ten documented falls between August 24, 2025, and December 12, 2025, three (3) of which resulted in fractures. A fall on August 24, 2025, resulted in a nasal fracture, and a fall on September 10, 2025, resulted in a subdural hematoma and right clavicle fracture. Specifically, the facility failed to identify an environmental hazard for a resident with a known history of falls. On December 12, 2025 at 3:20 p.m., the facility failed to identify an environmental hazard for a resident with a known history of falls. The facility staff left a grey rolling trash can near the resident's room; when the resident tried to use the trash can for support, it rolled away, causing the resident to fall and sustain a right femur fracture. Findings include:The facility's policy, Accident/Incident Reporting, revised 11/1/17, defined an incident as any adverse outcome directly resulting from treatment or care, and an accident as any unexpected, unintended event that can result in bodily injury.During the initial tour, on 1/21/26 at 9:25 a.m., of the C Hallway, R15's room was observed to have the resident's name displayed. The room was located near the outside exit door closest to the blue trash dumpsters and far from the nurse's station.On 1/21/26 at 10:00 a.m., observation of a church service revealed R15 in a wheelchair with anti-tippers, a cushion, and portable oxygen. The resident was wearing weather-appropriate clothing and non-skid footwear. At 11:30 a.m., the resident was observed in a wheelchair in front of the nurse's desk.On 1/22/26 at 8:40 a.m., the resident was seen in the common area of C Hallway eating breakfast, with staff visible in the hallway.The facility admitted R15 on 11/14/24 with diagnoses including a displaced left humerus fracture, severe dementia with anxiety, and muscle weakness. The resident's Morse Fall Scale score, dated 8/2/25, was 50, indicating a high risk of falls.The Quarterly Minimum Data Set (MDS) assessment, dated 6/30/25, prior to the 8/24/25 nasal fracture, showed a Brief Interview for Mental Status (BIMS) score of 00/15, indicating R15 had severe impairment, signaling the highest level of cognitive struggle. The facility assessed the resident as having minimal hearing difficulty, unclear speech, and disorganized thinking, along with daily wandering and delusional behaviors. R15 had upper extremity impairment, but no lower extremity impairment. The resident was functionally independent but required set-up assistance with toilet transfers and partial to moderate assistance with showering. The MDS noted two prior non-injury falls.A Significant Change MDS, with an Assessment Reference Date (ARD) of 9/25/25, revealed that R15 re-entered the facility on 9/12/25 following an acute hospital stay. The resident's BIMS score was 99, indicating the resident was unable to complete the interview.R15 exhibited both short-term and long-term memory loss and was severely impaired. The resident also demonstrated inattention and disorganization. The Patient Health Questionnaire-9 (PHQ-9) assessment showed the resident had little interest or pleasure in activities, along with feelings of sadness, depression, or hopelessness. R15 displayed daily wandering behavior.R15 required partial to moderate assistance with toileting hygiene, showering/bathing, and dressing both upper and lower body and required supervision or physical assistance with eating and oral hygiene, and set-up assistance for footwear and personal hygiene. There was no range of motion impairment in the upper or lower extremities. The resident used a walker and was independent with making two turns once seated in the wheelchair. R15's Fall Care Plan, dated 11/14/24, identified falling as a problem related to, but not limited to, immobility, muscle weakness, and vision. The goal was to keep the resident free from injury. Fall interventions included: 1) ensuring proper pants length, 2) using nonskid strips, 3) offering redirecting activities, and 4) placing a resident identifier outside the room. The Care Plan was updated on 9/15/25, after the 9/12/25 fall with major injury, with a new approach to remove slippers from the resident's room. The fall Care Plan, updated on 12/18/25, defined the problem as the resident being non-compliant with x1 assist. The goal was the resident would experience no more injuries until the next review. The approaches included: staff will assist the resident when seen walking without assistance, and will attempt to redirect the resident.Review of R15's Progress Note dated 8/24/25 at 11:05 p.m. (late entry recorded on 8/25/25 at 3:24 a.m.) showed the resident had an unwitnessed fall in another resident's room and was found on the floor near the bedside table with a facial injury to the forehead, an open area on the nasal bridge, and bruising under both eyes. Increased nasal swelling was noted, and the resident was transferred to the emergency room, where a closed displaced fracture of the nasal bone was diagnosed.On 8/30/25 at 4:40 p.m., a Progress Note indicated the resident fell while staff were attempting to walk the resident to the shower room; the resident leaned back, fell, and hit his/her head.On 9/10/25 at 7:54 p.m., a Progress Note documented the resident was behind the nurse's station, was leaning forward and sliding face-first. The facility assessed a silver dollar-sized laceration on the forehead, and the resident was sent to the hospital. The hospital record dated 9/15/25 confirmed a subdural hemorrhage and a closed displaced fracture of the right clavicle.On 10/6/25 at 9:24 p.m., a Progress Note indicated the resident was found in front of her wheelchair in the dining room, with no injury noted.On 10/8/25 at 6:51 p.m., a Progress Note indicated the resident was observed at the nurse's station falling backward.On 11/18/25, a late entry at 7:28 p.m., showed the resident was found on the floor at 1:00 p.m.; the resident denied pain and no visible injuries were noted.On 11/25/25 at 4:00 p.m., a Progress Note revealed the resident attempted to stand and slid from the wheelchair to the floor, not hitting his/her head and with no visible injuries.On 11/29/25 at 10:10 p.m. (late entry on 11/30/25), a Progress Note described an unwitnessed fall; the resident was found on the hallway floor with no injuries.On 12/12/25 at 3:20 p.m., a Progress Note indicated R15 was observed walking in the hallway and fell, hitting his/her head on the rail and shouting, ouch, ouch, while holding his/her right upper thigh.An interview, on 1/21/26 at 11:05 a.m,. with Certified Nursing Assistant (CNA)1, revealed familiarity with R15's care needs, describing the resident as active, ambulatory, and impulsive. The CNA reported witnessing the 12/12/25 fall, explaining that at the end of a shift, staff typically collect residents' trash in a large grey rolling receptacle, which was kept in the shower room and taken outside to the dumpsters. However, on 12/12/25, someone left the receptacle in the hallway; the resident held onto the trash can, which rolled, causing him/her to fall. The CNA stated an in-service was conducted to re-educate staff not to leave the trash receptacle in the hallway.A telephone interview, on 1/21/26 at 8:30 p.m., with CNA2, confirmed knowledge of R15's care needs, describing the resident as impulsive and prone to attempting to stand or ambulate without assistance, requiring consistent redirection. The CNA recalled the 12/12/25 fall occurred near the end of the shift, with the grey rolling trash can near the exit door by the resident's room. The CNA saw the resident exit his/her room, attempt to hold the trash can, and fall when it rolled away.An interview in the A-Hallway shower room on 1/22/26 at 9:25 a.m. with CNA4 revealed training upon hire that the grey rolling trash can must be kept in the shower room and never left in hallways, except when being emptied into the dumpster.An interview, on 1/22/26 at 9:25 a.m., in the surveyors' conference room with the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Clinical Service Director addressed the 12/12/25 fall. The DON acknowledged the resident's impulsive behavior and Dementia diagnosis, and agreed that the rolling trash can should not have been left in the hallway. The DON further stated an in-service was conducted to re-educate staff on this policy.During the administrative group interview on 1/22/26 at 9:24 a.m., the Administrator stated that falls and related interventions were discussed at the morning meeting. The Administrator confirmed the facility was aware of R15's multiple falls which resulted in three (3) major injuries. When the surveyor asked whether the facility had considered implementing one-on-one (1:1) supervision, the Administrator responded that 1:1 intervention was typically used for residents with behavioral issues. Upon further questioning about the purpose of 1:1 intervention, the Administrator stated that its goal is to ensure resident safety.

Based on record review, interviews, and facility policy review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of four residents (Resident (R) 13) reviewed for abuse of 21 sample residents. This failure had the potential to affect resident safety.Findings include: Review of the facility's undated policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revealed The facility's leadership prohibits neglect, mental, physical and/or verbal abuse. Types of abuse include but are not limited to: A. Physical assault/abuse: 1) Hitting 2) Slapping.Review of R13's Face Sheet located under the Resident-Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses which included Alzheimer's disease, vascular dementia, and major depressive disorder. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/14/25, located under the Resident Assessment Instrument (RAI) - MDS 3.0 Assessments tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R13 was severely cognitively impaired. During an interview on 08/25/25 at 1:28 PM, R13 stated she remembered the incident and stated she just let it go. R13 stated she was not fearful. Review of R47's Face Sheet located under the Resident-Face Sheet tab of the EMR revealed the resident was admitted on [DATE] with diagnoses which included epilepsy, dementia, depression, and other symptoms and signs involving appearance and behavior-aggressive behavior.Review of the annual MDS with an ARD of 07/01/25, located under the RAI - MDS 3.0 Assessments tab of the EMR, revealed a BIMS score of nine out of 15 which indicated R47 was moderately cognitively impaired. Review of the facility investigation, dated 07/16/25 and provided by the facility, revealed Date/Time of Reportable Incident: 7/11/2025@318pm . Shortly after 3pm shift change, the staff overheard [R47] and attempted to get to the residents to separate but were unsuccessful. [R47] hit [R13] in the face . Characteristics of injury: Redness of the left lower cheek of [R13]. A statement from Activity Assistant (AA), located in the facility investigation, revealed [R47] started yelling 'who the [F***] are you talking to like that.' I turned and seen him about to hit [R13]. I immediately started walking over to separate them. Then, he swung his right arm and couldn't get his arm around and swung again. As I was pulling [R13] away, he swung his right arm again and hit her on the cheek and neck. [R13] wasn't talking to him she was watching.Review of the social services Progress Notes, dated 07/11/25 and located under the Progress Notes tab of the EMR, revealed R47 stated I wasn't talking to nobody, she just talk sh-to me for no reason. [R47] stated she cursed me out. She said shut the F--- up . That's when I hit her but I didn't hit her that hard. I slapped her but it was a little tap .Review of the Psychotherapy Comprehensive Clinical Assessment, dated 07/25/25 and provided by the facility, revealed R47 Has been acting out physically verbally and emotionally towards others and recently hit another resident.During an interview on 08/25/25 at 1:20 PM, AA stated she was at the nurse's station at the time. AA stated R47 was rolling up on [R13] saying Why the **** are you talking to me like that? AA stated R47 used his right hand and the first time, he missed. AA stated the second time; he hit her left cheek. She confirmed R47 was aiming at R13. AA stated R47 told her that R13 was cussing at him. AA stated this was the only time she had seen R47 being aggressive with other residents. AA confirmed R47 intended to hit her. During an interview on 08/25/25 at 2:50 PM, the Administrator stated R47 had seizures. She stated he could go from one end to the next with his aggression. She confirmed she had unsubstantiated abuse. She stated she was not aware R47 had tried to hit R13 twice. She confirmed she was the abuse coordinator.

Based on record review, interview, and policy review, the facility failed to report an allegation of staff to resident physical abuse for one of two (Residents (R)18) abuse allegations reviewed in the sample of 21 residents to the State Agency (SA) immediately, but no later than 2 hours after the allegation was made when the incident involved abuse. This failure had the possibility to negatively impact all 83 residents currently residing at the facility.Findings include:Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revised 11/01/17, indicated, . The facility shall report immediately, but not later than two hours after the allegation is make if the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.Review R18's admission Sheet, found in the electronic medical record (EMR) under the Census tab, revealed R18 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's.Review of the facility's investigative file indicated the facility provided Five-Day Follow-Up Report, dated 07/11/25, revealed, .On 07/07/25, after reporting to work at 3:10 PM, Certified Nursing Assistant (CNA)1 and CNA2, notified the Director of Nursing (DON) of an event that they felt may be alleged abuse that occurred on 07/05/25 at approximately 9:15 PM. The CNAs alleged Licensed Practical Nurse (LPN)1 forced R18 to take her medication. The file revealed a body audit was completed on R18 without findings. The responsible party, nurse practitioner, and Sherriff's department were notified of the allegation. CNA1 and CNA2 were immediately re-educated that any alleged abuse is supposed to be reported immediately. The details of their alleged abuse were taken, and all three staff members were suspended pending investigation. The facility's conclusion of investigation stated, Based on the findings of the investigation, there is no evidence of willful intent to cause injury or harm, so abuse is not substantiated. Abuse re-education initiated. No further suspicion of abuse indicated throughout investigation. Ongoing monitoring of R18 will continue. Interventions and care plan updated accordingly and as needed.During an interview on 08/25/25 at 3:10 PM, the Administrator stated she did not substantiate this abuse allegation due to discrepancies in all three staff members' statements. The Administrator indicated that LPN1 had been terminated for interfering with the investigation.During a follow-up interview on 08/26/25 at 4:15 PM, the Administrator confirmed CNA1 and CNA2 left work on 07/05/25 without reporting the allegation. The Administrator stated two days after the alleged incident CNA 1 and CNA2 reported the allegation to the DON on 07/07/25.During an interview on 08/26/25 at 11:50 AM, the DON stated CNA1 and CNA2 were new hires and had completed abuse education, they knew to report abuse allegations immediately but failed to do so.

Based on interview, record review, facility document review, and facility policy review, the facility failed to timely report a resident-to-resident abuse allegation to the State Agency for 1 (Resident (R)3) of 3 residents reviewed for abuse. Findings include: An undated facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, specified, 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, and [sic] are reported immediately. 2. The Facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the StateSurvey [sic] Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. A Resident Face Sheet indicated the facility admitted R2 on 06/28/2019. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of encephalopathy, moderate vascular dementia with psychotic disturbance, personal history of mental and behavioral disorders, major depressive disorder, and bipolar type schizoaffective disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/14/2025, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated R2 had verbal behavioral symptoms directed towards others and other behavioral symptoms not directed toward others for four to six days during the assessment's lookback period. R2's Care Plan, included a problem statement revised 03/07/2025, that indicated the resident was at risk for alteration of psychosocial wellbeing due to recent resident-to-resident abuse; R2 was the aggressor. Approaches directed staff to provide inpatient psychiatric referral (initiated 03/03/2025), medication review by providers (initiated 03/07/2025), and social service visits for three days (initiated 03/03/2025). A Resident Face Sheet indicated the facility admitted R3 on 09/13/2022. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of vascular dementia with mood disturbances, severe vascular dementia with psychotic disturbances, and major depressive disorder. A quarterly MDS, with an ARD of 03/25/2025, revealed R3 had a BIMS score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated R3 had no behavioral symptoms during the assessment's lookback period. R3's Care Plan, included a problem statement revised 03/07/2025, that indicated the resident was at risk for alteration of psychosocial wellbeing due to recent resident-to-resident abuse; R3 was the victim. Approaches (initiated 03/03/2025) directed staff to complete a room change for the resident, complete body audits for three days, and provide social service visits for three days. R2's Resident Progress Notes, revealed a note dated 03/02/2025 at 2:16 PM, by Licensed Practical Nurse (LPN)3 that indicated R2's roommate (R3) had family visiting and R2 began cursing at R3's family when the family took R3 to the room to lay down for a nap. Per the Resident Progress Notes, R2 stated, This is my [expletive] room. I do not want [R3] in here. [R3] can go to the couch to sleep and watch tv [television]. All [R3] does is piss up my bed and I'm sick of [R3]. Your [family member] is nasty, and I do not want [R3] here. You both can leave my room now. Per the Resident Progress Notes, R3's family member approached staff visibly upset and afraid for the safety of [R3]. The Resident Progress Notes indicated a grievance was filed, the DON was notified, and instructions were given to move R3 to another room. An Initial Report, dated 03/03/2025, revealed a two-hour initial report was completed for mental abuse of R3. Per the Initial Report, R2 was listed as the alleged perpetrator. The Initial Report indicated the date and time of the reportable incident was 03/03/2025 at 10:30 AM. The Initial Report indicated the Social Service Director (SSD) brought a grievance that was under her door that revealed the roommate of R3 was being mentally abusive to them. A Complaint/Grievance Report, dated 03/02/2025, revealed Responsible Party (RP)5, R3's RP, was very concerned how the resident's roommate (R2) was treating R3. The Complaint/Grievance Report indicated, I'm very concerned how [R2] is treating [R3] kicking [the resident] out of [their] room, mentally abusing [the resident]. The Complaint/Grievance Report revealed a section titled Documentation of Investigation that indicated the staff member assigned responsibility for the investigation was the DON and it was assigned on 03/02/2025; the report revealed the DON signed that the section was completed on 03/03/2025. The Complaint/Grievance Report indicated the plan to resolve the grievance was to move the resident to another room. During a telephone interview on 04/10/2025 at 4:31 PM, RP5 stated they were visiting with R3 and when they took R3 back to their room, R2 started yelling at R3. Per RP5, R2 stated R3 was not allowed to watch television, and that the resident urinated and defecated everywhere. RP5 stated they reported what occurred to the nurse. RP5 stated they filled out a complaint form and the facility immediately moved R3 to another room. RP5 stated they had observed no negative outcomes from the incident, and they did not think R3 remembered the incident. During a telephone interview on 04/10/2025 at 4:20 PM, LPN3 stated R3's family approached her and said they did not like the way R3's roommate (R2) was talking to them. According to LPN3, R2 was yelling, and she reported the incident to the DON. LPN3 said they moved R3 out of the room and once the family visit was completed, the family wished to file a grievance. LPN3 stated she assisted R3's family member in completing the grievance form and walked with the family member to the SSDs office where the family member placed the form under the door of the SSDs office. LPN3 said they moved R3 to a new room immediately. LPN3 stated she did not see the grievance form and said R3's family member did not say abuse, so she did not think anything about the incident. During an interview on 04/11/2025 at 1:06 PM, the Administrator stated the incident should have been reported on 03/02/2025 when the incident occurred, even if R3's family member did not say the word abuse.

Based on interview, record review, and review of facility policy, the facility failed to ensure Residents (R)2 and R3 were free from neglect, which resulted in R2 and R3 successfully eloping from the facility, for 2 of 6 residents reviewed for neglect. On 08/13/24 at 6:31, PM, the Administrator was notified that the failure to properly supervise two residents, resulting in the two residents successfully eloping from the facility, constituted Immediate Jeopardy (IJ) at F600. On 08/14/24 at 12:52 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 08/11/24. The IJ was related to 42 CFR 483.25 - Freedom from Abuse, Neglect, and Exploitation. On 08/14/24, the facility provided an acceptable IJ Removal Plan. On 08/14/24, the survey team, validated the facility's corrective actions and determined the facility did their due diligence in addressing the noncompliance at F600. The IJ is considered at Past Noncompliance as of 08/12/24. An extended survey was conducted in conjunction with the Complaint Survey for noncompliance at F600, constituting substandard quality of care. Findings include: Review of the facility's undated policy titled Abuse, Neglect, Exploitation, or Mistreatment documented, The facility's Leadership prohibits neglect, mental, physical and or verbal abuse . Component IV: Identification . 2. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, vascular dementia, Alzheimer's Disease, and major depressive disorder. Review of R2's unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/24, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating R2 was severely cognitively impaired. Under the section behaviors, it recorded R2 as wandering daily. Review of R2's Elopement assessment dated [DATE], indicated R2 was not oriented to her surroundings, and she is confused. Additionally, R2 has a history of wandering and requires supervision, intervention, and wander guard. Review of R2's Physician Orders revealed an order dated 11/22/22, which revealed to have a wander guard on at all times, check function and placement every shift. Review of R2's Care Plan dated 06/18/24, revealed R2 was an elopement risk, requiring wander guard on wrist and will wander safely within the facility with no elopement attempts. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to, vascular dementia, osteoarthritis of the knee, major depressive disorder, and Atherosclerotic heart disease. Review of R3's Admission MDS with an ARD of 09/20/22, revealed R3 had a BIMS score of 6 out of 15, indicating R3 was severely cognitively impaired. Review of R3's Elopement assessment dated [DATE], revealed a diagnosis of vascular dementia, not oriented to place or time, has a history of wandering and states R3 does not have a diagnosis that requires supervision. The intervention listed was a wander guard. Review of R3's Physician Orders dated 09/14/22, revealed an order to monitor for function and placement of wander guard every shift. Review of Spartanburg Weather for the date of 08/11/24, recorded a high temperature of 87 degrees Fahrenheit and a low temperature of 71 degrees Fahrenheit with no precipitation. Review of a statement provided by Registered Nurse (RN) on 08/11/24 at approximately 9:00 PM, revealed R2 and R3 were let out the back door by the RN, on duty along, with other smokers with no escort or supervision. The RN's written statement reported, . [R2 and R3] verbalized attention to smoke and were last visualized at 2100 . Residents returned at approximately 2145. During an interview on 08/13/24 at 10:45 AM, the Assistant Director of Nursing (ADON) stated, I got a call from a nurse at the facility around 9:03 PM on 08/11/24, to report two residents were missing from Unit 2 and she couldn't find the nurse. She couldn't give me much information, so I got in my car and headed to the building. The [RN] called me to tell me they were missing as I was on the phone with 3 CNA's [Certified Nursing Assistants] on speaker, who were out looking for them. I heard the CNA say, Lets follow EMS as they passed the facility. They did and said they had found the two residents down [NAME] Road. I passed the facility and went there. I spoke to EMS. They said the residents were ok and will monitor their vitals, so I returned to the facility to do a head count, using the census, everybody was there. EMS brought the residents back about 15 minutes later. They were gone for approximately an hour. The sidewalk terminates so they either walked on grass or the road. During an interview on 08/13/24 at 11:32 AM, the Administrator stated, I arrived here about 9:40 PM, after I got a call from the ADON. She reported to me that [R2 and R3] were missing, that they had not seen them. I asked if they searched that whole building. I was told no. I instructed her to tell them to search everywhere. They were located about a mile down the road. I drove down to where they were located to be sure of the distance. During an interview on 08/13/24 at 12:10 PM, Certified Nurse Assistant (CNA)1, who was assigned to both residents, stated, I answered the doorbell, I thought it was my pizza. But it was two residents who were returning from outside and told me they saw two ladies outside. I immediately went to the hall I was working on, they were not there. I went to the nurse. He was from agency. He said, I let two ladies out of this door a little while ago, that was about 8:30 PM - 8:45 PM. I figured I'd let them out to smoke and they'd be right back. He said they looked like they could be allowed outside, they looked competent. I said what two ladies, one with a walker and one with sunglasses on and he said yes. I knew that was them. After that, I asked are they still out there. I walked outside and I didn't see them and started walking around the building. I grabbed a CNA from another hall and the hospitality aid who was out in the courtyard with the smokers. I went back to the nurse and told him I couldn't find those residents outside. I said I think we need to call a code or call someone. He said, I am not calling anybody until you check everybody in the facility. We then did that. I went back and informed him they were not there. The nurse on the other unit called the ADON and reported it to her. That's when the ADON said she was coming in. We went back outside and looked for the two ladies. There's another facility to the left of the building and two CNA's went that way to see if they were there. Then I saw an EMS truck go by, we followed them. I went with another CNA and followed the fire truck, ambulance and cop car. We followed them about a mile and a half or so. We saw them pulled over and the two residents were there. EMS said they are fine, it's just hot. We are going to take their vitals. The officer said someone had called it in, they drove by and saw them. It was about 1.5 - 2 miles away. [R2] was wearing a tee shirt and capri's with tennis shoes, [R3] had on a long sleeve shirt and pants with her ballerina slipper like shoes, she was very hot, sweating so bad. Her heart rate was 180, that is what EMS said. During an interview on 08/13/24 at 1:18 PM, CNA2 stated, I worked on Sunday on the 3 - 11 shift. I was working on station 1. One of the residents came to me and told me two of the ladies got out. I went outside to scope and see. I saw some other CNAs out there. We told the nurses. I got in my car and drove onto [NAME] Road to the right and didn't see them, so I went the opposite way and didn't see them. I guess I didn't go far enough because I didn't see them. During an interview on 08/13/24 at 2:04 PM, R7 stated, We just got back from the store. We seen [R2 and R3] coming out the back door. They walked the property. They went toward the entrance and never came in. I went to the street, and I didn't see them. I rang the doorbell and the nursing assistant answered. We told her about the two ladies we saw. She went to their rooms and didn't see them. I went to the nurse to tell him. I didn't see who let them out. On 08/14/24, the facility provided an acceptable IJ Removal Plan, which included the following: Residents #2 and #3 returned to the facility on [DATE]. Residents were assessed by the Assistant Director of Nursing on 8/11/24. No injuries identified . Social Services assessed residents for emotional distress on 8/13/24 and referrals made as indicated . Agency Nurse was sent home on 08/11/24 and agency notified for this nurse to not return to this facility. Elopement risk Assessments were completed on 8/12/24 . Those residents identified at risk had interventions initiated and care plan updated by 8/13/24. Facility staff were reeducated on Elopement Policy by the Director of Nursing/Designee on 8/12/24 . Facility staff were reeducated on Abuse, Neglect, & Misappropriation by the Administrator/Designee on 8/14/24 . Facility staff not receiving this education by the target date will receive prior to their next scheduled shift. Agency staff will be educated on the Elopement Policy and Abuse, Neglect & Misappropriation policy prior to their first assignment . An elopement drill will be completed by 8/14/24 on each shift . Director of nursing/Designee will interview a minimum of 5 staff members per week for 4 weeks to validate transfer of knowledge. The Administrator/Designee will interview a minimum of 5 residents per week for 4 weeks to validate residents feel safe and have no care concerns. The Director of Nursing/Designee will observe care and interactions of staff members with 3 residents per week for 4 weeks to validate residents feel safe and there is no care concerns. Any identified issues will be addressed at time of discovery. Ad Hoc QAPI was held on 8/14/24 to review the contents of this plan. The Medical Director was notified on 8/14/24 of the immediate Jeopardy and the contents of this plan. AOC date: 8/15/24

Based on interviews, record review and review of facility policy, the facility failed to provide appropriate supervision to prevent Resident (R)2, and (R)3's elopement from the facility. On 08/13/24 at 6:31 PM, the Administrator was notified that the failure to properly supervise two residents, resulting in the two residents successfully eloping from the facility, constituted Immediate Jeopardy (IJ) at F689. On 08/13/24 at 6:31 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 08/11/24. The IJ was related to 42 CFR 483.25 - Free of Accident Hazards/Supervision. On 08/14/24, the facility provided an acceptable IJ Removal Plan. On 08/14/24, the survey team, validated the facility's corrective actions and determined the facility did their due diligence in addressing the noncompliance at F689. The IJ is considered at Past Noncompliance as of 08/12/24. An extended survey was conducted in conjunction with the Complaint Survey for noncompliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy titled Elopement dated 11/01/17, stated, To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident. Once is it determined that a patient/resident is missing, all employees are notified immediately by paging overhead, and it was blank but states, insert code name. Review of the facility policy titled Accident/Incident Reporting - Patient/Resident stated, An accident is an unexpected, unintended event that can result in bodily injury. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease, vascular dementia, Alzheimer's Disease, and major depressive disorder. Review of R2's unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/24, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating R2 was severely cognitively impaired. Under the section behaviors, it recorded R2 as wandering daily. Review of R2's Elopement assessment dated [DATE], indicated R2 was not oriented to her surroundings, and she is confused. Additionally, R2 has a history of wandering and requires supervision, intervention, and wander guard. Review of R2's Physician Orders revealed an order dated 11/22/22, which revealed to have a wander guard on at all times, check function and placement every shift. Review of R2's Care Plan dated 06/18/24, revealed R2 was an elopement risk, requiring wander guard on wrist and will wander safely within the facility with no elopement attempts. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to, vascular dementia, osteoarthritis of the knee, major depressive disorder, and Atherosclerotic heart disease. Review of R3's Admission MDS with an ARD of 09/20/22, revealed R3 had a BIMS score of 6 out of 15, indicating R3 was severely cognitively impaired. Review of R3's Elopement assessment dated [DATE], revealed a diagnosis of vascular dementia, not oriented to place or time, has a history of wandering and states R3 does not have a diagnosis that requires supervision. The intervention listed was a wander guard. Review of R3's Physician Orders dated 09/14/22, revealed an order to monitor for function and placement of wander guard every shift. Review of Spartanburg Weather for the date of 08/11/24, recorded a high temperature of 87 degrees Fahrenheit and a low temperature of 71 degrees Fahrenheit with no precipitation. Review of a statement provided by Registered Nurse (RN) on 08/11/24 at approximately 9:00 PM, revealed R2 and R3 were let out the back door by the RN, on duty along, with other smokers with no escort or supervision. The RN's written statement reported, . [R2 and R3] verbalized attention to smoke and were last visualized at 2100 . Residents returned at approximately 2145. During an interview on 08/13/24 at 10:45 AM, the Assistant Director of Nursing (ADON) stated, I got a call from a nurse at the facility around 9:03 PM on 08/11/24, to report two residents were missing from Unit 2 and she couldn't find the nurse. She couldn't give me much information, so I got in my car and headed to the building. The [RN] called me to tell me they were missing as I was on the phone with 3 CNA's [Certified Nursing Assistants] on speaker, who were out looking for them. I heard the CNA say, Lets follow EMS as they passed the facility. They did and said they had found the two residents down [NAME] Road. I passed the facility and went there. I spoke to EMS. They said the residents were ok and will monitor their vitals, so I returned to the facility to do a head count, using the census, everybody was there. EMS brought the residents back about 15 minutes later. They were gone for approximately an hour. The sidewalk terminates so they either walked on grass or the road. During an interview on 08/13/24 at 11:32 AM, the Administrator stated, I arrived here about 9:40 PM, after I got a call from the ADON. She reported to me that [R2 and R3] were missing, that they had not seen them. I asked if they searched that whole building. I was told no. I instructed her to tell them to search everywhere. They were located about a mile down the road. I drove down to where they were located to be sure of the distance. During an interview on 08/13/24 at 12:10 PM, Certified Nurse Assistant (CNA)1, who was assigned to both residents, stated, I answered the doorbell, I thought it was my pizza. But it was two residents who were returning from outside and told me they saw two ladies outside. I immediately went to the hall I was working on, they were not there. I went to the nurse. He was from agency. He said, I let two ladies out of this door a little while ago, that was about 8:30 PM - 8:45 PM. I figured I'd let them out to smoke and they'd be right back. I asked are they still out there. I walked outside and I didn't see them and started walking around the building. I grabbed a CNA from another hall and the hospitality aid who was out in the courtyard with the smokers. I went back to the nurse and told him I couldn't find those residents outside. I said I think we need to call a code or call someone. He said, I am not calling anybody until you check everybody in the facility. We then did that. I went back and informed him they were not there. The nurse on the other unit called the ADON and reported it to her. That's when the ADON said she was coming in. We went back outside and looked for the two ladies. There's another facility to the left of the building and two CNA's went that way to see if they were there. Then I saw an EMS truck go by, we followed them. I went with another CNA and followed the fire truck, ambulance and cop car. We followed them about a mile and a half or so. We saw them pulled over and the two residents were there. EMS said they are fine, it's just hot. We are going to take their vitals. The officer said someone had called it in, they drove by and saw them. It was about 1.5 - 2 miles away. [R2] was wearing a tee shirt and capri's with tennis shoes, [R3] had on a long sleeve shirt and pants with her ballerina slipper like shoes, she was very hot, sweating so bad. Her heart rate was 180, that is what EMS said. During an interview on 08/13/24 at 1:18 PM, CNA2 stated, I worked on Sunday on the 3 - 11 shift. I was working on station 1. One of the residents came to me and told me two of the ladies got out. I went outside to scope and see. I saw some other CNAs out there. We told the nurses. I got in my car and drove onto [NAME] Road to the right and didn't see them, so I went the opposite way and didn't see them. I guess I didn't go far enough because I didn't see them. During an interview on 08/13/24 at 2:04 PM, R7 stated, We just got back from the store. We seen [R2 and R3] coming out the back door. They walked the property. They went toward the entrance and never came in. I went to the street, and I didn't see them. I rang the doorbell and the nursing assistant answered. We told her about the two ladies we saw. She went to their rooms and didn't see them. I went to the nurse to tell him. I didn't see who let them out. On 08/14/24, the facility provided an acceptable IJ Removal Plan, which included the following: Residents #2 and #3 returned to the facility on [DATE]. Residents were assessed by the Assistant Director of Nursing on 8/11/24. No injuries identified . Social Services assessed residents for emotional distress on 8/13/24 and referrals made as indicated . Agency Nurse was sent home on 08/11/24 and agency notified for this nurse to not return to this facility. Elopement risk Assessments were completed on 8/12/24 . Those residents identified at risk had interventions initiated and care plan updated by 8/13/24. Facility staff were reeducated on Elopement Policy by the Director of Nursing/Designee on 8/12/24 . Facility staff not receiving this education by the target date will receive prior to their next scheduled shift. Agency staff will be educated on the Elopement Policy and Abuse, Neglect & Misappropriation policy prior to their first assignment . An elopement drill will be completed by 8/14/24 on each shift . Director of nursing/Designee will interview a minimum of 5 staff members per week for 4 weeks to validate transfer of knowledge. Ad Hoc QAPI was held on 8/13/24 to review the contents of this plan. The Medical Director was notified on 8/13/24 of the immediate Jeopardy and the contents of this plan. AOC date: 8/14/24

Based on review of facility policy, record review, and interview, the facility failed to notify the responsible party for Resident (R) 2 and R3, of an elopement, for 2 of 3 residents reviewed for elopement. Findings include: Review of the facility policy titled Elopement dated 11/01/17, documented, When the resident is located . The Director of Nurses or the designee notifies the Administrator/designee and notifies the appropriate community agencies, attending physician and the residents legal representative. Review of R2's Face Sheet revealed the facility admitted R2 on 09/13/22, with diagnoses including but not limited to: chronic obstructive pulmonary disease, vascular dementia, Alzheimer's Disease, and major depressive disorder. Review of R2's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/24, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating R2 had severe cognitive impairment. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to: vascular dementia, osteoarthritis of the knee, major depressive disorder, and Atherosclerotic heart disease. Review of R3's Admission MDS with an ARD of 06/19/24, revealed R3 had a BIMS score of 6 out of 15, indicating R3 was severely cognitively impaired. Review of Registered Nurse (RN) written statement dated 08/11/24 at approximately 9:00 PM, revealed R2 and R3 were let out the back door of the facility by the RN on duty, along with other smokers, with no escort or supervision. The RN's written statement stated, They [R2 and R3] verbalized attention to smoke and were last visualized at 2100. Residents returned at approximately 2145. Record review of R2's progress notes did not record anything related to the elopement. Additionally, there was no notification to the Responsible Party. Record review of R3's progress notes did not record anything related to the elopement. Additionally, there was no notification to the Responsible Party. During an interview on 08/13/24 at 11:32 AM, the Administrator stated, I arrived here about 9:40 PM after I got a call from the ADON [Assistant Director of Nursing]. She reported to me that [R2 and R3] were missing, that they had not seen them. I asked if they searched that whole building. I was told no. I instructed her to tell them to search everywhere. They were located about a mile down the road. I drove down to where they were located to be sure of the distance. During an interview on 08/13/24 at 2:25 PM, R2's daughter stated, The only time they ever tell me stuff that's going on, is in the care plan meeting. I'm not aware of this situation, of her leaving the facility and walking down the street. This really ticks me off so bad. They ain't told me nothing. Whenever I call, they tell me, well so and so is out of the office, you'll have to call back. Mama's got Alzheimer's, they need to tell me. During an interview on 08/13/24 at 2:38 PM, R3's Guardian (court appointed) stated, I am the first point of contact for [R3]. I work for an advocacy group. I am not aware she got out and was walking down the street at night. I've not been notified at all. During an interview on 08/13/24 at 4:00 PM, the Administrator stated, For investigations regarding elopement we start the investigation as soon as possible. I don't call the Responsible Party, the nurses usually make that call, not me. During the investigation period, I will ask if someone notified the Responsible Party. There are times when I may have forgotten to give the information. The Administrator confirmed there was no documentation in R2's or R3's record that the responsible party had been notified.

Based on observations, interviews, and a review of facility policy, the facility failed to ensure foods stored in the refrigerator, and nourishment kitchen were free from expiration. This failure had the potential to affect residents in the facility who consumed food from the kitchen and received food from the nourishment kitchen. Findings include: A review of the facility's policy titled, Nutrition policy and procedures on cleaning walk-in refrigerator with a complete revision date of [DATE] states 2. Verify that all products are properly labeled and dated. On [DATE] at 10:35 AM and [DATE] at 04:45 PM, the following observations in the kitchen and nourishment kitchen were made with and verified by the Dietary Manager (DM): Main refrigerator/Cooler-Two clear bags, both with 6 heads of lettuce each with no open date and a use-by date of [DATE] listed on the bag. All 12 heads of lettuce in the bags were brown with pink build-up surrounding the entire head of lettuce. An observation of the nourishment kitchen, located in B Hall on [DATE] at 4:34 PM revealed the refrigerator has three (3) cartons of Dairy Pure 1% low-fat milk, with an expiration date of [DATE]th, 2024. An interview with the DM on [DATE] at 10:36 AM revealed that staff is expected to check the coolers, freezers, and all other food storage areas for expired foods. DM stated that it's everyone's responsibility. The DM stated, The heads of lettuce were at the very bottom, and it was overlooked. During a follow up interview on [DATE] at 04:45 PM, the DM stated, Typically every day, her staff delivers sandwiches and snacks to the nourishment kitchen and removes expired items. DM confirmed the milk was past its expiration date and didn't belong in the refrigerator. On [DATE] at approximately 12:06 PM, an interview with the Facility Administrator stated her expectation of the kitchen is for all items to be discarded by use-by dates. She said, Staff should be discarding items that have expired to not compromise other foods.

Based on observation, interview, and record review, the facility failed to ensure Resident (R)6 was treated with dignity by failing to ensure his catheter bag was covered to promote privacy. Finding include: Review of the Admission Record revealed R6 was admitted on [DATE] with diagnoses including but not limited to, major depressive disorder and Parkinson's disease. Review of R6's Minimum Data Set (MDS), located in the Electronic Medical Record (EMR) with an Assessment Reference Date (ARD) of 06/30/23, revealed R6 has a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating the resident was moderately cognitively intact. During an observation, R6 was observed sitting up in bed on 08/24/23 at 12:25 PM. He appeared unkempt, with long facial hair, and his catheter bag was full without a privacy bag. The privacy bag was observed at 12:25 PM and 1:56 PM on 08/24/23. An interview on 08/24/23 at 1:56 PM with R6 revealed that he does prefer to have his face shaved and it has not been shaved today. He stated he feels the facility uses cheap catheter bags, and it bursts many times, causing the urine to go all over the floor. During an interview on 08/24/23 at 2:30 PM with Assistant Director of Nursing revealed catheter bags should always have a privacy bag and changed as needed.

Based on review of the facility's policy, observations, and interview, the facility failed to ensure the processing of clean and dirty laundry was separated in the laundry room; and failed to ensure accessibility for handwashing for laundry staff. This failure effected all laundered items and any of the facility's 83 residents who received laundered items. Findings include: Review of the facility's Infection Prevention and Control Policies and Procedures, Subject: Linen and Laundry Services, completed revision 09/2011. Laundry Facilities: 1. A. Laundry areas are housed away from patient/resident care areas. B. The soiled laundry area is separated from the clean, through either use of negative pressure for the soiled area, or by physical separation. C. Areas where laundry is processed have hand washing facilities, appropriate hand washing supplies and personal protective equipment available for staff use. On 02/03/23 at 10:55 AM, a tour of the laundry room was conducted with the Acting Laundry Supervisor (ALS). The laundry room had one door entry for the clean and dirty processing of resident clothing. The bed linens and towels were processed by a company offsite. The laundry room was very small and contained one each of a commercial washer and dryer. A large bin of dirty laundry was stored near the washer with a plastic cover over the bin. A rack, approximately five feet long housing clean clothing and blankets was partially covered with a flat sheet. Longer clothing items were uncovered by the sheet. Two to four of the blankets were touching the floor. The ALS stated the laundry was cluttered with boxes of unclaimed clothing items. There was no visible hand washing facility in the laundry room. The ALS stated staff had to go out in the hall and enter a resident room, if available, to wash their hands. Two-plastic bottles were placed on a high shelf for eye wash. A dusty fan was mounted high on the wall and blowing in the direction of the clothing processing area. During an interview on 02/03/23 at 11:10 AM during the tour, the ALS confirmed the processing of clean and dirty with a separation of space was not provided by the layout of the laundry room and monitoring of the separation can not be assured. She also confirmed that hand washing was not assessable in the laundry room. During an interview with the Assistant Director of Nursing/Infection Control Preventionist on 02/03/23 at approximately 6:50 PM, she confirmed that the lack of accessibility for handwashing and assurance of separation of processing dirty and clean laundry was not acceptable practice.

Based on review of the Resident Assessment Instrument Manual, record review, and interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the regulatory timeframe for one resident (R) 45 reviewed for Resident Assessments. Findings include: Review of the ''Resident Assessment Instrument [RAI] Manual,'' October 2019 edition, indicated that a quarterly MDS assessment was to be completed at least every 92 days when a comprehensive assessment was not required. R45 was originally admitted to the facility on [DATE]. A review of the MDS assessments for R45 revealed the most recent quarterly MDS completed had an assessment reference date (ARD) of 09/23/22. An interview and electronic medical record review was conducted with the MDS Coordinator on 02/03/23 at 5:37 PM. The MDS Coordinator confirmed R45's quarterly last quarterly MDS was on 09/23/22. The MDS Coordinator stated he was responsible for timely completion of MDS and that he had missed R45's quarterly MDS and it was late. The MDS Coordinator acknowledged the quarterly MDS assessment for R45 was not completed within the regulatory timeframe. During an interview with the Administrator on 02/03/23 at 6:32 PM, she stated she was aware of some issues with timely MDSs and this was part of the Quality Assurance and Performance Improvement (QAPI) indicators under review.

Based on review of the facility policy, record review, and interviews, the facility failed to follow the Preadmission Screening and Resident Review (PASARR) process for individuals prior to admission to the facility by failing to complete Level I screening for 2 of 2 residents (Resident (R)11 and R71) reviewed for PASARR. Findings include: Review of facility's policy title PASSR Documentation Policy dated 04/2022 revealed . GENERAL GUIDELINES FOR PASARR: PASARR requires that: All applicants to a Medicaid-certified nursing facility are evaluated for mental illness A. and or intellectual disability, prior to admission and, B. Offered the most appropriate setting for their needs which may be in the community, a nursing facility, or an acute care setting, and C. Receive necessary services in those settings to address any specific need related to the diagnosis of mental illness or intellectual disability. 1. Review of R11's admission record located in the Profile tab of the electronic medical record (EMR), revealed R11 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, vascular dementia, major depressive disorder, and Parkinson's disease. A Level I PASARR could not be located in R11's EMR. During an interview on 02/03/23 at 2:15 PM, the Administrator stated R11 was admitted from home as a private pay resident and did not need a PASARR. 2. According to R71's admission record located in the Profile tab of the EMR, R71 was admitted to the facility on [DATE] with diagnoses that included acute prostatitis, schizoaffective disorder, bipolar disorder, depression, and generalized muscle weakness. A Level I PASARR could not be located in R71's EMR. During an interview with the Administrator on 02/03/23 at 2:15 PM the Administrator admitted R71 did not have a PASARR on file and had no explanation for the absence of PASARR documentation for R71.

Based on facility policy review, record review, and interviews, the facility failed to a ensure an end date was added to an as needed (PRN) psychotropic medication order, a medication that alters the mood or thought process for 1of 5 residents (Resident (R) 46) reviewed for unnecessary medications. The facility also failed to ensure a prescriber provided clinical rational for the continuation of a PRN medication beyond 14 days. This failure could have led to the resident remaining on a PRN psychotropic medication longer than necessary. Findings include: Review of the facility's policy dated 04/01/22, titled PSYCHOTROPIC DRUGS - USE OF revealed: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: A. Anti-psychotic. B. Anti-depressant. C. Anti-anxiety, and D. Hypnotic. Further review of the policy revealed: D. PRN orders for psychotropic drugs are limited to 14 days. Except as provided in if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. E. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. . 14. PRN Orders for Psychotropic Medications A. The facility will only order PRN psychotropic medications to treat a diagnosed specific condition and the prescribing physician must document the diagnosed specific condition and the indication for the PRN in the medical record and should be ordered for no more than 14 days. For psychotropic medications, excluding antipsychotics, if the attending physician believes a PRN order for longer than 14 days is appropriate, the attending physician can extend the prescription beyond 14 days for the resident by documenting their rationale along with a specific duration in the residents' medical record. At the time a PRN is administered, documentation must be present to justify the need for the medication, the non-pharmacological interventions attempted, and that monitoring for side-effects and effectiveness has occurred. Review of R46's Admission Record located in the resident's electronic medical record (EMR) under the Profile tab, revealed R46 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, vascular dementia, anxiety disorder, and major depressive disorder. Review of R46's current Physician Orders, located in the resident's EMR under the Orders tab, revealed R46 was prescribed lorazepam (an antianxiety medication) 0.5 milligram (mg) every four hours PRN (as needed) for anxiety disorder on 09/21/22. Continued review of the order revealed the order was open ended and did not include an end date. Review of the Note to Attending Physician/Prescriber pharmacist communication document dated 09/22/22 revealed Resident has a PRN order for an anxiolytic, Lorazepam 0.5 mg Q4H [every four hours] which has been in place for greater than 14 days without a projected stop date or duration of therapy. Recommendation: Please discontinue the PRN order or if the medication cannot be discontinued at this time, CMS requires that the prescriber document the indication for use, the intended duration of therapy and the rationale for the extended time period. Further review of the document revealed the physician's response as follows: - pt [patient] hospice; no due to patient being hospice. The physician's response failed to reveal an indication for use or projected duration of therapy. During an interview on 02/03/23 at 7:25 PM, the MDS Coordinator stated that per facility policy, a PRN psychotropic medication should be evaluated after 14 days.

Based on review of facility policy, record review, observation, and interview, the facility failed to ensure that intravenous (IV, medication given through the vein) fluids administered were labeled with the date, time, and initials of the person who hung them according to facility policy for 1 resident observed on IV fluids (Resident (R)16). Findings include: Review of the facility's police number 6.4 titled Medication Labeling revised on 04/01/22 revealed, 1. The Facility shall ensure that the pharmacy provider labels medications dispensed in accordance with State and Federal regulations. 2. The Facility shall ensure that all medications are labeled appropriately. Further review of the policy revealed, .8. Nursing should ensure that infusion therapy labels include the medication name, volume, infusion rate, name and quantity of each additive, date of preparation, initials of compounder, date and time of administration, initials of person administering the medication, ancillary labeling and expiration date. Review of R16's physician orders located in the electronic medical record (EMR) under the Orders tab revealed an order dated 02/02/23 for 1 liter NS [normal saline] via clysis at 40ml/hr [milliliters per hour] x 2. Observation on 02/02/23 at 11:16 AM in R16's room revealed two-1000 milliliter (ml) bags of normal saline IV fluid hanging and infusing. Neither bag was labeled with the date, time, rate of infusion and initial of the person who hung the bags. Further observation in R16's room on 02/03/23 at 3:45 PM revealed the two bags still hanging and infusing and still unlabeled. During an interview and observation on 02/03/23 at 4:51 PM, Licensed Practical Nurse (LPN)1 was asked how to tell who hung the IV fluids and on what date and time. LPN1 stated you don't. LPN1 acknowledged the IV fluids were unlabeled and stated the standard was to label hanging infusion with date, time, and initial of the person hanging them. LPN1 stated the IV fluids were hung by another nurse (LPN) the previous day. During an interview with the Assistant Director of Nursing on 02/03/23 at 5:11 PM, she stated IV fluids should be labeled with nurse's initials when hung.

Based on interview and record review of the facility's Daily Staffing Sheet for January, 2022 the facility failed to have Registered Nursing Coverage on 22 days during this time period. The findings include: A phone interview with Resident (R)#1 Resident Representative on 2/23/22 at 10:15 AM revealed several concerns related to staffing and quality of care that R#1 received while he was a resident at the facility. They stated that the facility is running short-handed and because of the lack of staff the quality of care has declined. It can take staff up to an hour to respond to a call light and I have witnessed this wait time when I visited the resident. R#1 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Daily Staffing Sheet for January, 2022 revealed the facility did not have RN coverage on the following dates. 1/1/22, 1/2/22,1/4/22,1/7/22, 1/8/22,1/10/22, 1/11/22, 1/12/22, 1/13/22, 1/15/22, 1/19/22, 1/20/22, 1/21/22, 1/22/22, 1/23/22, 1/24/22, 1/26/22, 1/27/22, 1/28/22, 1/29/22, 1/30/22, and 1/31/22. An interview with the Administrator on 2/23/22 at 12:30 PM revealed that the facility did not have RN coverage on 22 out of 31 days for the month of January, 2022.

Based on observations, record review, interviews, and facility policies, the facility failed to ensure proper food storage and kitchen sanitation in 1 of 1 kitchen observed. Specifically, the facility failed to ensure the proper storage, labeling, and dating of dry and refrigerated foods; ensure the proper cleaning of equipment and storage of sanitized dishware; and maintain records of the dishwasher temperatures and sanitizer level. These failures placed all 70 residents at risk for food contamination and potential foodborne illness. Findings include: 1. Proper storage, labeling, and dating of dry and refrigerated foods: Review of the facility's policy and procedure titled Nutrition Policies and Procedures, last revised [DATE], revealed safety precautions shall be followed when delivery containers, crates or boxes are opened, and when food and supply items are stored. The policy and procedure directed staff to: Clearly label all containers Refrigerated, ready-to-eat Time/Temp. Control for Safety Foods (TCS) are properly covered, labeled, dated with a use-by-date and refrigerated immediately. Mark them clearly to indicate the day by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day one. Discard after three days unless otherwise indicated. Refuse contaminated food and return to the vendor for credit. If the food cannot be returned immediately, store it away from other food and supplies to prevent contamination. Dented cans are stored in a designated location (labeled dented cans) until they can be returned to the vendor. Observation of the kitchen conducted on [DATE] at 10:30 AM, in the presence of the Certified Dietary Manager (CDM), revealed the dry storage area contained several undated cases of packaged food, three dented can food items, and four bottles of lemon juice which expired on [DATE] available for use. The walk-in refrigerator several undated boxes of packaged food (i.e., shredded lettuce, shredded cheese, etc.) and one 10-pound package of hamburger meat that was brownish/greenish in color. Observation of the kitchenet located between the A and B unit conducted on [DATE] at 3:47 PM, in the presence of the CDM, revealed one case of outdated (,d+[DATE]) thickened dairy [NAME] located in the cabinet above the sink. Also, a 20-ounce Coke bottle and Styrofoam cup belonging to staff was on located on the countertop. 2. Proper cleaning of equipment and storage of sanitized dishware Review of the facility's policy and procedure titled Nutrition Policies and Procedures, last revised [DATE], revealed utensils and dishes washed by a mechanical dishwasher will be cleaned and sanitized. Store clean sanitized dishes and utensils in a clean, dry location not exposed to splash or other contamination. Observations of the Kitchen conducted on [DATE] at 10:30 AM and [DATE] at 11:47 PM revealed two baking sheet containing dried food and three dirty pans mixed in with the clean dishware. The can opener blade was dirty and contained a dried black substance. Observation of the refrigerator located between the A and B unit conducted on [DATE] at 3:47 PM, in the presence of the CDM, revealed the refrigerator was dirty and contained dried food and debris on the shelves, sides, and bottom of the refrigerator. The pipe under the sink was not connected properly and there was a bucket located under the pipe to catch leaking water. 3. Maintain records of the dishwasher temperature and sanitizer level. The facility's policy and procedure titled Nutrition Policies and Procedures, last revised [DATE], directed staff to check the cleanliness of the machine (dishwasher). Fill and rinse tanks with clear water. Check the temperature of the wash & rinse cycles, verifying that both meet the temperature posted on the dishwashing machine. If using a low temp machine, check the sanitizer level at contact times specified in accord with the product label. Record data on the Temperature and Sanitizer Log. On [DATE] at 11:45 AM, an observation of the CDM checking the temperature and sanitizer of level of the low temp dishwasher. The CDM needed to run the low temperature dishwasher twice to reach the appropriate temperature (120 degrees Fahrenheit) and check the sanitizer level. Review of the dishwasher Temperature and Sanitizer Logs, dated ,d+[DATE] through ,d+[DATE], revealed staff did not record the dishwasher temperature and sanitizer level [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], and [DATE] through [DATE]. During an interview with Dietary Assistant (DA) 1 on [DATE] at 1:07 PM, DA1 stated dented cans are dated and placed in a separate area for non-use. Refrigerated, frozen, or dry storage foods, staff place a received date on the outside of the cases. Once items are removed from cases, staff are supposed to note the received date on each container. Cooked food covered with saran [NAME] or a proper fitting lid, dated the day it was prepared and discarded within three days. DA1 stated that staff are supposed to spray all excess food off dishware, place dishware on a dish rack, ensuring not to overcrowd the dish rack prior to placing the dishware in the dishwasher. The dish racks are then placed in dishwasher, and staff are supposed to check to ensure the dishwasher temperature is 120 degrees Fahrenheit. DA1 also indicated that s/he checks the sanitizer (parts per million, (PPM)) every hour. If the PPM drops below the required level, the sanitizer is changed. The temperature of the dishwasher is checked during every cycle. Dishwasher temperature/PPM of the sanitizer is supposed to be checked three times/day and documented in logbook but sometimes staff forgets. During an interview with the CDM on [DATE] at 10:30 AM and [DATE] at 11:47 PM The CMD acknowledged the two-baking sheet containing dried food and three dirty pans mixed in with the clean dishware. The CDM indicated staff did not have a chance to clean the dirty backing sheet. The CDM stated that the dirty backing sheet and pans should not be mixed with the clean dishware. During an interview with the CDM on [DATE] at 1:15 PM, the CDM stated staff are supposed to date can foods upon receipt, dented cans are removed from use and placed in a separate area. The CDM contacts the vender to notify them of the dented cans and depending on the number of dented cans the facility will return them for a credit or throw them away. Refrigerated, frozen, or dry storage foods, a date in which the product was received is put on the cases. Once items are removed from cases, staff are supposed to note the received date on each container. Staff are supposed to check the temperature and sanitizer level of the dishwasher three times a day and document the results on the temperature and sanitizer log. If dishware comes out of the dishwasher dirty, staff are to re-wash/scrub the dishware before putting it away. In addition, staff are supposed to wipe down the reach-in refrigerator (referred to as the ice cream refrigerator) daily and deep cleaned it once a week.

Based on interview and record review, the facility failed to provide residents with regular post on Saturdays for 1 of 1 facility reviewed. The resident council voiced concerns that mail was not delivered on Saturdays without the Activities Director. Follow up interviews with staff confirmed lack of regular mail delivery on Saturdays. The findings included: Interview with the five members of the Resident Council on 6/21/21 at approximately 4:06 PM revealed the residents don't get consistent mail on Saturdays. They continued that mail delivery is less reliable on Saturdays where the Activities Director is not present. Interview with Activities Director on 6/24/21 at approximately 9:24 AM revealed the Activities Director is present every other Saturday to deliver mail. On weekends when they are not present, it is the responsibility of the manager on duty to distribute mail. The Maintenance Director was the last manager on duty. Interview with the Maintenance Director on 6/25/21 at approximately 9:34 AM confirmed that mail was not passed out that previous weekend, as was the responsibility of the manager on duty. Review of the Mail Distribution Policy on 6/24/21 at approximately 9:59 AM revealed that personal mail is to be delivered within 24 hours of receipt by Activity Staff or Designated Volunteer.

Based on observations and interviews, the facility failed to ensure an anti-rollback device installed on the wheelchair for 1 of 1 resident (Resident (R) 464) reviewed for a safe environment was not in disrepair. This failure had the potential to allow the resident's wheelchair to roll backwards when the resident stood up from the wheelchair without assistance. Findings include: Review of the Resident Face Sheet revealed R464 was admitted to the facility on [DATE]. R464's pertinent admission diagnoses included dementia without behavioral disturbances, age-related debility, and unspecified fall. Since R464 was admitted to the facility on [DATE], the admission Minimum Data Set (MDS) assessment was not available for review. Review of R464's baseline care plan, dated 06/16/2021, and comprehensive care plan dated 06/18/2021 revealed R464 was at risk for falls. The interventions directed staff to encourage the use of the call light, orient the resident to the room and bathroom, and keep the room free of clutter, and safety devices as indicated. The care plan did not indicate the use of an anti-rollback device to R464's wheelchair. Observations of R464's wheelchair, conducted on 6/22/21 at 1:43 PM and 4:13 PM, and 06/23/2021 at 9:20 AM, revealed the anti-rollback device installed on R464's wheelchair were in disrepair. The right brake arm was missing, and the left brake arm did not wrap around the tire of the wheelchair. Observation conducted on 06/23/2021 at 9:25 AM, in the presence of the Certified Occupational Therapy Assistant (COTA), revealed R464's wheelchair had an anti-rollback device in place. The COTA acknowledge the anti-rollback device was in disrepair. The right brake arm was missing, and the left brake arm rested on the center of the wheelchair tire instead of wrapping around the tire of the wheelchair. Although the anti-rollback device was in disrepair, the COTA pulled R464's wheelchair backward, and the anti-rollback device prevented the wheelchair from rolling back. During an interview with the COTA on 06/23/2021, at 9:25 AM, the COTA confirmed the anti-rollback device installed on R464's wheelchair was in disrepair. S/he said the right brake arm was missing and the left brake arm should wrap around the tire of the wheelchair. Although the device was in disrepair and prevented the wheelchair from rolling back, s/he indicated the anti-rollback device would be more effective if it was not in disrepair.

Based on observations, record reviews, interviews, and facility policy, the facility failed to complete a restraint assessment and attempt less restrictive measures for 1 of 1 resident (Resident (R) 464) before and during the use of half-side rails and an alarm after R464 sustained an unwitnessed fall in the facility. This failure placed the resident at potential risk for not functioning at their highest level in the least restrictive environment possible. Findings include: Review of the facility's Nursing Policies and Procedures, under the subject title Restraints, last revised 01/20/2017, indicated the resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms . The use of side rails as a restraint is prohibited. Side rails are only used when necessary to treat the patient/resident's medical symptoms. Side rails can be used for physical function but only after assessment and should be considered as a last resort . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Falls do not constitute self-injurious behavior or a medical condition that warrants the use of a physical restraint . Complete Restraint Assessment, if appropriate. Review of the Resident Face Sheet revealed R464 was admitted to the facility on [DATE]. R464's pertinent admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Since R464 was admitted to the facility on [DATE], the admission Minimum Data Set (MDS) assessment was not available for review. Review of R464's baseline care plan, dated 06/16/2021, revealed R464 was at risk for falls. The interventions directed staff to encourage the use of the call light, orient the resident to the room and bathroom, and keep the room free of clutter. Review of R464's comprehensive care plan, dated 06/18/2021, revealed R464 was at risk for falls related to a fall on 06/17/2021. The pertinent intervention included safety devices as indicated. Pad alarm to bed as tolerated while in bed. The care plan did not include prior interventions attempted and failed, the use of half-side rails, type of monitoring or supervision provided during the use of the side rails or pad alarm, or the time and frequency staff should release these devices. Observations on 06/21/2021 at 11:59 AM, 06/22/2021 at 1:50 PM, and 06/23/2021 at 9:13 AM, R464 was observed in bed with the bed alarm in place and half-side rails in the up position. The half-side rails were positioned in the center of each side of the bed. R464 did not attempt to move or get out of bed when observed. Observation conducted on 06/23/2021 at 11:39 AM, in the presence of the Unit Manager (UM), revealed R464's side rails were down, and R464 was seated in his/her wheelchair with the pad alarm in place. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor every 30 minutes and release and reposition every two hours and PRN [as needed] for toileting and/repositioning . Review of the Patient/Resident Incident/Accident Investigation Worksheet, dated 06/17/2021, revealed R464 sustained an unwitnessed fall at 5:00 AM. Reportedly R464 stated s/he was going to the bathroom, felt weak and dizzy, and fell to the floor. R464 thought s/he could go to the bathroom on her own. R464 reminded to use his/her all light, staff educated on low bed position, half-side rails ordered and placed on the bed. AT 4:15 PM, R464 returned to the facility . request granted for low bed, half-side rails, and bed alarm was in place. 06/18/2021 at 5:00 PM, R464 has been compliant using the call light for assistance and not ambulating alone. Review of R464's Progress Note, dated 6/17/202, revealed R424's returned from the emergency room after an unwitnessed fall in the facility . Per family request, we have placed 1/2 side rails and bed alarm on bed . Review of the Siderail Review and Consent form, dated 06/17/2021, revealed R464 would have half-side rails. The diagnosis/medical condition for which the use of side rails was considered included falls/weakness. R464's cognition was noted as modified independence-some difficulty in new situations only. R464 required supervision with bed mobility, staff assistance needed for weight-bearing support or guiding of limbs, history of falls unknown, no risk factors for entrapment, alternatives attempted included the call bell in reach and low bed. Side rails are used to assist with transfer and bed mobility. Side rail type: half-side rails. Review of the physician's Progress Note, dated 06/18/2021, R464 had frequent falls and was recently in the hospital for a fall prior to his/her admission to the facility, s/he had a fall shortly after admission and because of being on [MEDICATION(S)] (a medication that helps prevent blood clots from forming), was sent to the emergency department for further workup, which was negative and s/he returned to facility . Assessment and Plan: Fall precautions, keep the bed at lowest position, frequent feeding and toileting, nonskid footwear, preferred items, and call light within reach. Continue to monitor and escalate prevention efforts as needed without restraints. Keep in common rooms while awake. Continue aggressive fall prevention and injury prevention efforts. Review of R464's electronic health record, under the section titled Resident Documents, revealed the facility did not complete a physical restraint assessment before or during the use of side rails or the pad alarm. During an interview with Certified Nursing Assistant (CNA) 6 on 06/23/2021 (time not noted), CNA6 stated R464 could potentially get out of bed on his/her own if the side rails were not in place. S/he puts the side rails down when s/he was in the room with R424. S/he checked on R464 at least every hour and a half. S/he said the facility does not use restraints and that s/he did not consider the side rails or bed alarm a restraint. During an interview with the UM on 06/23/2021 at 11:39 AM, the UM stated that s/he advised staff to keep the rails up when the resident was in bed and to put them down when the resident was out of bed. S/he stated that there was no plan at the time to assess the resident for removing the side rails. S/he indicated R464 would not likely be able to put the side rails down herself and encouraged her to use her call light for toileting. S/he said the resident fell during his/her first day at the facility and initiated the bed rails and alarm because R464's representative insisted on their use. During an interview with the Director of Nursing (DON) on 06/23/2021 (time not noted), the DON stated that the family insisted on installing full-side rails on R464's bed. The DON advised the family that the facility could not install full-side rails on R464's bed because they are considered a restraint and suggested installing half-side rails, which were less restrictive. The DON said the side rails and alarm were implemented to help prevent R464 from falling and assist with bed mobility due to R464's weakness, related to his/her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . After R464's initial fall, s/he considered placing a fall mat next to R464's but was concerned R464 would trip over the fall mat if R464 stood up. So, s/he agreed to install the half-side rails and bed alarm. S/he said R464 was not assessed for a toileting schedule, staff check on R464 and assist with toileting during rounds. S/he said they could have tried further reorienting the resident before installing the side rails and alarm. S/he acknowledged the staff completed a side rail review and consent but did not complete a restraint assessment before installing the side rails and bed alarm. S/he said at the time s/he thought the half-side rails and pad alarm were the least restrictive measures.

Based on interviews and record review, the facility failed to complete and provide the required transfer documents to the receiving provider for 1 of 1 resident (Resident (R) 66) discharged to a hospital. This failure placed the resident at risk for complications and adverse events during the resident's transition to the hospital. Findings include: Review of the facility's Nursing Policies and Procedures, under the subject title Transfer/Discharge, dated 11/01/2017, Indicated: Types of discharges . B. Emergency: Complete an emergent transfer form. Send the patient's/resident's face sheet, Advance Directives, bed-hold policy, physician orders, MAR and TAR, and any state specific [sic] records in accordance with state regulations with the patient/resident. If unable to complete the information, verbally communicate the necessary information and fax when complete .C. Planned Resident-Initiated Discharge to Another Healthcare Facility: Complete the Resident Transfer Form when the patient/resident is discharged to another health care agency such as a hospital or nursing facility. Send copies of the patient's/resident's face sheet, advance directives, copies of physician orders, MAR and TAR, and any state specific [sic] records in accordance with state regulations. Maintain copies of all completed discharge/transfer forms in patient's/resident's permanent medical record . Review of the Resident Face Sheet revealed R66 was admitted to the facility on [DATE]. R66's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that on 04/02/2021, R66 had an unplanned discharge to the hospital. A review of R66 Discharge Assessment, dated 04/02/2021, revealed R66 was discharged to an Acute Hospital. R66 was not anticipated to return to the facility. A review of R66's progress note dated 04/02/2021 at 5:54 AM revealed R66 had a chance in condition. R66 had not been feeling well during this shift, and pain medications were provided as needed. R66 complained of abdominal pain and now leg cramps . R66 did not want to go out to the hospital earlier because s/he verbalized that s/he was leaving today for a different facility. R66 called the nurse screaming around 5:30 AM and requested to be sent to the hospital. The nurse contacted the on-call doctor, who ordered the resident to be sent out-Emergency Medical Services (EMS) on the way to the facility. The nurse printed the patient's face sheet and med list to send with EMS. A review of R66's electronic health record, under the sections titled Transfer and Discharge, revealed the facility did not complete an emergent transfer form or discharge summary. There was no evidence the facility provided the receiving provider with R66's, transfer form, advance directives, Medication Administration Records (MARs), Treatment Administration Records (TARs), discharge summary, and any state-specific records according to state regulations. On 06/24/2021 (times not noted), on several occasions, a request for copies of the R66's transfer form and discharge summary. The facility was unable to locate a transfer form, transfer documents, or discharge summary for R66. During an interview with the Assistant Director of Nursing (ADON) on 06/24/2021 (time not noted), The ADON confirmed the facility did not have any record of R66's transfer form, transfer documents, or discharge summary. S/he indicated these documents should be in the residents' clinical records, per the facility's policies and procedures.

Based on record review, interview, and review of facility files, the facility failed to provide basic life support to Resident #1, 1 of 6 sampled residents reviewed for death in the facility. Cardiopulmonary Resuscitation (CPR) was initiated for Resident #1 and was discontinued prior to the arrival of emergency medical personnel. The findings included: Resident #1 was admitted to the facility with Full Code status on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility investigation, including witness statements, on [DATE] at 10:11 AM, revealed Resident #1 was found in bed, on [DATE] at 12:30 AM, unresponsive with no pulse and no respirations. An Emergency Code Blue was called and staff responded to provide Basic Life Support, including Cardio Pulmonary Resuscitation. 911 was called to notify Emergency Medical Services (EMS). The facility's investigation indicated CPR had been discontinued prior to the arrival of EMS. Review of a statement by Licensed Practical Nurse (LPN) #2 revealed LPN #1 and #2 were taking turns performing CPR, when LPN #1 stopped chest compressions and stated the resident is gone. LPN #2's statement also indicated they thought EMS was in the facility. CPR was discontinued, and per LPN #2's statement, when LPN #1 pulled the covers up and said the resident is gone I figured I couldn't force her to do anything else because the resident was her patient. LPN #2 walked back to her/his nursing station and after sitting down, saw EMS coming down the hall. Review of a signed statement by LPN #1, revealed s/he initiated the Code Blue and CPR on [DATE] at 12:30 AM. The statement indicated Certified Nursing Assistant (CNA) #1 had been at the front door waiting for EMS to arrive. When LPN #1 saw CNA #1 walk by the room, LPN #1 assumed that EMS was in the building. I stopped (CPR) and did a 60 second apical pulse but was unable to obtain and that's when the fire department guys walked in. It was 12:40 am at that time. Since I was unable to obtain an apical pulse, I stopped CPR because an apical pulse could not be obtained and the fire department was there. I pulled the covers over his chest because the fire department was there. Review of a statement signed by CNA #1 revealed s/he heard LPN #1 call Code Blue. LPN #2 got the crash cart and we all went to the room. LPN #1 was doing CPR and s/he told me to go to the door because they had called 911. So I took off running so I could let them in. When they arrived I took them back to the room. When we got there, they said No CPR? There was nobody in the room so I called LPN #1 over. Review of a statement signed by CNA #2 revealed s/he responded and assisted with the Code Blue. CNA #2 left the room I went up front and I asked the other CNA's to bring EMS back when they arrived and they said ok. Since they were at the front I went back to the resident's room. When I walked in LPN #1 was covering up the resident's body. LPN #1 said the resident was gone. Rescue arrived approximately 5 minutes after LPN #1 said the resident was gone and pulled the sheet up. This just didn't seem right to me. During an interview with Certified Nursing Assistant (CNA) #1, on [DATE] at 11:25 AM, CNA #1 confirmed her/his statement from [DATE]. CNA #1 stated s/he was waiting at the door for EMS to arrive when two responders from the [NAME] Fire department arrived. CNA #1 stated s/he escorted them to Resident #1's room. CNA #1 stated no one was in the room doing CPR at that time. S/he stated LPN #1 then came over from the nurse's station to talk to the fireman. During an interview with LPN #2, on [DATE] at 11:32 AM, LPN #2 confirmed her/his signed statement. LPN #2 stated s/he was against LPN #1 stopping CPR, but it was a tense situation and s/he didn't want to start any kind of confrontation by telling LPN #1 they couldn't stop CPR. LPN #2 confirmed CPR was discontinued prior to the arrival of EMS. When asked how long CPR had been stopped prior to the arrival of EMS, LPN #2 stated it was approximately 10 minutes. During an interview with LPN #1, on [DATE] at 11:46 AM, LPN #1 confirmed s/he stopped CPR before the firemen came into the resident's room. S/he stated chest compressions were done until about 12:40 AM when the firemen came in. LPN #1 was asked to clarify if came in meant the firemen came into the resident's room or into the building. LPN #1 stated came in meant the firemen came into the building. LPN #1 stated CNA #1 brought the firemen to the resident's hall and they were standing outside the door. LPN #1 stated s/he went ahead and moved out of the way so they could come in and take over. LPN #1 stated s/he had never been instructed CPR had to be continued until you are relieved by EMS. LPN #1 stated s/he thought it was ok to stop CPR because the firemen were in the building. LPN #1 stated s/he didn't stop CPR until s/he saw the firemen outside the resident's door. S/he stated when s/he saw them she stopped CPR and got out of the room so they could take over. During an interview with [NAME] Fire Department Responder (IFDR) #1, on [DATE] at 2:33 PM, IFDR #1 confirmed s/he responded to the call on [DATE] with IFDR #2. IFDR #1 stated they were on standby for Spartanburg County EMS and respond to 911 calls until EMS arrives on the scene. IFDR #1 stated when they arrived at the resident's room the resident was in bed with a sheet pulled over him/her. IFDR #1 stated there was no staff in the room and no one was doing CPR when they arrived. IFDR #1 stated it was unusual to respond to a 911 call and find no one doing CPR when they arrive. During an interview with [NAME] Fire Department Responder (IFDR) #2, on [DATE] at 2:41 PM, IFDR #2 confirmed s/he responded to the call on [DATE] with IFDR #1. S/he also confirmed no one was doing CPR when they arrived and no staff were in the resident's room.

Based on record review, interview, review of facility files and facility policy, the facility failed to provide care in accordance with professional standards of practice and the resident's choices for 1 of 6 sampled residents reviewed for death in the facility. Cardiopulmonary Resuscitation (CPR) was initiated for Resident #1 and was discontinued prior to the arrival of emergency medical services (EMS). The findings included: Resident #1 was admitted to the facility with Full Code status on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility investigation, including witness statements, on [DATE] at 10:11 AM, revealed Resident #1 was found in bed, on [DATE] at 12:30 AM, unresponsive with no pulse and no respirations. An Emergency Code Blue was called and all staff responded to provide basic life support, including CPR. 911 was called to notify Emergency Medical Services (EMS) of the code situation. The facility's investigation indicated CPR had been discontinued prior to the arrival of EMS. In addition, the investigation revealed there was no evidence indicating the on call physician was called for an order to discontinue CPR. Per the facility investigation summary, four scheduled Certified Nursing Assistants all report Licensed Practical Nurse (LPN) #1 did initiate CPR, but discontinued CPR and left the resident's room before EMS arrived. LPN #2 was assisting LPN #1 with CPR. LPN #2 stated LPN #1 stopped CPR because s/he thought EMS was in the building. LPN #2 did not continue CPR or encourage LPN #1 to do so, per the investigation summary. Review of the Spartanburg County Unattended Death Report, on [DATE] at 10:19 AM, revealed the resident was pronounced dead by EMS on [DATE] at 12:54 AM. The report indicated there were no signs of lividity or decomposition. During an interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 11:32 AM, LPN #2 stated s/he was against LPN #1 stopping CPR, but it was a tense situation and s/he didn't want to start any kind of confrontation by telling LPN #1 they couldn't stop CPR. LPN #2 confirmed CPR was discontinued prior to the arrival of EMS. When asked how long CPR had been stopped prior to the arrival of EMS, LPN #2 stated it could not have been long, less than 10 minutes. During an interview with Certified Nursing Assistant (CNA) #1, on [DATE] at 11:25 AM, CNA #1 stated s/he was waiting at the door for EMS to arrive when two responders from the [NAME] Fire department arrived. CNA #1 stated s/he took them to Resident #1's room. CNA #1 stated no one was in the room doing CPR at this time. S/he stated LPN #1 then came over from the nurse's station to talk to the fireman. During an interview with LPN #1, on [DATE] at 11:46 AM, LPN #1 confirmed s/he stopped CPR before the firemen came into the resident's room. S/he stated chest compressions were done until about 12:40 AM when the firemen came in. LPN #1 was asked to clarify if came in meant the firemen came into the resident's room or into the building. LPN #1 stated came in meant the firemen came into the building. LPN #1 stated CNA #1 brought the firemen to the resident's hall and they were standing outside the door. LPN #1 stated s/he went ahead and moved out of the way so they could come in and take over. LPN #1 stated s/he had never been instructed CPR had to be continued until you are relieved by EMS. LPN #1 stated s/he thought it was ok to stop CPR because the firemen were in the building. LPN #1 stated s/he didn't stop CPR until s/he saw the firemen outside the resident's door. S/he stated when s/he saw them she stopped CPR and got out of the room so they could take over. During an interview with [NAME] Fire Department Responder (IFDR) #1, on [DATE] at 2:33 PM, IFDR #1 confirmed s/he responded to the call on [DATE] with IFDR #2. IFDR #1 stated they were on standby for Spartanburg County EMS and respond to 911 calls until EMS arrives on the scene. IFDR #1 stated when they arrived at the resident's room the resident was in bed with a sheet pulled over him/her. IFDR #1 stated there was no staff in the room and no one was doing CPR when they arrived. IFDR #1 stated it was unusual to respond to a 911 call and find no one doing CPR when they arrive. During an interview with [NAME] Fire Department Responder (IFDR) #2, on [DATE] at 2:41 PM, IFDR #2 confirmed s/he responded to the call on [DATE] with IFDR #1. S/he also confirmed no one was doing CPR when they arrived and no staff were in the resident's room. Review of the facility's Cardiopulmonary Resuscitation, Emergency Code Blue policy revealed: -The Facility implements policies and procedures for the provision of CPR by staff, safely and according to Basic Life Support guidance. -The Facility ensures CPR certified healthcare providers are available immediately, 24-hours per day to provide basic life support, including CPR to residents requiring emergency care prior to the arrival of EMS, and subject to accepted professional guidelines, the residents's advance directive and physician orders. -The Facility ensures provision of basic life support and CPR for residents who do not show obvious clinical signs of irreversible death. -Continue CPR efforts as appropriate, etc. in accordance with patient/resident Advance Directives, until advanced rescue team arrives or until spontaneous respirations, pulse and blood pressure return.

Based on interview and record review, the facility failed to keep residents free from abuse and neglect for 1 of 5 residents reviewed for abuse. Resident #188, who had a well-documented history of sexually abusive behavior, sexually abused Resident #45. On 1/2/19 Resident #188 had his/her hand on a Residents crotch area, on 1/15/19 Resident #188 was noted with his/her hand in Resident #45's pants, with his/her hand in motion and on 2/3/19 Resident #188 placed his/her hand on a resident's genitals and rubbed. The findings included: Review of Initial report on 4/22/19 at approximately 3:20 PM revealed Resident #188 touched Resident #45 without permission at approximately 11 AM on 1/15/19. Review of the 5-day report on 4/22/19 at approximately 3:25 PM revealed that Resident #45 was uninjured, both Residents #45 and #188 were cognitively impaired. Resident #188 had a prior history of sexually inappropriate behavior. One of the planned interventions was to move the victim to a further room. Review of witness statements on 4/23/19 at approximately 10 AM revealed that Licensed Practical Nurse (LPN) #7 witnessed Resident #188 leaning forward from his/her wheelchair with his/her right hand extended inside the pants/thighs of Resident #45. Resident #188 moved his/her hand back and forth. When LPN #7 called Resident #188's name, the resident withdrew his/her hand and disappeared into his/her room. LPN #6 performed a body audit on Resident #45 and noted no perineal/vaginal trauma. Housekeeper #1 also witnessed Resident #188 with hand on private part of Resident #45. Review of Resident #188's nursing notes on 4/23/19 at approximately 10:05 AM revealed several notes documenting a history of sexually inappropriate behavior from Resident #188. Nursing note from 1/2/19 documenting that Resident #188 had his/her hand on a Residents crotch area, and the resident was immediately removed. Nursing note on 1/15/19 revealed Resident #188 was noted by 3 employees who took immediate action with his/her hand in Resident #45's pant, with his/her hand in motion. Nursing note on 2/3/19 documenting that Resident #188 placed his/her hand on a resident's genitals and rubbed. This was witnessed by several other residents. A witness (Resident) stated, I'm scared, and started to cry. Record review revealed that the only reference to the two incidents dated 1/2/19 and 2/3/19 were located in Resident #188's nurses notes. The notes did not provide the names of the other residents involved. During an interview with Licensed Practical Nurse (LPN) #6 on 4/23/19 at approximately 12:08 PM s/he confirmed that Resident #188 had attempted to sexually assault a resident at least one other time, though s/he was unable to name the specific date.There was no evidence that the facility reported or investigated the incidents dated 1/2/19 and 2/3/19. Review of Resident #188 Care Plan on 4/23/19 at approximately 10:20 AM revealed Resident #188 was care planned to be taken to a private area for self-intimacy. There was no documented interventions to protect other residents from Resident #188's history of publicly masturbating while staring at female residents and groping female residents. During an interview with LPN #6 on 4/23/19 at approximately 12:08 PM revealed that Resident #188 put his/her hand into Resident #45's pants and moved hand up and down. Residents were immediately separated and the Nurse Practitioner assessed Resident #45. The family of both residents and management were immediately notified. LPN #6 stated that Resident #188 had a history of [REDACTED]. During an interview with Housekeeper #1 on 4/23/19 at approximately 12:44 PM s/he confirmed that Resident #188 had his/her hand in the pants of Resident #45. During an interview with LPN #7 on 4/23/19 at approximately 4 PM revealed that Resident #188 had his/her hand reached down the pants of Resident #45. When LPN #7 discovered this was happening, another nurse was already separating the two. LPN #7 knew of no other instances of Resident #188 touching residents. During an interview with the Administrator and review of Resident #188 and Resident #45's charts on 4/24/19 at approximately 8:50 AM revealed neither residents changed rooms after the incident dated 1/15/19. Review of Resident #188's record revealed that the resident was discharged from the facility on 2/7/19.

Based on interview, record review and review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment the facility failed to implement the facility policy to keep residents free from abuse. Resident #188, who had a well-documented history of sexually abusive behavior, sexually abused Resident #45. On 1/2/19 Resident #188 had his/her hand on a Residents crotch area, on 1/15/19 Resident #188 was noted with his/her hand in Resident #45's pants, with his/her hand in motion and on 2/3/19 Resident #188 placed his/her hand on a resident's genitals and rubbed. Additionally, the facility failed to report abuse to the state agency and investigate incidents dated 1/2/19 and 2/3/19 involving Resident #188. The facility failed to report incidents of sexual abuse dated 1/2/19, 1/15/19 and 2/3/19 involving Resident #188 to Law Enforcement. The facility failed to investigate abuse, Resident #187 made an allegation of abuse and the facility failed to interview the staff members involved or who had knowledge of the allegations. 2 of 5 residents reviewed for abuse The findings included: Resident #188 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Initial report on 4/22/19 at approximately 3:20 PM revealed Resident #188 touched Resident #45 without permission at approximately 11 AM on 1/15/19. Review of the 5-day report on 4/22/19 at approximately 3:25 PM revealed that Resident #45 was uninjured, both Residents #45 and #188 were cognitively impaired. Resident #188 had a prior history of sexually inappropriate behavior. One of the planned interventions was to move the victim to a further room. Review of Resident #188's nursing notes on 4/23/19 at approximately 10:05 AM revealed several notes documenting a history of sexually inappropriate behavior from Resident #188. Nursing note from 1/2/19 documenting that Resident #188 had his/her hand on a Residents crotch area, and the resident was immediately removed. Nursing note on 1/15/19 revealed Resident #188 was noted by 3 employees who took immediate action with his/her hand in Resident #45's pants, with his/her hand in motion. Nursing note on 2/3/19 documenting that Resident #188 placed his/her hand on a resident's genitals and rubbed. This was witnessed by several other residents. A witness (Resident) stated, I'm scared, and started to cry. Review of Resident #188 Care Plan on 4/23/19 at approximately 10:20 AM revealed Resident #188 was care planned to be taken to a private area for self-intimacy. There was no documented interventions to protect other residents from Resident #188's history of publicly masturbating while staring at female residents and groping female residents. During an interview with LPN #6 on 4/23/19 at approximately 12:08 PM revealed that Resident #188 put his/her hand into Resident #45's pants and moved hand up and down. Residents were immediately separated and the Nurse Practitioner assessed Resident #45. The family of both residents and management were immediately notified. LPN #6 stated that Resident #188 had a history of [REDACTED]. During an interview with Housekeeper #1 on 4/23/19 at approximately 12:44 PM s/he confirmed that Resident #188 had his/her hand in the pants of Resident #45. During an interview with LPN #7 on 4/23/19 at approximately 4 PM revealed that Resident #188 had his/her hand reached down the pants of Resident #45. When LPN #7 discovered this was happening, another nurse was already separating the two. LPN #7 knew of no other instances of Resident #188 touching residents. During an interview with the Administrator and review of Resident #188 and Resident #45's charts on 4/24/19 at approximately 8:50 AM revealed neither residents changed rooms after the incident. Record review revealed there was no evidence that Law Enforcement was notified of the incidents dated 1/2/19, 1/15/19 and 2/3/19 involving Resident #188. During an interview with the Administrator on 4/23/19 at approximately 12:15 PM revealed that incidents dated 1/2/19, 1/15/19 and 2/3/19 involving Resident #188 were not reported to Law Enforcement. It was also revealed that incidents dated 1/2/19 and 2/3/19 involving Resident #188 were not reported to the State Agency. Record review revealed that the only reference to the two incidents dated 1/2/19 and 2/3/19 were located in Resident #188's nurses notes. The notes did not provide the names of the other residents involved. During an interview with Licensed Practical Nurse (LPN) #6 on 4/23/19 at approximately 12:08 PM s/he confirmed that Resident #188 had attempted to sexually assault a resident at least one other time, though s/he was unable to name the specific date. There was no evidence that the facility investigated the incidents dated 1/2/19 and 2/3/19. Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed under Policy 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse . 2. The facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .Under section III. Prevention 5. Ongoing assessment, care planning, and monitoring of those patients/residents with special needs that may lead to neglect, for example: A. History of aggressive behavior; B. History of entering other patient/resident rooms; C. History of self-injury; D. Communication disorder; and/or, E. Patients/residents requiring excessive nursing care or staff attention. F. Residents with history of resident to resident altercations. Under Component V. Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator and the other officials in accordance with state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities). Review of Resident #188's record revealed that the resident was discharged from the facility on 2/7/18. The facility admitted Resident #187 on 10/16/18 with [DIAGNOSES REDACTED]. A review of the facility's abuse investigation on 4/24/19 at approximately 2:20 PM revealed that Resident #187 informed the facility on 10/30/18 he/she was neglected and verbally/mentally abused by the assigned physical therapist and a certified nursing aide. Further review of the facility's investigation documentation revealed there was no documentation to indicate the alleged perpetrator was interviewed. There was also written documentation provided by Certified Nursing Aide (CNA) #1 involved in the incident that revealed there was another CNA working with the resident on the unit at the time of the incident that was not interviewed. During an interview on 4/24/19 at approximately 2:35 PM with the facility Administrator revealed during his/her investigation into the allegations of abuse/neglect he/she failed to interview the alleged perpetrator and another CNA that was named in CNA #1 witness statement. Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed under Component VI: Investigation 1. The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken. 5. The investigation may include but is not limited to the following: E. Written summaries of interviews with individuals having first-hand knowledge of the incident .

Based on record review and interview, the facility failed thoroughly investigation an allegation of staff to resident abuse by failing to interview the alleged perpetrator and a possible witness to an allegation of abuse. Resident #187 made an allegation of abuse and the facility failed to interview the staff members involved or who had knowledge of the allegations. The facility failed to investigate incidents of sexual abuse dated 1/2/19 and 2/3/19 involving Resident #188. 2 of 5 residents reviewed for abuse. The findings included: The facility admitted Resident #187 on 10/16/18 with [DIAGNOSES REDACTED]. A review of the medical record on 4/24/19 at approximately 1:24 PM revealed a social services progress note dated 10/18/18 that indicated the resident was admitted for short term rehab services due to respiratory virus and knee issue. A review of the facility's abuse investigation on 4/24/19 at approximately 2:20 PM revealed that Resident #187 informed the facility on 10/30/18 he/she was neglected and verbally/mentally abused by the assigned physical therapist and a certified nursing aide. Further review of the facility's investigation documentation revealed there was no documentation to indicate the alleged perpetrator was interviewed. There was also written documentation provided by Certified Nursing Aide (CNA) #1 involved in the incident that revealed there was another CNA working with the resident on the unit at the time of the incident that was not interviewed. An interview on 4/24/19 at approximately 2:35 PM with the facility Administrator revealed during his/her investigation into the allegations of abuse/neglect he/she failed to interview the alleged perpetrator and another CNA that was named in CNA #1 witness statement. Resident #188 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #188's nursing notes on 4/23/19 at approximately 10:05 AM revealed several notes documenting a history of sexually inappropriate behavior from Resident #188. Nursing note from 1/2/19 documenting that Resident #188 had his/her hand on a Residents crotch area, and the resident was immediately removed. Nursing note on 1/15/19 revealed Resident #188 was noted by 3 employees who took immediate action with his/her hand in Resident #45's pants, with his/her hand in motion. Nursing note on 2/3/19 documenting that Resident #188 placed his/her hand on a resident's genitals and rubbed. This was witnessed by several other residents. A witness (Resident) stated, I'm scared, and started to cry. During an interview with the Administrator on 4/23/19 at approximately 12:15 PM revealed that incidents dated 1/2/19, 1/15/19 and 2/3/19 involving Resident #188 were not reported to Law Enforcement. It was also revealed that incidents dated 1/2/19 and 2/3/19 involving Resident #188 were not reported to the State Agency. Record review revealed that the only reference to the two incidents dated 1/2/19 and 2/3/19 were located in Resident #188's nurses notes. The notes did not provide the names of the other residents involved. During an interview with Licensed Practical Nurse (LPN) #6 on 4/23/19 at approximately 12:08 PM s/he confirmed that Resident #188 had attempted to sexually assault a resident at least one other time, though s/he was unable to name the specific date. There was no evidence that the facility investigated the incidents dated 1/2/19 and 2/3/19. Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed under Component VI: Investigation 1. The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken. 5. The investigation may include but is not limited to the following: E. Written summaries of interviews with individuals having first-hand knowledge of the incident .

Based on observation, record review and interview, the facility failed to review and revise the care plans for Resident's #188, #45 and #58, 3 of 19 sampled resident Care Plans reviewed. Resident #58's care plan was not revised related to a leaking [MEDICATION NAME]. The care plans for Residents #188 and #45 were not revised related to Abuse. The findings included: The facility admitted Resident #58 with [DIAGNOSES REDACTED]. During an interview with Resident #58 on 4/22/19 at 10:35 AM the resident stated his/her [MEDICATION NAME] has been leaking since it was last changed by his/her Urologist. When asked when s/he was last seen by Urology, the resident stated it had been a long time, more than a year. During a wound care observation on 4/24/19 at 2:16 PM, with Registered Nurse (RN) #5 present, urine was observed leaking from the [MEDICATION NAME]. RN #5 confirmed the [MEDICATION NAME] was leaking. Record review of Resdient #58's Care Plan on 4/24/19 at 3:08 PM revealed a problem area related to the resident's [MEDICATION NAME]. The Care Plan had not been revised to indicate the resident's [MEDICATION NAME] was leaking and there were no interventions related to the leaking [MEDICATION NAME]. In addition, the care plan included multiple interventions for a Urinary Catheter, which was not in use for the resident. During an interview with RN #2, with the Director of Nursing present, on 4/24/19 at 3:15 PM, RN #2 stated the resident's leaking [MEDICATION NAME] has been a long term issue. RN #2 stated the resident has been seen by Urology and Urology has slowed the leaking as much as they can, but there was nothing more they could do to prevent the leaking. During an interview with RN #1 on 4/25/19 at 9:15 AM RN #1 confirmed the Care Plan had not been revised to reflect the resident's leaking [MEDICATION NAME]. RN #1 also confirmed the resident did not have a Urinary Catheter and the Care Plan included multiple interventions for the care of a Urinary Catheter. Resident #188 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility 5-Day Report on 4/22/19 at approximately 3:25 PM revealed that on 1/15/19 Resident #188 sexually assaulted resident #45. Interventions to prevent recurrence included care conference with both residents and updates to the care plans. Review of chart and care plan of Resident #188 on 4/23/19 at approximately 10:20 AM revealed no evidence of a care plan conference or review/revision of care plan following the sexual assault on 1/15/19. During an interview with Licensed Practical Nurse (LPN) #6 on 4/23/19 at approximately 12:08 PM revealed s/he was uncertain if the care plan was reviewed or revised. Review of chart and care plan of Resident #45 on 4/23/19 at approximately 1:15 PM revealed no evidence of a care plan conference or review/revision of care plan following the sexual assault on 1/15/19. During an interview with the Administrator on 4/24/19 at approximately 8:50 PM s/he confirmed the facility was unable to prove that the care plans of Residents #188 and #45 were reviewed/revised following the sexual abuse on 1/15/19. Further Review of Resident #188's nursing notes on 4/23/19 at approximately 10:05 AM revealed a Nursing note on 2/3/19 documenting that Resident #188 placed his/her hand on a resident's genitals and rubbed. This was witnessed by several other residents. A witness (Resident) stated, I'm scared, and started to cry. Review of Resident #188's record revealed that the resident was discharged from the facility on 2/7/18.

Based on observation, record review and staff interview the facilty failed to accurately assess the status for one resident (#71) for Range of Motion resulting in an avoidable decline. Findings include: Review of Resident #71's clinical record conducted on 01/10/17 at 11:00 AM revealed an admission date of [DATE]. The resident ' s [DIAGNOSES REDACTED]. Review of the Therapy Screen dated 04/22/16 directed the staff member completing the form to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy the area of Joint limitations/Contractures was not checked and No Recent Change/Deficits Noted was checked therefore therapy services were not initiated. In the comment section it was documented that the resident was on hospice. Review of the clinical record revealed the resident was hospitalized from [DATE] through 05/16/16. Review of the Joint Mobility Screen dated 05/16/16 revealed the resident had some resistance with left hand when trying to perform ROM (range of motion) and resident unable to perform bilateral finger flexion/extension active range of motion. Passive range of motion was not assessed at that time. Review of the Nursing Data Collection Tool dated 05/16/16 revealed the resident was assessed with [REDACTED]. Review of the clinical record revealed the resident was not screened by physical or occupational therapy upon readmission. Review of the Therapy Screen dated 07/01/16 and 09/19/16 directed the staff member completing the form to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy the area of Joint limitations/Contractures was not checked and No Recent Change/Deficits Noted was checked therefore therapy services were not initiated. Review of the Joint Mobility Screen dated 09/28/16 revealed the resident was assessed with [REDACTED]. Review of the Nursing Data Collection Tool dated 09/28/16 revealed the Musculoskeletal Functional Limitation in ROM section was not completed as required per facility protocol. Review of the Quarterly MDS dated [DATE] Section G0400A Functional Limitation in Range of Motion revealed the resident was assessed with [REDACTED]. Review of the Therapy Screening Form dated 12/16/16 directed the staff member completing the form to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy the area of Joint limitations/Contractures was not checked and No Recent Change/Deficits Noted was checked therefore therapy services were not initiated. Review of the Joint Mobility Screen dated 12/20/16 revealed the resident was assessed with [REDACTED]. The resident was unable to extend right and left fingers. Review of the Nursing Data Collection Tool dated 12/20/16 revealed the resident was assessed with [REDACTED]. Review of the Quarterly MDS dated [DATE] section G0400A Functional Limitation in Rang of Motion revealed the resident was assessed with [REDACTED]. During an observation on 1/10/17 at 1:20 PM Unit Manager Licensed Practical Nurse #72 performed range of motion on the resident ' s bilateral hands. The resident was not able to perform active range of motion of the left hand and fingers. The Unit Manager Licensed Practical Nurse #72 was unable to fully flex or extend the resident ' s left hand and fingers. The resident was able to move his right hand however was not able to fully extend or flex the right fingers. Unit Manager Licensed Practical Nurse #72 was not able to fully extend the resident ' s right fingers. During an interview conducted on 01/10/17 at 1:40 PM Unit Manager Licensed Practical Nurse #72 verified the aforementioned Therapy Screening forms did not identify the decline in the resident's bilateral hand range of motion and therefore did not proceed with a formal therapy evaluation. In addition, verified the aforementioned inconsistencies between the Joint Mobility Screens and the Nursing Data Collection Tools. Unit Manager Licensed Practical Nurse #72 stated the resident was never placed on a restorative nursing program as indicated by the Occupational Therapy Discharge Summary dated 04/11/14. Also verified the resident was never placed on hospice. During an interview conducted on 011/10/17 at 2:18 PM Physical Therapy Assistant Director of Rehabilitation staff #99 verified the Therapy Screening Forms dated 01/15/16 and 04/8/16 did not identify a change in the resident's bilateral hand range of motion, verified the Therapy Screening Tool dated 04/22/16 identified the resident was receiving hospice services and stated they must have been misinformed since the resident was never on hospice. Physical Therapy Assistant Directory of Rehabilitation staff #99 verified the Therapy Screening Forms dated 07/01/16, 09/19/16 and 12/16/16 did not identify a change in the resident's bilateral hand range of motion. When queried as to how the therapy screens were conducted in order to identify a decline in range of motion, Physical Therapy Assistant Director of Rehabilitation staff #99 stated they were not allowed to physically touch the resident when conducting a screening therefore they review the nursing documentation such as the Joint Mobility Screen and Nursing Data Collection tool along with speaking to the nursing staff in order to identify a change in range of motion. Physical Therapy Assistant Director of Rehabilitation staff #99 stated the Joint Mobility Screen was confusing making it difficult to ascertain declines based on how the nursing staff were completing the form. Physical Therapy Assistant Director of Rehabilitation staff #99 stated they were not made aware by nursing staff that Resident #71 had experienced a decline in bilateral hand range of motion. In addition, Physical Therapy Assistant Director of Rehabilitation staff #99 verified a therapy screening form was not completed upon the resident's readmission on 05/16/16 and verified the resident had not received therapy services since being discharged from Physical Therapy on 04/11/14 and Occupational Therapy on 04/24/14. During an interview conducted on 01/10/17 at 3:06 PM Assessment Nurse staff #17 verified the Quarterly MDS dated [DATE] Section G0400A Functional Limitation in Range of Motion revealed the resident was assessed with [REDACTED]. When queried as to how they assessed the resident in order to code Section G0400A Assessment Nurse staff #17 stated they reviewed the Nursing Data Collection Tool, the Joint Mobility Screen and they would speak with the nursing staff. Assessment Nurse staff #17 verified the Joint Mobility Screen dated 09/28/16 revealed the resident was assessed with [REDACTED]. Assessment Nurse staff #17 verified the Quarterly MDS dated [DATE] Section G0400A Functional Limitation in Range of Motion was not coded correctly. In addition, Assessment Nurse staff #17 verified the Quarterly MDS dated [DATE] section G0400A Functional Limitation in Range of Motion revealed the resident was assessed with [REDACTED]. Assessment Nurse staff #17 verified the Joint Mobility Screen dated 12/20/16 revealed the resident was assessed with [REDACTED]. The resident was unable to extend right and left fingers and the Nursing Data Collection Tool dated 12/20/16 revealed the resident was assessed with [REDACTED]. Assessment Nurse staff #17 verified the Quarterly MDS dated [DATE] Section G0400A Functional Limitation in Range of Motion was not coded correctly. Assessment Nurse staff #17 verified the current plan of care did not include the assessed problem of limited range of motion of bilateral upper extremities and did not include interventions to address the residents limited range of motion for bilateral upper extremities. During an interview conducted on 01/11/17 at 8:30 AM Unit Manager Licensed Practical Nurse (LPN) staff #93 verified they completed the Joint Mobility Screen dated 05/16/16 and verified they documented the resident had some resistance with left hand when trying to perform ROM and resident unable to perform bilateral finger extension or flexion. Unit Manager LPN staff #93 verified they completed the Nursing Data Collection Tool dated 05/16/16 and only documented the resident with a functional limitation in range of motion of the left upper extremity. Unit Manager LPN staff #93 verified they completed the Nursing Data Collection Tool dated 07/06/16 in which the Musculoskeletal Functional Limitation in ROM section was left blank. In addition, verified the change in range of motion was not verbally communicated to the therapy department. Unit Manager LPN staff #93 was queried as to what type of training they had been provided on the use of the Joint Mobility Screen and the Nursing Data Collection Tool. Unit Manager LPN #93 stated they were shown upon hire how to complete an admission packet which contained the aforementioned documents. However, no formal training had been provided on the Joint Mobility Screen tool. They stated they would mark lines and or make notes on the Joint Mobility Screen to indicate a range of motion deficit but had difficulty articulating how they would identify on the form a decline in finger extension and flexion. They stated if they had a question on how to complete the form they would ask someone. Unit Manager LPN staff #93 verified the Instructions on the form stated Draw a line through the arc showing how far the limb can be moved (PROM). Note any difference in active range (AROM) with a dotted line. Unit Manager LPN staff #93 stated they now delegate the completion of the form to other nurses on the unit. During an interview conducted on 01/11/17 at 8:40 AM Unit Manager LPN staff #72 stated they had not received training on the Nursing Data Collection Tool and Joint Mobility Screen. They stated they would make lines on the Joint Mobility Screen which would indicate a range of motion deficit and may make notes on the form. However, they had difficulty articulating how they would identify on the form a decline in finger extension and flexion. During interview conducted on 01/11/17 at 9:06 AM Staff Development staff #33 stated they train new nurses during orientation on how to complete the Joint Mobility Screen and Nursing Data Collection Tool, however there is no follow-up skills assessment or training to ensure the Nursing Data Collection Tool and Joint Mobility Screen tool were being implemented correctly. Review of Occupational Therapy Plan of Care dated 01/11/17 revealed Reason for Referral: Contractures L (left) hand and wrist, decline in R (right) hand wrist range of motion. Therapy Necessity: Therapy necessary for positioning, feeding, orthotic/ROM management, Caregiver/nursing/RNP training with plan. Without therapy patient is at risk for decreased hand and wrist ROM, pain, impaired functional positioning. Prior Residence and Living Arrangement: Pt (patient) has resided at this facility for almost 3 years. Pt seen for skilled OT 2/4/14-4/11/14. Pt was feeding self with Mod A (moderate assist) and 50% tactile cuing up in w/c (wheelchair) when OOB (out of bed). Pt is now being fed by care staff and sits in geri chair when OOB. Previous Therapy: Pt seen for skilled OT 2/4/14-4/11/14. Pt was feeding self w/mod A and 50% tactile cueing. Pt d/c from OT pt RUE (right upper extremity) AROM (active range of motion) WFL (within functional limits), LUE (left upper extremity) PROM (passive range of motion) to 1/4 to 1/3 normal ranges with [DIAGNOSES REDACTED]: shoulder flexion 90 degrees, elbow WFL, flexion/extension of wrist and fingers 1/4 to 1/2 normal ranges. Precautions: LUE limited P/AROM w/pt (with patient) c/o (complaint) of soreness. ROM: RUE A/PROM shoulder flexion 0-40/0-120 degrees, elbow flexion and extension WFL A/PROM, wrist flexion neutral to 40 degrees A/PROM, Fingers 1-4 minus 40/20 degrees flexion and minus 40/20 degrees extension, thumb 1/2 normal ranges. LUE PROM no AROM LUE shoulder flexion 0-40 degrees, elbow flexion 0-60 degrees, extension WFL, wrist held in neutral less than 10 degrees flexion, Fingers 1-4 minus 40 degrees flexion and minus 45 degrees extension. Pt grimaces w/attempts to passively range L thumb. During an interview conducted on 01/11/17 at 10:02 AM Occupational Therapist #106 verified the aforementioned Occupational Therapy Plan of Care dated 01/11/17 revealed the resident was reassessed and had experienced a decline in bilateral hand range of motion resulting in a worsening of the contractures of the left fingers and had developed new contractures of the right fingers and wrist. In addition, Occupational Therapist #106 acknowledged the resident had experienced an avoidable decline due to a lack of staff intervention and had the potential for improvement with staff intervention. During an interview conducted on 1/11/17 at 10:29 am Director of Nursing staff #20 stated Resident #71 was never on hospice as documented on the Therapy Screening Tool dated 04/22/16 and was never on a formal restorative nursing program. Director of Nursing staff #20 stated the therapy recommendation for the resident to be on a restorative nursing program was not meant for the resident to be a formal restorative plan and that the certified nursing assistants caring for Resident #71 were trained and responsible for delivering the restorative nursing program interventions as recommended by therapy. The Director of Nursing staff #20 was unable to provide documentation demonstrating the certified nursing assistants were educated on the therapy recommendations for Resident #71 stating the directions would have been written on Resident #71's Resident Profile which directs the care given by the certified nursing assistants. Director of Nursing staff #20 verified the restorative nursing recommendations were not documented on Residents #71's Resident Profile. Director of Nursing staff #20 verified inconsistent nursing documentation on the Joint Mobility Screens and the Nursing Data Collection Tools which are conducted in conjunction with one another to ensure an accurate resident assessment per facility protocol. Director of Nursing staff #20 acknowledged the resident had experienced an avoidable decline in range of motion due to a lack of staff intervention.

Based on observation, record review and staff interview the facility failed to ensure 1 of 1 resident reviewed in Stage 2 for Range of Motion(ROM) received the appropriate treatment and services to prevent an avoidable decline in ROM. Findings include: Review of Resident #71's clinical record conducted on 01/10/17 at 11:00 AM revealed an admission date of [DATE]. The resident ' s [DIAGNOSES REDACTED]. The resident received physical therapy from 02/22/14 thru 04/11/14 for bed mobility and transfers and occupational therapy from 02/24/14 thru 04/24/14 for decrease in functional mobility and decrease in range of motion. The Occupational Therapy Evaluation and Plan of Treatment dated 02/24/14 revealed the resident was assessed to have impaired left upper extremity [DIAGNOSES REDACTED] and the right upper extremity was within functional limits. Review of the Admission Minimum Data Set ((MDS) dated [DATE] Section C1000 revealed the resident was assessed with [REDACTED]. Review of the Occupational Therapy Discharge Summary dated 04/11/14 revealed the resident was a moderate assist with 50% tactile stimulation for feeding. To facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNPs (restorative nursing programs) has been completed with the IDT: grooming and eating/self feeding. Review of the Therapy Screen dated 01/15/16 directed the staff member completing the form to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy the area of Joint limitations/Contractures was not checked and No Recent Change/Deficits Noted was checked therefore therapy services were not initiated. Review of the Annual MDS assessment dated [DATE] section C1000 revealed the resident was assessed with [REDACTED]. Section G0400A Functional Limitation in Range of Motion the resident was assessed with [REDACTED]. Review of the Therapy Screen dated 04/08/16 directed the staff member completing the form to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy the area of Joint limitations/Contractures was not checked and No Recent Change/Deficits Noted was checked therefore therapy services were not initiated. Review of the Therapy Screen dated 04/22/16 directed the staff member completing the form to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy the area of Joint limitations/Contractures was not checked and No Recent Change/Deficits Noted was checked therefore therapy services were not initiated. In the comment section is was documented that the resident was on hospice. Review of the clinical record revealed the resident was hospitalized from [DATE] through 05/16/16. Review of the Joint Mobility Screen dated 05/16/16 revealed the resident had some resistance with left hand when trying to perform ROM (range of motion) and resident unable to perform bilateral finger flexion/extension active range of motion. Passive range of motion was not assessed at that time. Review of the Nursing Data Collection Tool dated 05/16/16 revealed the resident was assessed with [REDACTED]. Review of the clinical record revealed the resident was not screened by physical or occupational therapy upon readmission on 05/16/16. Review of the Therapy Screen dated 07/01/16 and 09/19/16 directed the staff member completing the form to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy the area of Joint limitations/Contractures was not checked and No Recent Change/Deficits Noted was checked therefore therapy services were not initiated. Review of the Joint Mobility Screen dated 09/28/16 revealed the resident was assessed with [REDACTED]. Review of the Nursing Data Collection Tool dated 09/28/16 revealed the Musculoskeletal Functional Limitation in ROM section was not completed as required per facility protocol. Review of the Quarterly MDS dated [DATE] Section G0400A Functional Limitation in Range of Motion revealed the resident was assessed with [REDACTED]. Review of the Therapy Screening Form dated 12/16/16 directed the staff member completing the form to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy the area of Joint limitations/Contractures was not checked and No Recent Change/Deficits Noted was checked therefore therapy services were not initiated. Review of the Joint Mobility Screen dated 12/20/16 revealed the resident was assessed with [REDACTED]. The resident was unable to extend right and left fingers. Review of the Nursing Data Collection Tool dated 12/20/16 revealed the resident was assessed with [REDACTED]. Review of the Quarterly MDS dated [DATE] section G0400A Functional Limitation in Range of Motion revealed the resident was assessed with [REDACTED]. Review of the current plan of care did not include the assessed problem of limited range of motion of bilateral upper extremities and did not include interventions to address the residents limited range of motion for bilateral upper extremities. In addition the plan of care did not include a restorative program for eating/self feeding. During an observation on 1/10/17 at 1:20 PM Unit Manager Licensed Practical Nurse #72 performed range of motion on the resident ' s bilateral hands. The resident was not able to perform active range of motion of the left hand and fingers. The Unit Manager Licensed Practical Nurse #72 was unable to fully flex or extend the resident ' s left hand and fingers. The resident was able to move his right hand however was not able to fully extend or flex the right fingers. Unit Manager Licensed Practical Nurse #72 was not able to fully extend the resident ' s right fingers. During an interview conducted on 01/10/17 at 1:40 PM Unit Manager Licensed Practical Nurse #72 verified the aforementioned Therapy Screening forms did not identify the decline in the resident's 'bilateral hand range of motion and therefore did not proceed with a formal therapy evaluation. In addition, verified the aforementioned inconsistencies between the Joint Mobility Screens and the Nursing Data Collection Tools. Unit Manager Licensed Practical Nurse #72 stated the resident was never placed on a restorative nursing program as indicated by the Occupational Therapy Discharge Summary dated 04/11/14. Also verified the resident was never placed on hospice. During an interview conducted on 011/10/17 at 2:18 PM Physical Therapy Assistant Director of Rehabilitation staff #99 verified the Therapy Screening Forms dated 01/15/16 and 04/8/16 did not identify a change in the resident ' s bilateral hand range of motion, verified the Therapy Screening Tool dated 04/22/16 identified the resident was receiving hospice services and stated they must have been misinformed since the resident was never on hospice. Physical Therapy Assistant Directory of Rehabilitation staff #99 verified the Therapy Screening Forms dated 07/01/16, 09/19/16 and 12/16/16 did not identify a change in the resident ' s bilateral hand range of motion. When queried as to how the therapy screens were conducted in order to identify a decline in range of motion, Physical Therapy Assistant Director of Rehabilitation staff #99 stated they were not allowed to physically touch the resident when conducting a screening therefore they review the nursing documentation such as the Joint Mobility Screen and Nursing Data Collection tool along with speaking to the nursing staff in order to identify a change in range of motion. Physical Therapy Assistant Director of Rehabilitation staff #99 stated the Joint Mobility Screen was confusing making it difficult to ascertain declines based on how the nursing staff were completing the form. Physical Therapy Assistant Director of Rehabilitation staff #99 stated they were not made aware by nursing staff that Resident #71 had experienced a decline in bilateral hand range of motion. In addition, Physical Therapy Assistant Director of Rehabilitation staff #99 verified a therapy screening form was not completed upon the resident's readmission on 05/16/16 and verified the resident had not received therapy services since being discharged from Physical Therapy on 04/11/14 and Occupational Therapy on 04/24/14. During an interview conducted on 01/10/17 at 2:40 AM Restorative Aid staff #55 stated Resident #71 was not placed on a restorative nursing program for feeding or range of motion services. During an interview conducted on 01/10/17 at 2:35 PM with Certified Nursing Assistant staff #98 stated while getting the resident dressed they move the residents arms and hands but other than that does not provide the resident with additional range of motion exercises. Certified Nursing Assistant staff #98 stated they were never educated on specific range of motion services or a specific feeding program for Resident #71 and further stated the resident is dependent upon the staff and must be fed all meals. During an interview conducted on 01/10/17 at 3:06 PM Assessment Nurse staff #17 verified the Quarterly MDS dated [DATE] Section G0400A Functional Limitation in Range of Motion revealed the resident was assessed with [REDACTED]. When queried as to how they assessed the resident in order to code Section G0400A Assessment Nurse staff #17 stated they reviewed the Nursing Data Collection Tool, the Joint Mobility Screen and they would speak with the nursing staff. Assessment Nurse staff #17 verified the Joint Mobility Screen dated 09/28/16 revealed the resident was assessed with [REDACTED]. Assessment Nurse staff #17 verified the Quarterly MDS dated [DATE] Section G0400A Functional Limitation in Range of Motion was not coded correctly. In addition, Assessment Nurse staff #17 verified the Quarterly MDS dated [DATE] section G0400A Functional Limitation in Range of Motion revealed the resident was assessed with [REDACTED]. Assessment Nurse staff #17 verified the Joint Mobility Screen dated 12/20/16 revealed the resident was assessed with [REDACTED]. The resident was unable to extend right and left fingers and the Nursing Data Collection Tool dated 12/20/16 revealed the resident was assessed with [REDACTED]. Assessment Nurse staff #17 verified the Quarterly MDS dated [DATE] Section G0400A Functional Limitation in Range of Motion was not coded correctly. Assessment Nurse staff #17 verified the current plan of care did not include the assessed problem of limited range of motion of bilateral upper extremities and did not include interventions to address the residents limited range of motion for bilateral upper extremities. In addition, the plan of care did not include the assessed problem of eating/self feeding and did not include interventions to address the resident's eating/self feeding needs. During an interview conducted on 01/11/17 at 8:30 AM Unit Manager Licensed Practical Nurse (LPN) staff #93 verified they completed the Joint Mobility Screen dated 05/16/16 and verified they documented the resident had some resistance with left hand when trying to perform ROM and resident unable to perform bilateral finger extension or flexion. Unit Manager LPN staff #93 verified they completed the Nursing Data Collection Tool dated 05/16/16 and only documented the resident with a functional limitation in range of motion of the left upper extremity. Unit Manager LPN staff #93 verified they completed the Nursing Data Collection Tool dated 07/06/16 in which the Musculoskeletal Functional Limitation in ROM section was left blank. In addition, verified the change in range of motion was not verbally communicated to the therapy department. Unit Manager LPN staff #93 was queried as to what type of training they had been provided on the use of the Joint Mobility Screen and the Nursing Data Collection Tool. Unit Manager LPN #93 stated they were shown upon hire how to complete an admission packet which contained the aforementioned documents. However, no formal training had been provided on the Joint Mobility Screen tool. They stated they would mark lines and or make notes on the Joint Mobility Screen to indicate a range of motion deficit but had difficulty articulating how they would identify on the form a decline in finger extension and flexion. They stated if they had a question on how to complete the form they would ask someone. Unit Manager LPN staff #93 verified the Instructions on the form stated Draw a line through the arc showing how far the limb can be moved (PROM). Note any difference in active range (AROM) with a dotted line. Unit Manager LPN staff #93 stated they now delegate the completion of the form to other nurses on the unit. During an interview conducted on 01/11/17 at 8:40 AM Unit Manager LPN staff #72 stated they had not received training on the Nursing Data Collection Tool and Joint Mobility Screen. They stated they would make lines on the Joint Mobility Screen which would indicate a range of motion deficit and may make notes on the form. However, they had difficulty articulating how they would identify on the form a decline in finger extension and flexion. During interview conducted on 01/11/17 at 9:06 AM Staff Development staff #33 stated they train new nurses during orientation on how to complete the Joint Mobility Screen and Nursing Data Collection Tool, however there is no follow-up skills assessment or training to ensure the Nursing Data Collection Tool and Joint Mobility Screen tool were being implemented correctly. Review of Occupational Therapy Plan of Care dated 01/11/17 revealed Reason for Referral: Contractures L (left) hand and wrist, decline in R (right) hand wrist range of motion. Therapy Necessity: Therapy necessary for positioning, feeding, orthotic/ROM management, Caregiver/nursing/RNP training with plan. Without therapy patient is at risk for decreased hand and wrist ROM, pain, impaired functional positioning. Prior Residence and Living Arrangement: Pt (patient) has resided at this facility for almost 3 years. Pt seen for skilled OT 2/4/14-4/11/14. Pt was feeding self with Mod A (moderate assist) and 50% tactile cuing up in w/c (wheelchair) when OOB (out of bed). Pt is now being fed by care staff and sits in geri chair when OOB. Previous Therapy: Pt seen for skilled OT 2/4/14-4/11/14. Pt was feeding self w/mod A and 50% tactile cueing. Pt d/c from OT pt RUE (right upper extremity) AROM (active range of motion) WFL (within functional limits), LUE (left upper extremity) PROM (passive range of motion) to 1/4 to 1/3 normal ranges with [DIAGNOSES REDACTED]: shoulder flexion 90 degrees, elbow WFL, flexion/extension of wrist and fingers 1/4 to 1/2 normal ranges. Precautions: LUE limited P/AROM w/pt (with patient) c/o (complaint) of soreness. ROM: RUE A/PROM shoulder flexion 0-40/0-120 degrees, elbow flexion and extension WFL A/PROM, wrist flexion neutral to 40 degrees A/PROM, Fingers 1-4 minus 40/20 degrees flexion and minus 40/20 degrees extension, thumb 1/2 normal ranges. LUE PROM no AROM LUE shoulder flexion 0-40 degrees, elbow flexion 0-60 degrees, extension WFL, wrist held in neutral less than 10 degrees flexion, Fingers 1-4 minus 40 degrees flexion and minus 45 degrees extension. Pt grimaces w/attempts to passively range L thumb. During an interview conducted on 01/11/17 at 10:02 AM Occupational Therapist #106 verified the aforementioned Occupational Therapy Evaluation and Plan of Treatment dated 02/24/14 revealed the resident was assessed to have impaired left upper extremity [DIAGNOSES REDACTED] and the right upper extremity was within functional limits. Occupational Therapist #106 verified the aforementioned Occupational Therapy Plan of Care dated 01/11/17 revealed the resident was reassessed and had experienced a decline in bilateral hand range of motion resulting in a worsening of the contractures of the left fingers and had developed new contractures of the right fingers and wrist. In addition, Occupational Therapist #106 acknowledged the resident had experienced an avoidable decline due to a lack of staff intervention and had the potential for improvement with staff intervention. During an interview conducted on 1/11/17 at 10:29 am Director of Nursing staff #20 stated Resident #71 was never on hospice as documented on the Therapy Screening Tool dated 04/22/16 and was never on a formal restorative nursing program. Director of Nursing staff #20 stated the therapy recommendation for the resident to be on a restorative nursing program was not meant for the resident to be a formal restorative plan and that the certified nursing assistants caring for Resident #71 were trained and responsible for delivering the restorative nursing program interventions as recommended by therapy. The Director of Nursing staff #20 was unable to provide documentation demonstrating the certified nursing assistants were educated on the therapy recommendations for Resident #71 stating the directions would have been written on Resident #71 ' s Resident Profile which directs the care given by the certified nursing assistants. Director of Nursing staff #20 verified the restorative nursing recommendations were not documented on Residents #71's Resident Profile. Director of Nursing staff #20 verified inconsistent nursing documentation on the Joint Mobility Screens and the Nursing Data Collection Tools which are conducted in conjunction with one another to ensure an accurate resident assessment per facility protocol. Director of Nursing staff #20 acknowledged the resident had experienced an avoidable decline due to a lack of staff intervention. ,

Based on record review and interview, the facility failed to ensure nursing staff provided appropriate care and services related to pressure ulcer treatment and wound documentation for Resident #56, 1 of 3 sampled residents reviewed with pressure ulcers. There were no wound measurements, staging, or descriptions of the resident's pressure ulcers noted on re-admission to the facility on [DATE]. Wound measurements and/or staging were not documented in the record until 1/23/15. There was no documentation that wound treatment orders had been clarified with the physician upon re-admission to the facility. Wounds documented on the re-admission body audit did not match the treatments that had been restarted by the facility. A left lateral foot pressure ulcer noted on re-admission did not have a treatment initiated. physician's orders [REDACTED]. Treatments had been discontinued without orders or notations in the record that these wounds had resolved/healed. Wound documentation indicated that the resident's pressure ulcers were not healing and/or had worsened. The findings included: The facility admitted Resident #56 with [DIAGNOSES REDACTED]. According to the facility's wound nurse, the resident had been in the facility for several years (since 2010) and his/her wounds had been inherited except for a pressure ulcer to the right elbow which had been acquired at the facility. A review of the resident's January 2015 Quarterly Minimum Data Set Assessment revealed a Brief Interview of Mental Status score of 15, indicating the resident was cognitively intact at the time of the assessment. Resident #56 refused to have the surveyor observe his/her wounds/wound care. A review of the facility census report revealed Resident #56 had been discharged to the hospital on [DATE], re-admitted on [DATE]; sent back to the hospital on [DATE], and returned on 12/19/14; discharged back to the hospital on [DATE], and returned to the facility on [DATE]. The resident was diagnosed with [REDACTED]. Review of the 12/23/14 hospital transfer information on 03/18/2015 at 2:19 PM revealed the resident had been discharged with stage 3/stage 4 wounds with wet to dry dressings daily and as needed to the left hip, right hip, buttocks; and a [MEDICATION NAME] dressing to the left foot. A re-admission body audit dated 12/23/14 included information that the resident had open areas to the elbows (bilaterally), left lateral foot, left buttocks, left ischium (right ischium noted on body audit?), and right hip. The 12/23/14 re-admission Nurse's Note documented that the dressings had been changed that day per hospital report. A second note documented, "Skin warm and dry. Dressing to open areas (two places) to lateral outer L(eft) foot, dressing to both elbows, dressing to R(ight) hip, R(ight) ischium." A review of the December 2014 Treatment Administration Record revealed the Normal Saline wet to dry treatments noted on the hospital transfer summary had not been continued. Previously ordered facility treatments (to the resident's left buttocks, left ischium, right elbow, and right hip; along with skin prep to the left elbow, toes, and bilateral heels) had been continued on 12/24/14 without orders from the physician or documentation that the resident's wounds had been evaluated by facility staff to determine if these treatments were still appropriate. There were no documented wound measurements or staging of the wounds on re-admission. The facility was unable to provide documentation that this had been done until 1/23/15. According to the wound nurse, this is the date that s/he started. Prior to this date, the floor nurses were responsible for the wound care. The wound nurse was unaware of any prior documentation of wound measurements from the resident's re-admission to the facility on [DATE]. The wounds documented by the nursing staff on the body audit and in the Nurse's Notes on re-admission to the facility did not match all the areas of the body where the treatments had been continued on 12/24/14. According to the re-admission body audit, there was an open area on the resident's left lateral foot, but there were no orders initiated for a treatment to this area until 1/23/15. The first wound measurements and staging for this left lateral foot wound had not been documented until 1/23/15 at which time it had been documented as a stage II pressure ulcer that measured 1.1 cm by 2 cm. There were no treatments to the left lateral foot that had been documented on the Treatment Records until 1/23/15. One Nurse's note in December 2014 documented a treatment to the foot. The area to the left lateral foot was documented as resolved as of 3/17/15. These findings were verified by the wound treatment nurse. The re-admission body audit also indicated an open area with dressing intact to the left elbow. The treatment that had been documented as having been continued was a skin prep to the left elbow every shift. A Nurse's Note dated 12/26/14 documented, "Dressing (changed) R(ight) hip- drainage moist, wound bed pink/yellow, no odor. Surrounding skin WNL (within normal limits): R(ight) elbow-moist, yellow drainage, wound bed pink, surrounding skin WNL. R(ight) ischial- moist, wound bed pink, surrounding skin pink. L(eft) ischial- moist, wound bed red, surrounding skin pink. L(eft) lateral foot moist + wound bed yellow/pink, surrounding skin pink...". A nurse's note dated 1/11/15 documented a wound treatment to 3 open areas on the buttocks. The nursing documentation was inconsistent and/or unclear and sometimes indicated a right ischial and/or left ischial wound, or wounds noted to several areas on the buttocks with treatment orders noted only for a left ischial/ left buttocks pressure ulcer. A review on 3/18/15 of January 2015 Physician order [REDACTED]. New orders were written to address the right buttocks and the right hip (both stage 4 pressure ulcers) and the right elbow. The orders included treatment to a stage III wound on the perineum and a stage II to the left posterior thigh (not identified before), along with a stage II pressure ulcer to the left lateral foot. When asked how and when the pressure ulcer to the perineum had been identified, the wound care nurse stated the pressure ulcer to the perineum may have been called something else previously. The wound nurse stated the wound care ordered previously for the left buttocks was changed on 1/23/15 to the right buttocks since there was no wound on the left buttocks. The nurse believed the resident did have a wound on the left buttocks at some point in the past. When asked what had happened to the left ischial wound (treatment had been discontinued on the 1/23/15 physician telephone orders), the wound nurse stated that the treatment had been discontinued since there was no wound to the left ischium at that time. The wound nurse could not recall a wound to the right ischium. A review and comparison of the January 2015 Treatment Record (TAR) with the January 2015 Physician order [REDACTED]. However, the January 2015 Treatment Record documented that both treatments had continued to the right elbow on 1/24, 1/25, 1/28. 1/29, 1/30, and 1/31. There was no treatment initialed on the January 2015 MAR for the 1/26/15 right hip, right buttock, left lateral foot, left posterior thigh, and right elbow treatments (ordered once daily). A review of the February 2015 TAR revealed an entry for a treatment daily to the left posterior thigh. The entry had been marked as discontinued as of 2/6/15. However, there was no corresponding order to discontinue the treatment or documentation that the area had healed. According to the wound nurse, the area had healed and the treatment had been taken off the TAR. Treatments to the right elbow had been changed on 2/19/15 and 2/23/15 with no corresponding physician's orders [REDACTED]. A review of Physician/Nurse Practitioner notes in the chart revealed a note dated 2/25/15 which documented information that the resident's wounds were not healing and that they would get a wound center consult. A review of a Wound Center note dated 3/17/15 revealed that Resident #56 had been last seen at the wound center in April of 2013. The facility's wound nurse had been present at the March 17, 2015 wound center appointment and, according to the note, the wound nurse thought that the resident's ischial and hip wounds actually looked worse than 2 months previously. During an interview on 3/18/15, the wound nurse verified this documentation. S/he stated that the wounds had looked worse, but now were improving. Wound measurements were reviewed with the wound nurse on 3/18/15 at approximately 4:30 PM and included the following: Right hip stage IV- -1/30/14 with 10% slough and 90% granulation tissue and measured 4 x 3.5 cm (centimeters) with no undermining. - 2/20/15 the wound measurements were 3.4 x 3.7 cm with a depth of 1.5 cm with undermining, 20% slough and 80% granulation tissue. - 3/17/15 wound center notes indicated a measurement of 3 cm x 3.3 cm with a depth of 0.5 cm and undermining of 1.2-1.4 cm, red moist base. Right buttock stage IV- -1/30/15 with 100% granulation tissue measuring 2 cm x 2 cm. -2/26/15 measuring 3 cm x 1.5 cm x 0.4 cm depth, with wound bed purple. -3/17/15 wound center notes indicated a measurement of 2.7 cm x 1.4 cm, x 0.3 cm depth with red moist base and undermining 0.2 cm. Perineum/Left Buttock stage IV -1/23/15- 7 cm x 3 cm x 0.5 cm. -2/20/15- 6 cm x 1.8 cm, wound bed red to pink with scant amount of slough. -3/17/15 wound center notes indicated a measurement of 2.0 cm x 7.8 cm x 0.2 cm with a red yellow moist base appearance. Observation of the resident with the wound nurse on 3/18/15 at approximately 4:55 PM revealed the resident in bed with a specialty air mattress in place. The resident's heels were elevated on a pillow. According to the wound nurse, the resident refused to wear the soft heel boots while in bed as ordered.

On the days of the Complaint Inspection, based on record reviews, observations and interview, the facility failed to aggressively treat pressure sores for one of one resident with identified pressure areas on admission, and inappropriate care during dressing change for 2 of 2 residents with skin wounds. Resident #1 was admitted with suspected deep tissue injury and received delayed treatment. Resident #2's nurse did not wash hands between cleaning and dressing the wound. The findings included: Resident #1 admitted to the facility with purple boggy heels documented on the Admission Body Audit dated 12/10/13, the facility did not aggressively treat the wounds when they were first identified. There was no treatment ordered for three days and nursing interventions of pressure reducing devices, floating of heels did not occur for nine days after identification of the areas. S/he was admitted with [DIAGNOSES REDACTED]. Review of the medical record revealed the Admission Minimum Data Set ((MDS) dated [DATE] coded the resident as requiring extensive assistance for bed mobility, transfers, locomotion, dressing and hygiene, and total assistance with bathing. Resident #1 fed herself and was continent of bowel and bladder. The MDS coded the resident as at risk for pressure sores with an unhealed pressure sores on admission. S/he was coded as having 2 suspected deep tissue injury in evolution on admission. Review of the Weekly Skin Documentation revealed the heels were identified as purple and boggy on 12/10/13 on the Admission body audit; on 12/16/13 continued with the purple boggy heels, treatment in progress. 12/23/13, 12/30/13, 1/6/14 and 1/27/14 treatment in progress for heels was documented on the Weekly Skin sheets. Review of the Physician order [REDACTED]. Q shift - Every Shift; AM 0700 AM - 0700 PM, PM 07:00 PM - 07:00 AM..." The heels were not noted. Review of the Physician's telephone orders revealed on 12/13/13 an order for [REDACTED]. On 12/19/13 a new order for skin prep to heels twice a day and to float heels on pillow while in bed, (nine days after wounds identified). On 1/8/14 a Physician's telephone order was written to continue current treatment to blister on heel. The suspected deep tissue injury developed into a blister. On 1/15/14 [MEDICATION NAME] cream was ordered for the open blister on the left lateral heel. The telephone order of 1/23/14 contained new orders for dressing treatment. There was also an order [REDACTED]. Review of the Physician's Progress Notes from 12/12/13 - 1/28/14 revealed that Resident #1 was admitted for rehabilitation following a hospitalization for pinning of the right hip. A 12/12/13 note did not address the resident's boggy heels. The 1/8/14 note for skin indicated an intact blister along the lateral margin of the left heel, non hemorrhagic and no skin breakdown. "...Plan: ...The blister is just due to abrasion from favoring that left foot. ...Continue topical padding that's already being used..." The note dated 1/15/14 stated, "...There is a blister on the outer aspect of the heel which has now ruptured. A padded dressing is being applied over it daily... Plan: [MEDICATION NAME] cream to be applied topically to the ulcer bed twice daily..." On 1/23/14 the progress note stated under the heading labeled Skin: "...Left heel open area, large with pink wound bed and approximately 30% slough. No malodor. The bed is clean. There is no [DIAGNOSES REDACTED] or warmth. Small amount of serosanguineous drainage on the dressing. Surrounding tissue slightly darkened. Right heel small, approximately 3cm (centimeter) open wound dry, with pink wound bed, no drainage. Surrounding area darkened. Mild discomfort... Plan: Vitamin C 500 mgm (milligrams) qd (daily)... Floating heel boots for feet while bed... Refer to Wound Center..." The 1/28/14 Discharge Summary documented "...Skin: Left heel open area, large with 80% macerated wound bed and few isolated islands of pink tissue. No malodor. The bed is clean. Wound permetry is pale, macerated... Small amount of serosanguineous drainage on the dressing. Surround tissue slightly darkened. Tender to touch. Right Heel small approximate 3 cm open wound dry, with pink wound bed, no drainage. Surrounding area darkened... Less tender than last week... Discharge Instructions: Home with daughter... Defer to wound Center for further wound instructions..." The facility admitted Resident #2 with [DIAGNOSES REDACTED]. On 4/29/14 at approximately 11:30 AM, the wound care was observed to the resident's left heel. After cleaning the wound with wound cleaner and gauze, the Licensed Practical Nurse (LPN) with gloved hand used to clean the wound, reached into the treatment cart and obtained more gauze. The nurse did not wash his/her hands or remove his/her gloves after cleaning the wound. At approximately 2:15 PM the LPN was interviewed by the surveyor. The LPN stated, "I thought I changed gloves before going into the cart for more gauze." The LPN confirmed s/he did not wash her/his hands between cleaning and dressing the wound.

On the days of the complaint inspection, based on record review and interviews, the facility failed to develop a care plan (Profile) with clearly expressed measures to ensure that the Certified Nursing Assistants (CNA) provided the appropriate care to meet Resident #1's needs and ensure the safety of the resident during care. Resident #1 experienced a fall resulting in a laceration to her/his head and a fracture of her/his right hip after being left in a wheelchair with a self release belt while the CNA was away (1 of 3 residents reviewed for falls). The findings included: On 3/26/13, during an interview and review of Resident #1's CNA Profile (care plan) in use when the surveyor entered the facility, the Director of Nursing (DON) verified that the CNA Profile for Resident #1 stated that the resident was to have a self release alarming belt while in the wheelchair and was not to be left alone in her room while up in wheelchair for extended periods of time and also stated do not leave resident alone in room while up in wheelchair. When asked by the surveyor what an extended period of time was, the DON stated that s/he did not know. When asked how the CNA was to know, s/he stated that s/he did not know and that was why the incident was reported to the state. The DON failed to explain why the Profile was not changed after the incident occurred on 3/8/13. Review of the CNA Profile with a start date 12/06/2012 and in use at the time of the incident on 3/8/13 stated, "Resident to have SELF RELEASE ALARMING BELT intact while in wheelchair, DO NOT LEAVE PT (patient) ALONE IN ROOM WHILE UP IN W/C (wheelchair) FOR EXTENDED PERIODS OF TIME. Special instructions: ***decreased safety awareness and increased risk for falls*** DO NOT LEAVE PT. ALONE IN ROOM WHILE UP IN WHEELCHAIR***" The CNA Profile in use when the surveyor entered the facility on 3/25/13 had not been updated since the incident on 3/8/13. An updated copy of the resident's Profile was provided on 3/26/13 at 9:00 AM by the DON with a print date of 3/20/13. The Profile stated "Res. (resident) to have SELF RELEASE ALARMING BELT intact while in wheelchair. DO NOT LEAVE PT. ALONE IN ROOM WHILE UP IN W/C FOR EXTENDED PERIODS OF TIME. Special instructions: ***decreased safety awareness and increased risk for falls***" A third copy was presented to the surveyor on 3/26/13 with a print date of 3/26/13 by the DON who stated it was changed last night (3/25/13). This Profile read "Res to have SELF RELEASE ALARMING BELT intact while in wheelchair, Special instructions***decreased safety awareness and increased risk for falls***" The DON also verified that the Nursing Care Plan had not been updated to include a self release alarming belt. The care plan start date was 9/17/12 and included a soft belt restraint. The care plan for falls updated on 3/21/13 by the MDS (Minimum Data Set) Coordinator addressed "soft belt restraint..." During interviews with Licensed Practical Nurse #1 on 3/25/13 at 5:15 PM, CNA #1 on 3/25/13 at 6:00 PM, and Registered Nurse #1 on 3/25/13 at 6:25 PM, all stated that they were not aware that the resident's Profile stated that the resident was not to be left alone in her/his room in the wheelchair.

On the days of the complaint inspection, based on record reviews, interviews, review of the facility policy entitled "Fall Management", Resident #1's Certified Nursing Assistant Profile (care plan), Fall Assessment and Nursing Care Plan the facility failed to ensure that the resident received the appropriate supervision to prevent falls and injuries. The findings included: Review of the medical chart for Resident #1 on 3/25/13 indicated that the resident had a history of [REDACTED].) taken to room in WC with belt on to be put to bed after supper per CNA, an alarm went off, CNA stepped out to notify nurse, CNA then went back in room to find pt. (patient) had undone belt, stood up and fell in floor, hit head against drawers..." The nurse entered the room and noted a laceration to the resident's head, applied first aide to the laceration and took the resident's vital signs. The resident complained of right hip pain. The staff put the resident in bed and applied an ice pack to the hip. The physician was called and while waiting on the return call the resident vomited. When the physician called the resident was sent to the emergency department. The hospital admission notes dated 3/8/13 indicated that the resident presented to the emergency department (ED) with a history of fall from the wheelchair. "S/he... had a laceration to the scalp which had been stitched in the ED, and also s/he had a fracture of the right hip femoral neck..." Review of the facility Five-Day Follow-Up Report received via Fax on 3/15/13 revealed that Resident #1 fell and was injured when Certified Nursing Assistant (CNA) #1 left the resident unattended in a wheelchair equipped with a self release alarming belt. The facility was "... unable to substantiate for neglect. Written warning given to employee (CNA #1) to review each section of the profile in Matrix when caring for patients..." The follow-up report included a Resident Profile last updated 3/11/13 that stated under the section entitled "...Profile Care Plan Approaches... Restraints (start date) 12/06/2012 Res (resident) to have SELF RELEASE ALARMING BELT intact while in wheelchair, DO NOT LEAVE PT (patient) ALONE IN ROOM WHILE UP IN W/C (wheelchair) FOR EXTENDED PERIODS OF TIME. Special instructions: ***decreased safety awareness and increased risk for falls*** DO NOT LEAVE PT. ALONE IN ROOM WHILE UP IN WHEELCHAIR***" The profile listed two different approaches for the CNA to follow. When the surveyor entered the facility on 3/25/13 the CNA Profile (care plan) in use stated, "...Resident to have SELF RELEASE ALARMING BELT intact while in wheelchair, DO NOT LEAVE PT (patient) ALONE IN ROOM WHILE UP IN W/C (wheelchair) FOR EXTENDED PERIODS OF TIME. Special instructions: ***decreased safety awareness and increased risk for falls*** DO NOT LEAVE PT. ALONE IN ROOM WHILE UP IN WHEELCHAIR***" The profile in use at the time of the survey was the same as the profile used at the time of the injury on 3/8/13. The DON on 3/26/13 at 9:00 AM provided an updated copy of the resident's Profile that had a print date of 3/20/13. The Profile stated "Res. (resident) to have self release alarming belt intact while in wheelchair. Do not leave pt. alone in room while up in w/c (wheelchair) for extended periods of time. Special instructions;***decreased safety awareness and increased risk for falls***" A third copy was presented to the surveyor on 3/26/13 with a print date of 3/26/13 at 8:21 AM by the DON who stated it was changed last night (3/25/13). This Profile read "Res to have self release alarming belt intact while in wheelchair, Special instructions***decreased safety awareness and increased risk for falls*** " The DON also verified that the Nursing Care Plan had not been updated to include a self release alarming belt, hipsters and soft helmet. The care plan start date was 9/17/12 and included a soft belt restraint. The care plan was updated on 3/21/13 by the MDS (Minimum Data Set) Coordinator and listed the soft belt restraint instead of the self release alarming belt. During interviews with Licensed Practical Nurse #1 on 3/25/13 at 5:15 PM, CNA #1 on 3/25/13 at 6:00 PM, and Registered Nurse #1 on 3/25/13 at 6:25 PM, all stated that they were not aware that the resident's Profile stated that the resident was not to be left alone in her/his room in the wheelchair. On 3/26/13, during review of the resident's Fall Risk assessment dated [DATE] with Licensed Practical Nurse (LPN) #2, the assessment indicated the resident was scored at 16 with scores of 10 or higher being at risk. No other assessments were provided and LPN #2 verified that no assessment had been completed for Resident #1 prior to 3/8/13. When asked by the surveyor if the resident should have been assessed as a fall risk with her/his fall history, s/he stated yes and that s/he did not know why it had not been done prior to the 3/8/13 fall. Review of the facility's policy entitled Fall Management" revealed "...Policy: 1. The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. 2. Qualified staff will complete the Fall Risk Evaluation to determine if patient/resident is a fall risk. 3. A patient/resident fall management program will be implemented that educates staff in creative, functional strategies while recognizing patient/resident rights and their need to maintain the highest practical level of function... Procedures: 11. Qualified staff evaluates all patients/residents for fall risk at a minimum upon admission, quarterly and with a significant change... 4. If a fall occurs, qualified staff evaluates patient/resident for injury from the fall, immediately investigates the reason for the fall, determines interventions to prevent future falls and completes a Fall Investigation Worksheet..."

On the days of the Recertification, Complaint and Extended Survey, based on interview, record review, review of the facility policy and procedure entitled "Physician Communication/Change in Condition " and review of the files in reference to a complaint received by this office, the facility failed to timely notify the resident's responsible party of new onset knee pain and of a fracture noted on an MRI (Magnetic Resonance Imaging) for Resident #11, 1 of 2 residents reviewed with a fracture and 1 of 9 residents reviewed for pain and comfort. In addition the facility failed to notify the Orthopedic Physician regarding the MRI to ensure appropriate treatment was provided and failed to notify the facility physician that the resident continued to regularly receive narcotic pain medication for her left knee for more than 3 months. The findings included: The facility admitted Resident #11 to the facility with [DIAGNOSES REDACTED]. On 10/2/12 review of the Nurse's Notes dated 6/19/12 through 6/28/12 revealed the resident complained of pain to the left lower extremity on 6/19/12 and was medicated with Tylenol at 9:00 PM. At 12:20 AM on 6/20/12, the nurse notified the physician on call of the resident's continued complaints of pain and received an order to administer [MEDICATION NAME] 50 milligrams for pain. The physician declined to send the resident for an x-ray at that time and wanted to try medication first per the note. The Nurse's Notes stated Resident #11 received the [MEDICATION NAME] at 1:00 AM. Further review of the Nurse's Notes from 6/26/12 through 6/27/12 revealed the following: "6/26/12 2:45 PM Res. going LOA @ this time to MD to have MRI (magnetic resonance imaging) of (L) knee and... hips scheduled @ 3:30 PM... 6/27/12 10:15 AM Res. daughter @ facility to bring report from Ortho Specialist from appt. today. [DIAGNOSES REDACTED].t. (physical therapy) is necessary. Daughter informed this nurse that knee brace was placed on (L) knee for res (resident) to wear while OOB (out of bed)... " There was no documentation that the resident's responsible party was notified of the new onset of knee pain or the order for new medication on 6/20/12 and there was no documentation that the responsible party was notified of the results of the MRI done on 6/26/12. Review of the MAR (Medication Administration Record) on 10/3/12 at 10:58 AM revealed the resident received narcotic pain medication regularly since 6/19/12. Resident #11 had a total of 15 days that s/he did not experience pain and receive narcotic pain medication: 6/24, 6/29, 6/30, 7/1, 7/9, 7/14, 7/29, 8/20, 8/25, 8/26, 8/30, 9/12, 9/14, 9/18, and 9/27/12. Review of the Nurse's Notes revealed no documentation that the resident's physician was notified of the resident's continued complaints of pain and need for narcotic pain medication. Review of an MRI Left Knee without Contrast dated 6/26/12 stated, "...Impression: 1. Nondisplaced subacute comminuted [MEDICAL CONDITION] femur with fracture lines extending into the patellofemoral joint and intercondylar notch. 2. Fraying versus an atypical oblique linear tear in the inferior aspect of the posterior horn of the medial meniscus. 3. [MEDICAL CONDITIONS] versus a moderate sprain of the medial collateral ligament. 4. 5 mm (millimeter) full-thickness chondral defect in the medal facet of the trochlear notch... " On 10/2/12 at 4:28 PM a review of the orthopedic physician's consultation report dated 6/27/12 stated, "S/he had a MRI after her/his initial visit that showed no fracture and severe osteopenia." There was no documentation that the MRI report (6/26/12) was provided to the resident's orthopedic physician. In an interview with the surveyor on 10/2/12 at 2:30 PM, the responsible party (RP) discussed her/his mother's injury in June (2012) and confirmed the facility did not inform her/him of her/his mother's complaints of pain in her/his knee. The RP stated that s/he was informed of the x-ray and CT scan results. During an interview on 10/22/12 at 3:00 PM, the resident's physician stated that s/he was never informed that the resident was continuing to have pain. S/he stated that Resident #11 never complained of pain to her/him. The physician also stated that the facility usually notified the Nurse Practitioners first of any concerns and that, if the Nurse Practitioners were not able to handle the issue, they would then call the doctor. Review of the facility's policy entitled "Nursing Policies and Procedures, Physician Communication/Change in Condition" revealed in "Procedures" that nurses should conduct a complete assessment of the resident "which may include recent labs, x-ray results." The policy further stated, "...4. The patient's/resident's family member/legal representative will be notified of any changes in medical condition or treatment plan..." and that "all attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record." On 10/22/2012 at 10:00 AM the Director of Nurses and the Nurse Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-157 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/27/2012 related to Resident #11 who sustained an injury on 6/19/12 while being assisted to bed. MRI confirmed the injury on 06/26/2012 to be a fracture. The Orthopedic Specialist who assessed Resident #11 on 06/27/2012 did not see the MRI; s/he treated the resident for knee pain, ordered a brace and physical therapy. The resident continued to complain and was treated regularly for pain from 06/19/2012 until 10/02/2012 without follow up by the Orthopedic Specialist; without an assessment of the continued use of pain medication by the nursing staff and without notification of the resident's continued pain to the physician. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 10/23/2012 had been implemented by the facility and in practice removing the immediacy of the deficient practice. The Director of Nurses and the Regional Vice President was informed of this on 10/23/2012. The Immediate Jeopardy at F-157 was removed but the citation at F-157 remained at a lower scope and severity of "E".

On the days of the Recertification, Complaint and Extended Surveys, based on record review and interviews, the facility failed to provide services in accordance with acceptable professional standards for Resident #11 who sustained an injury on 6/19/12 while being assisted to bed. The facility failed to ensure that test results were communicated to the consulting physician, provided treatment that had potentially negative outcomes, failed to ensure that follow-up appointments were received as ordered, and failed to discuss the resident's continued pain with the attending physician. The findings included: Resident #11 on 6/19/12 was assisted to bed by CNA #3 without the use of the prescribed transfer disc. Resident #11 complained of left knee pain after the transfer. An x-ray done on 6/20/12 indicated a [MEDICAL CONDITION] medial condyle and a CT scan on 6/21/12 showed no fracture. On 6/26/12 a MRI (magnetic resonance imaging) of the left knee was done. Review of an MRI Left Knee without Contrast dated 6/26/12 stated, "...Impression: 1. Nondisplaced subacute comminuted [MEDICAL CONDITION] femur with fracture lines extending into the patellofemoral joint and intercondylar notch. 2. Fraying versus an atypical oblique linear tear in the inferior aspect of the posterior horn of the medial meniscus. 3. [MEDICAL CONDITIONS] versus a moderate sprain of the medial collateral ligament. 4. 5 mm (millimeter) full-thickness chondral defect in the medal facet of the trochlear notch... " A follow up visit with an Orthopedic Specialist was scheduled for 6/27/12. At the time of the survey the record of the follow up visit with the Orthopedic Specialist's on 6/27/12 was not available at the facility and was faxed to the State Agency on 10/15/12. Review of the follow up visit revealed the Orthopedic Specialist treated Resident #11's injury as knee pain and the resident was provided a knee orthosis (brace), referred to physical therapy and asked to return in 6 weeks. Review of the order received from the Orthopedist for physical therapy indicated the resident had a follow-up appointment scheduled for 9:00 AM on 7/31/12. Review of the appointment calendar revealed the appointment had been changed to 8/16/12. Further review revealed the 8/16/12 appointment was cancelled and no further appointments were scheduled. On 10/22/12 at 2:45 PM, during the Extended Survey, the Director of Rehabilitation (DOR) stated that the DON (Director of Nurses) and NHA (Nursing Home Administrator) had requested Resident #11 be evaluated for therapy. The DOR also stated the therapy department was not aware that the resident had a fracture. The DOR confirmed that the resident was being treated for [REDACTED]. When asked if the treatment plan would have been different if the therapists had known the resident had a fracture, the DOR responded "Absolutely." The DOR further stated that the resident "essentially should have been non-weight bearing" and stated that the treatment plan as initiated would have potentially "prevented healing' of the fracture. On 10/23/12 at 2:30 PM, the Physical Therapist (PT) confirmed that s/he was not aware of the MRI results indicating a distal femoral fracture. The therapist also stated "a distal femoral fracture would automatically be non-weight bearing." The PT also stated that, because the resident had already been to the orthopedic doctor and came to therapy with a knee brace in place, s/he did not look for any radiological studies. Review of the MAR (Medication Administration Record) on 10/3/12 at 10:58 AM revealed the resident received narcotic pain medication regularly since 6/19/12. Resident #11 had a total of 15 days that she did not experience pain and receive narcotic pain medication: 6/24, 6/29, 6/30, 7/1, 7/9, 7/14, 7/29, 8/20, 8/25, 8/26, 8/30, 9/12, 9/14, 9/18, and 9/27/12. Review of the Nurse's Notes revealed no documentation that the resident's physician was notified of the resident's continued complaints of pain and need for narcotic pain medication. During an interview on 10/22/12 at 3:00 PM, the resident's physician stated that s/he was never informed that the resident was continuing to have pain. S/he stated that Resident #11 never complained of pain to her/him. The physician also stated that the facility usually notified the Nurse Practitioners first of any concerns and that, if the Nurse Practitioners were not able to handle the issue, they would then call the doctor. On 10/22/2012 at 10:00 AM the Director of Nurses and the Nurse Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-281 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/27/2012 related to Resident #11 who sustained an injury on 6/19/12 while being assisted to bed. MRI confirmed the injury on 06/26/2012 to be a fracture. The Orthopedic Specialist who assessed Resident #11 on 06/27/2012 did not see the MRI; s/he treated the resident for knee pain, ordered a brace and physical therapy. The resident continued to complain and was treated regularly for pain from 06/19/2012 until 10/02/2012 without follow up by the Orthopedic Specialist; without an assessment of the continued use of pain medication by the nursing staff and without notification of the resident's continued pain to the physician. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 10/23/2012 had been implemented by the facility and in practice removing the immediacy of the deficient practice. The Director of Nurses and the Regional Vice President was informed of this on 10/23/2012. The Immediate Jeopardy at F-281 was removed but the citation at F-281 remained at a lower scope and severity of "E".

On the days of the Recertification, Complaint and Extended Surveys, based on record review and interviews, the facility failed to adequately provide the necessary care and follow up needed to ensure optimal improvement without deterioration in physical and mental well being for Resident #11 who sustained an injury on 6/19/12 while being assisted to bed. MRI (magnetic resonance imaging) on 06/26/2012 confirmed the injury as a fracture. The Orthopedic Specialist who assessed Resident #11 on 06/27/2012 did not see the MRI; s/he treated the resident for knee pain, ordered a brace and physical therapy. The resident continued to complain and was treated regularly for pain from 06/19/2012 until 10/02/2012 without follow up by the Orthopedic Specialist or an assessment of the continued use of pain medication. The findings included: The facility admitted Resident #11 to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a BIMS (brief interview of mental status) of 8. S/he required extensive assistance with bed mobility one person physical assist; transfer required extensive assistance with two person physical assist. The Annual MDS dated [DATE] indicated a BIMS of 10. S/he required extensive assistance with bed mobility one person physical assist; transfer was coded as total dependence with two person physical assist. On 9/15/12 the Quarterly MDS coded the resident as having a BIMS of 5. Extensive assistance with bed mobility one person physical assist; transfer required extensive assistance with two person physical assist. Resident #11 on 6/19/12 was assisted to bed by CNA #3 without the use of the prescribed transfer disc. Resident #11 complained of left knee pain after the transfer. An x-ray done on 6/20/12 indicated a [MEDICAL CONDITION] medial condyle and a CT (computed tomography) scan on 6/21/12 showed no fracture. On 6/26/12 a MRI (magnetic resonance imaging) of the left knee was done that showed a [MEDICAL CONDITION] distal femur with fracture lines extending into the patellofemoral joint and intercondylar notch. A follow up visit with an Orthopedic Specialist was scheduled for 6/27/12. A the time of the survey the record of the follow up visit with the Orthopedic Specialist's on 6/27/12 was not available at the facility and was faxed to the State Agency on 10/15/12. Review of the follow up visit revealed the Orthopedic Specialist treated Resident #11's injury as knee pain and the resident was provided a knee orthosis (brace), referred to physical therapy and asked to return in 6 weeks. There was no documentation the resident was seen by the Orthopedic Specialist after 6/27/12. Review of the Physician's Progress Notes dated 7/20/12 and 8/20/12 refer to the [MEDICAL CONDITION] distal femur; the 8/20/12 note addressed the need for follow up with the orthopedic surgeon. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/2/12 at 12:35 PM, a review of the Five-Day Follow-up in reference to a facility reported incident received by this office, revealed the facility investigation indicated the resident was injured while putting herself to bed on 6/19/12 with stand-by assistance from CNA #3. The CNA failed to use the prescribed transfer disc. Review of the Nurse's Notes from 05/27/12 through 10/1/12 revealed the following regarding Resident #11 injury and knee pain. "6/19/12 @ (at) 10 P (M) PRN (as needed) given at 9 p r/t (related to) (L) (left) knee pain warm to touch no redness or swelling noted. 6/20/12 @ 12:20 A MD on call... notified about Res (resident) c/o (complaint of) (L) leg and knee pain... ordered 50 mg (milligrams) of [MEDICATION NAME] pain. This nurse asked for x-ray or doppler for possible break or clot. MD stated no try meds first... 9:55 AM 1:00 AM patient given 50 mg [MEDICATION NAME]. Resting yells out until, 2:00 AM, Resident resting in bed quietly... awoke resident at 5:30 AM to give meds, Resident stated was hurting in lt (left) knee, Tylenol scheduled was included with this med pass... Pt evaluated by MD x-ray with result of (+) fracture to (L) knee. Pt c/o pain to (L) knee after 'turning wrong in bed. Pt denies any falls'... doctor confirmed with pt a f/u (follow up) appt (appointment) with Orthopedist would be scheduled... 3 PM late entry for 6/20/12 7:15 AM. When this nurse arrived to nurse's station res. granddaughter reported that res. is complaining of pain to (L) knee and not able to tolerated (L) lower ext (extremity) to be moved... This nurse assessed... asked res when did (L) leg... begin hurting? Res states, 'I put myself to bed last night and has hurt ever since.'... Reported pain to Nurse Practitioner and new orders to give [MEDICATION NAME] 50 mg po (by mouth) now and give tylenol 325 mg ii po now for pain and send for x-ray of (L) hip and (L) knee... 3:15 PM late entry for 6/20/12 @ 9:00 AM. Res transferred to imaging @ this time via stretcher... 3:15 PM late entry for 6/20/12 @ 10:30 AM DON (director of nursing) @ facility informed the nurse that... res has possible fx (fracture) of (L) knee and reported to MD... MD rounding @ facility today will eval (evaluate) resident... 4:20 PM... verbal order to apply ice pack to (L) knee... 5:10 PM Still awaiting a phone call from Orthopedist office... x-ray results faxed over earlier and spoke with receptionist... 6:17 PM This nurse has not received a phone call back from Orthopedist... Late entry 6/21/12 2:15 PM Spoke with nurse at Orthopedist office multiple times today regarding possible fracture to (L) knee. Orthopedist recommended a CT (computed tomography) scan of (L) knee. Transport arranged and appointment made with imaging for 3:30 PM... 6/22/12 10:30 AM... Res. LOA (leave of absence) to appt. with Orthopedist..." 6/23/12 through 6/25/12 multiple nursing notes related to pain and the administration of pain medication. 6/26/12 2:45 PM Res. going LOA @ this time to MD to have MRI (magnetic resonance imaging) of (L) knee and... hips scheduled @ 3:30 PM... 6/27/12 10:15 AM Res. daughter @ facility to bring report from Ortho Specialist from appt. today. [DIAGNOSES REDACTED].t. (physical therapy) is necessary. Daughter informed this nurse that knee brace was placed on (L) knee for res to wear while OOB (out of bed)... 6/28/12 1:30 PM... Res has new orders per ortho for P.T. and O.T. (occupational therapy) Res tolerated transferring from bed to w/c (wheelchair) with transfer disc and two person assist with knee brace in place on (L) knee. Res to keep knee brace on (L) knee when OOB and during therapy per ortho. Res received prn [MEDICATION NAME] after eval with p.t..." The nursing documentation revealed Resident #11 received pain medication Further review of the medical record revealed an MRI dated 6/26/12 that stated, "...IMPRESSION: 1. Nondisplaced subacute comminuted [MEDICAL CONDITION] femur with fracture lines extending into the patellofemoral joint and intercondylar notch. 2. Fraying versus an atypical oblique linear tear in the inferior aspect of the posterior horn of the medial meniscus. 3. [MEDICAL CONDITIONS] versus a moderate sprain of the medial collateral ligament. 4. 5 mm (millimeter) full-thickness chondral defect in the medal facet of the trochlear notch... " In a telephone interview with the Director of Nurses on 10/15/12 the surveyor requested a copy of the 6/27/12 Orthopedist visit referenced in the 6/27/12, 10:15 AM nurse's note. The information faxed to the State Agency and received 10/15/12 stated, "...There was not a copy of this in resident's chart. The family did not give us copies of anything sent back from physician visits. The family, daughter, always went to appts (appointments) with resident but never brought information back to us. I called physician office 10-3-12 to request this note... 'Orthopedic Specialties of... 06/27/2012 08:57 AM... History of Present Illness... presents for a recheck of Left Knee Pain. The onset of the left knee pain has been sudden and has been occurring in a persistent pattern for 3 days. The course has been constant. The left knee pain is moderate to severe... The left knee pain is aggravated by physical activity, any movement, twisting, squatting, kneeling, climbing stairs, prolonged standing and walking. There were no relieving factors. The symptoms have been associated with muscle swelling, joint swelling, medial pain, lateral pain, difficulty arising from chair and difficulty going up and down stairs. The left knee pain was preceded by trauma (patient fell on her knee getting into bed). Previous diagnostic tests include plain radiographs which showed a possible impaction [MEDICAL CONDITION] femoral condyle and CT which was normal and only showed arthritis... S/he had a MRI after her/his last visit which showed no fracture and some severe osteopenia. The injections s/he received gave her/him some mild relief. S/he is still having trouble with range of motion... Musculoskeletal: Lower Extremity; Knee/Patella: Evaluation of related systems reveals - neurovascularly intact bilaterally. Note: Calf is soft and nontender. Examination of the left knee reveals - no swelling or [MEDICAL CONDITION], normal deep tendon reflexes and normal coordination normal strength and tone, normal sensation and no known fractures... Left: Flexion: AROM - 5 degrees, Extension: AROM - 0 degrees... Exam extremely limited by pain and patient being on a stretcher... Assessment and Plan PAIN IN JOINT, LOWER LEG Current Plan: *Kneeorthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment routine * Refer to Physical Therapy *Patent instructed to return in 6 weeks.' " Review of the Physician's Progress Notes dated 6/20/12 indicated Resident #11 went out to get an x-ray on 6/20/12 and was found to have a possible fracture of her knee. The note indicated the resident had a pending appointment with her regular orthopedic physician. A note dated 7/20/12 stated Resident #11 had a "recent injury of the left knee and has a comminuted [MEDICAL CONDITION] femur and meniscal derangement. S/he is wearing a brace. S/he is followed by Orthopedics... Left leg is inspected. S/he has a brace in place at the knee. S/he has mild tenderness with palpation of the peripatellar area... MRI of the left knee without contrast done on 06/26/2012 showed a nondisplaced subacute comminuted [MEDICAL CONDITION] femur with fracture lines extending in the patellofemoral joint and intercondylar notch. S/he also had a versus atypical oblique tear in the inferior aspect of the posterior horn of medial meniscus, [MEDICAL CONDITIONS] versus a a sprain at the medial collateral ligament... " Plan: Apply an ice pack to the left knee 15 minutes b.i.d. (twice a day) prn (as needed) to help with pain management... Following a hospital admission on 8/15/12 the facility physician did a readmission history and physical dated 8/20/12 that stated, "... Functional status: S/he needs to be lifted in transfer... Musculoskeletal: Range of motion is very limited. Lower extremity range of motion is limited secondary to her knee joint arthritis as well as body habitus... Patient is wearing knee brace because of the distal femoral epicondyle fracture which is treated conservatively... Imaging Studies: CAT scan of the abdomen and pelvis done on August 15 show bilateral pleural effusion... Knee x-ray showed possible impacted fracture, which is also MRI of the left knee show nondisplaced subacute comminuted [MEDICAL CONDITION] femur... Consults: She needs to follow up with her own orthopedic surgeon..." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR further revealed s/he received narcotic pain medication regularly since 6/19/12. Resident #11 had a total of 15 days that s/he was not medicated for pain: 6/24, 6/29, 6/30, 7/1, 7/9, 7/14, 7/29, 8/20, 8/25, 8/26, 8/30, 9/12, 9/14, 9/18, and 9/27/12. Review of the nursing documentation from 06/20/2012 through 10/01/2012 indicated the resident's regularly use pain medication and there was no documentation that the physician or pharmacy consultant addressed this. On 10/23/12, during the Extended Survey, the Pharmacist declined an interview. During a telephone interview on 10/24/12 at 2:58 PM, the Pharmacist confirmed that he had reviewed the medication regimen for Resident #11 by reviewing the MAR but stated he couldn't specifically state that the PRN (as needed) medications were reviewed. When asked if s/he had made any recommendations related to the resident's pain medication, the Pharmacist did not respond. On 10/22/12 at 2:45 PM, during the Extended Survey, the Director of Rehabilitation (DOR) stated that the Director of Nursing and Nursing Home Administrator requested that Resident #11 be evaluated for therapy. The DOR also stated the therapy department was not aware that the resident had a fracture. The DOR confirmed that the resident was being treated for [REDACTED]. When asked if the treatment plan would have been different if the therapists had known the resident had a fracture, the DOR responded "Absolutely." The DOR further stated that the resident "essentially should have been non-weight bearing" and stated that the treatment plan as initiated would have potentially "prevented healing' of the fracture. On 10/23/12 at 2:30 PM, the Physical Therapist (PT) confirmed that s/he was not aware of the MRI results indicating a distal femoral fracture. The therapist also stated "a distal femoral fracture would automatically be non-weight bearing." The PT also stated that, because the resident had already been to the orthopedic doctor and came to therapy with a knee brace in place, s/he did not look for any radiological studies. During an interview on 10/22/12 at 3:00 PM during the Extended Survey, the resident's physician confirmed that the 8/20/12 progress note stated Resident #11 should follow-up with her orthopedic doctor. S/he stated that s/he did not recall when s/he evaluated the resident's knee and associated pain and stated that s/he regarded that as being managed by her/his orthopedic physician. S/he further confirmed that s/he did not know if the resident had a follow up with the orthopedic physician. On 10/22/2012 at 10:00 AM the Director of Nurses and the Nurse Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-309 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/27/2012 related to Resident #11 who sustained an injury on 6/19/12 while being assisted to bed. MRI confirmed the injury on 06/26/2012 to be a fracture. The Orthopedic Specialist who assessed Resident #11 on 06/27/2012 did not see the MRI; s/he treated the resident for knee pain, ordered a brace and physical therapy. The resident continued to complain and was treated regularly for pain from 06/19/2012 until 10/02/2012 without follow up by the Orthopedic Specialist; without an assessment of the continued use of pain medication by the nursing staff and without notification of the resident's continued pain to the physician. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 10/23/2012 had been implemented by the facility and were in practice removing the immediacy of the deficient practice. The Director of Nurses and the Regional Vice President was informed of this on 10/23/2012. The Substandard Quality of Care and Immediate Jeopardy at F-309 was removed but the citation at F-309 remained at a lower scope and severity of "E".

On the days of the Recertification, Complaint and Extended Surveys, the Pharmacist failed to identify the prolonged use of narcotic medication for Resident #11, without clear clinical indications that would warrant the continued use of the medication. There was no evidence of a review for the continued necessity of the dose or of attempts at, or consideration of, tapering the medication. The Pharmacist failed to report the prolonged use of the medication to the Attending Physician or the Director of Nursing. The findings included: The facility admitted Resident #11 to the facility with [DIAGNOSES REDACTED]. On 6/19/12 Resident #11 was assisted to bed by CNA #3 without the use of the prescribed transfer disc. Resident #11 complained of left knee pain after the transfer. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR (Medication Administration Record) further revealed s/he received narcotic pain medication regularly since 6/19/12. Resident #11 had a total of 15 days that s/he was not medicated for pain: 6/24, 6/29, 6/30, 7/1, 7/9, 7/14, 7/29, 8/20, 8/25, 8/26, 8/30, 9/12, 9/14, 9/18, and 9/27/12. Review of the Telephone Orders revealed an order dated 6/20/12 for OxyContin 10 milligrams (mg) every 12 hours for pain and Lortab 5/500 (mg) 1 tablet by mouth every 6 hours PRN (as needed) for pain. The OxyContin was subsequently discontinued the same day at the family's request. Review of the PRN Medication Notes revealed the resident received OxyContin on 6/21/12 at 4:30 PM, 6/22/12 9:30 AM, 6/27/12 8:00 AM and 6/28/12 at 4:30 PM after the medication had been discontinued on 6/20/12. Further review revealed an order dated 6/22/12 to discontinue the Lortab 5 mg and start Lortab 7.5 mg/ 500 mg 1 tablet every 4-6 hours as needed. Review of the June MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. Per the MAR, the Lortab was discontinued on 6/28/12 and an order was received for Norco 7.5/325 mg 2 tablets every 4 hours PRN was transcribed. Review of the July MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. 2 tablets on 7/2, 7/3 (2 doses), 7/4, 7/5 (2 doses), 7/6, 7/7 (2 doses), and 7/8/12. A notation on the MAR indicated [REDACTED]. Review of the Medication Regimen on 10/23/12 revealed the Pharmacist had reviewed the residents medications on 6/12/12 and 7/18/12 and indicated "NI *" each month. At the bottom of the record was the following statement "* Based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment that at such time, the resident's medication regimen contained no new irregularities..." There was no evidence that the Pharmacist had identified that 2 tablets of Lortab 7.5/500 mg was being administered with an order for [REDACTED]. There was no evidence that the Pharmacist made any recommendations or reported any irregularities to the facility. On 10/23/12, during the Extended Survey, the Pharmacist declined an interview. During a telephone interview on 10/24/12 at 2:58 PM, the Pharmacist confirmed that s/he had reviewed the medication regimen for Resident #11 by reviewing the MAR but stated s/he couldn't specifically state that the PRN medications were reviewed. When asked if s/he had made any recommendations related to the resident's pain medication, the Pharmacist did not respond. On 10/22/2012 at 10:00 AM the Director of Nurses and the Nurse Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-428 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/27/2012 related to Resident #11 who sustained an injury on 6/19/12 while being assisted to bed. MRI confirmed the injury on 06/26/2012 to be a fracture. The Orthopedic Specialist who assessed Resident #11 on 06/27/2012 did not see the MRI; s/he treated the resident for knee pain, ordered a brace and physical therapy. The resident continued to complain and was treated regularly for pain from 06/19/2012 until 10/02/2012 without follow up by the Orthopedic Specialist; without an assessment of the continued use of pain medication by the nursing staff and without notification of the resident's continued pain to the physician. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 10/23/2012 had been implemented by the facility and were in practice removing the immediacy of the deficient practice. The Director of Nurses and the Regional Vice President was informed of this on 10/23/2012. The Immediate Jeopardy at F-428 was removed but the citation at F-428 remained at a lower scope and severity of "E".

On the days of the Recertification, Complaint and Extended Surveys, based on record review and interviews, the facility Administration failed to utilize its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being of Resident #11. The findings included: Resident #11 sustained an injury on 6/19/12 while being assisted to bed. MRI (magnetic resonance imaging) on 06/26/12 confirmed the injury as a fracture. The Orthopedic Specialist who assessed Resident #11 on 06/27/12 did not see the MRI; s/he treated the resident for knee pain, ordered a brace and physical therapy. The resident continued to complain and was treated regularly for pain from 06/19/2012 until 10/02/2012 without follow up by the Orthopedic Specialist or an assessment of the continued use of pain medication. Review of the record revealed Physician and Nurse Practitioner Progress Notes that indicated the resident, had a fracture. During the survey, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) indicated the resident's MRI was negative and indicated the resident did not have a fracture. The DON and the NHA both stated they were unaware that the MRI indicated a distal femoral fracture. Neither the DON nor NHA could confirm that the MRI had been sent to the orthopedic physician. While confirming that the facility physician had indicated in a progress note dated 8/20/12 that Resident #11 needed follow up with the orthopedic doctor, the DON or the NHA confirmed that the resident had not returned for follow up. During the Extended Survey, the Nursing Home Administrator was no longer employed at the facility and the Interim Nursing Home Administrator was unavailable for an interview. On 10/22/2012 at 10:00 AM the Director of Nurses and the Nurse Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-490 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/27/2012 related to Resident #11 who sustained an injury on 6/19/12 while being assisted to bed. MRI confirmed the injury on 06/26/2012 to be a fracture. The Orthopedic Specialist who assessed Resident #11 on 06/27/2012 did not see the MRI; s/he treated the resident for knee pain, ordered a brace and physical therapy. The resident continued to complain and was treated regularly for pain from 06/19/2012 until 10/02/2012 without follow up by the Orthopedic Specialist; without an assessment of the continued use of pain medication by the nursing staff and without notification of the resident's continued pain to the physician. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 10/23/2012 had been implemented by the facility and were in practice removing the immediacy of the deficient practice. The Director of Nurses and the Regional Vice President was informed of this on 10/23/2012. The Immediate Jeopardy at F-490 was removed but the citation at F-490 remained at a lower scope and severity of "E".

On the days of the Recertification, Complaint and Extended Surveys, based on record review and interviews, the facility Medical Director failed to ensure effective and efficient management of facility resources to ensure the care of Resident #11 who sustained an injury on 6/19/12 while being assisted to bed. MRI (magnetic resonance imaging) confirmed a fracture on 06/26/2012. The Orthopedic Specialist who assessed Resident #11 on 06/27/2012 did not see the MRI; s/he treated the resident for knee pain, ordered a brace and physical therapy. The resident continued to complain and was treated regularly for pain from 06/19/2012 until 10/02/2012 without follow up by the Orthopedic Specialist or an assessment of the continued use of pain medication. The findings included: In an interview with a surveyor on 10/19/2012 at 2:40 PM the Director of Nurses stated that after the surveyor asked questions about Resident #11's injury s/he gathered all the x-rays and faxed them to the Medical Director on 10/02/2011. The DON stated that s/he was directed by the Medical Director to call the Orthopedic Specialist and have her/him review the case. In an interview with a surveyor on 10/23/2012 at 4:45 PM the Medical Director stated s/he thought the facility may have called him/her about the resident but s/he could remember any specifics. On 10/22/2012 at 10:00 AM the Director of Nurses and the Nurse Consultant were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-501 at a scope and severity of "J". The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 06/27/2012 related to Resident #11 who sustained an injury on 6/19/12 while being assisted to bed. MRI confirmed the injury on 06/26/2012 to be a fracture. The Orthopedic Specialist who assessed Resident #11 on 06/27/2012 did not see the MRI; s/he treated the resident for knee pain, ordered a brace and physical therapy. The resident continued to complain and was treated regularly for pain from 06/19/2012 until 10/02/2012 without follow up by the Orthopedic Specialist; without an assessment of the continued use of pain medication by the nursing staff and without notification of the resident's continued pain to the physician. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 10/23/2012 had been implemented by the facility and were in practice removing the immediacy of the deficient practice. The Director of Nurses and the Regional Vice President was informed of this on 10/23/2012. The Immediate Jeopardy at F-501 was removed but the citation at F-501 remained at a lower scope and severity of "E".

On the days of the Recertification and Complaint Surveys, based on record review and interview, and review of the facility file in reference to a complaint received by the State Agency, the facility failed to review and revise the care plans for Resident #11, 1 of 10 records reviewed for care plans. The care plan contained inaccurate information regarding the current status and conflicting care needs of Resident #11. In addition, the Resident Profile (Certified Nurse Aide care plan) was not revised to reflect the current method of transferring the resident. The findings included: The facility admitted Resident #11 to the facility with [DIAGNOSES REDACTED]. On 10/2/12 at approximately 4:28 PM, review of the resident's care plan date 8/28/12 revealed that assistance with ADLs (Activities of Daily Living) was identified as a problem with an intervention listed for "Transfers: Assist of 2 with a hoyer lift." An additional care plan identified the need for "assistance by staff with transfers" with the intervention as "total assist transfer with assist of 2 and a swivel disk," which was inconsistent with the ADL care plan. Further review revealed a care plan dated 6/20/12 for "possible fracture in L (left) knee." The care plan was updated on 6/22/12 that an MRI (Magnetic Resonance Imaging) was to be performed on Monday, 6/25/12. An undated notation on the care plan stated "MRI results are negative for fracture." No interventions were listed related to transferring the resident. Review of the MRI dated 6/26/12 revealed "IMPRESSION: 1. Nondisplaced subacute comminuted [MEDICAL CONDITION] femur with fracture lines extending into the patellofemoral joint and intercondylar notch." Review of the Resident Profile, the CNA (certified nurse aide) care plan, revealed "TRANSFER STATUS: must use a hoyer lift for all transfers with assist of 2 CNA's." On 10/2/12 at approximately 4:28 PM, record review of the monthly Physician order [REDACTED]. During an interview on 10/3/12 at 1:10 PM, CNA #3 confirmed that she did not look in the Kiosk to see how the resident was supposed to be transferred and further verified that she did not know the Resident Profile with resident care needs was available in the Kiosk. She said she got report from the previous shift. During an interview at 1:00 PM on 10/3/12, Licensed Practical Nurse (LPN) #1 confirmed the CNA care plan, the Resident Profile, indicated the resident was to transfer with a Hoyer lift and that the CNA care plan was inconsistent with the current order. She also verified that CNAs should use the Resident Profile for information related to resident care needs. During an interview on 10/3/12 at 1:40 PM, LPN #2 also confirmed the Resident Profile was not accurate and stated "obviously she didn't look at that cause she didn't use a Hoyer." During an interview on 10/3/12 at 2:02 PM, the Director of Nursing (DON) was shown the care plan, the Resident Profile and the September Physician order [REDACTED]. The DON responded "I'm confused myself" and confirmed the discrepancies on the care plan and between the care plan, the Resident Profile and the Physician order [REDACTED].

On the days of the Recertification and Complaint Surveys, based on record review and interviews, the facility failed to provide adequate supervision, communicate the resident's care needs and ensure that interventions were implemented related to transfers to prevent injury to Resident #11, 1 of 2 residents reviewed for accidents and incidents. The facility failed to train Certified Nursing Assistant (CNA) #3 on the use of the Kiosk, used to communicate resident care needs, and ensure that interventions listed in the Kiosk and on the Resident Plan of Care were accurate. In addition, the facility failed to provide supervision of the provision of care to ensure that interventions were implemented appropriately. The findings included: The facility admitted Resident #11 to the facility with [DIAGNOSES REDACTED]. On 10/2/12 at 12:35 PM, a review of the Five-Day Follow-up in reference to a facility reported incident received by this office, revealed the facility's investigation indicated the resident put herself/himself to bed on 6/19/12 with stand-by assistance from CNA #3. The CNA failed to use the prescribed transfer disk. Resident #11 complained of left knee pain after the transfer. An x-ray done on 6/20/12 indicated a fracture of the left medial condyle and a CT scan on 6/21/12 showed no fracture. On 6/26/12 a MRI was done that showed a fracture of the left distal femur with fracture lines extending into the patellofemoral joint and intercondylar notch. During an interview on 10/3/12 at 1:10 PM Certified Nurse Aide #3 stated that s/he had been told by 2 other CNAs that the resident used "a wheel" to transfer but that the resident told her "s/he didn't need it." S/he further stated that the resident stood and pivoted. CNA #3 physically demonstrated that the resident pivoted, hopping in a circular motion, until s/he could sit on the bed. The CNA did not recall if the transfer disk was in the resident's room. CNA #3 confirmed that s/he did not look in the Kiosk to see how the resident was care planned to be transferred and verified that s/he did not know the Resident Profile with resident care needs was available in the Kiosk. S/he said s/he got report from the previous shift. At approximately 1:30 PM CNA #3 informed the surveyor that s/he had returned to the floor and asked to see the Resident Profile after the interview. Review of the Physician order for [REDACTED]. At 1:30 PM on 10/3/12, Licensed Practical Nurse #2 stated that the CNAs gave report to each other during change of shifts. S/he also stated that s/he thought a lot of the CNAs, even some CNAs who had been with the facility for awhile, did not know that the Resident Profile could be viewed in the Kiosk. During an interview on 10/3/12 at 2:18 PM, the Staff Development Coordinator stated that new CNAs receive training on the use of the Kiosk from the CNA who has been assigned to help train the new CNA. S/he further stated "I don't think they all know" about the Resident Profile in the Kiosk. S/he confirmed that no training related to the Kiosk was done during orientation but stated "it would be a good idea." During an interview on 10/3/12 at 2:02 PM, the Director of Nursing (DON) was shown the care plan, the Resident Profile and the September Physician Order Report and asked how the resident was supposed to be transferred. The DON responded "I'm confused myself" and confirmed the discrepancies on the care plan and between the care plan, the Resident Profile and the Physician Order Report. S/he also verified that it would be difficult for the staff to know how to transfer Resident #11 with the conflicting information /

On the day of Recertification and Complaint Surveys, based on record review and interview, the facility failed to implement a plan to ensure that Certified Nurse Aide (CNAs) could demonstrate competency in skills necessary to provide care for residents. The facility had no policy in place to train the Certified Nurse Aide to retrieve information from the Kiosk related to resident care needs. The findings included: On 10/3/12 at 10:56 AM, record review of the Resident Profile, the CNA care plan maintained in the Kiosk for CNA review, stated that Resident #11 was to be transferred using a Hoyer lift with the assistance of 2 CNAs. During an interview on 10/3/12 at 1:10 PM, Certified Nurse Aide #3 stated s/he documented residents' ADLs (Activities of Daily Living), meals, and bowel movements in the Kiosk but did not know about the Resident Profile. S/he stated "I only know to get report from the previous shift." When asked about Resident #11's transfer on 6/19/12 Certified Nurse Aide #3 stated that s/he had been told by 2 other CNAs that the resident used "a wheel" to transfer but that the resident told her/him "s/he didn't need it." S/he further stated that the resident stood and pivoted and physically demonstrated that the resident pivoted, hopping in a circular motion, until s/he could sit on the bed. The CNA did not recall if the transfer disk was in the resident's room. CNA #3 confirmed that s/he did not look in the Kiosk to see how the resident was care planned to be transferred and verified that s/he did not know the Resident Profile with resident care needs was available in the Kiosk. S/he said s/he got report from the previous shift. At approximately 1:30 PM CNA #3 informed the surveyor that s/he had returned to the floor and asked to see the Resident Profile after the interview. At 1:30 PM on 10/3/12, Licensed Practical Nurse #2 stated that the CNAs gave report to each other during change of shifts. S/he also stated that s/he thought a lot of the CNAs did not know that the Resident Profile could be viewed in the Kiosk, even some of the older CNAs who had been with the facility for awhile. During an interview on 10/3/12 at 2:18 PM, the Staff Development Coordinator stated that new CNAs receive training related to the Kiosk on the floor from the CNA who has been assigned to help train the new CNA. S/he confirmed that no training related to the Kiosk is done during orientation but stated "it would be a good idea." S/he further stated "I don't think they know" about the Resident Profile in the Kiosk.

On the days of the Complaint and Extended Survey based on record review, interview and review of the facility's policy on Physician Communication, Immediate Jeopardy was identified related to the facility failure to notify the physician of acute changes in condition for Residents #1, #2, #3 and #7 and the facility's failure to notify the physician of critically low or high blood sugar levels Residents #2, #5, #6, #7, #8 and #9. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 12/24 at 9:45 AM, "Resident voicing concern of difficulty breathing. New order for O2 @ 2 L/min. O2 sat 97% on room air." 12/26 at 2 PM, "C/O inability to breath early AM lung fields have moist rales A+P (?) bilateral lower bases. O2 sat 97%." At 10:30 PM, "Res c/o SOB this shift. OOB to w/c and @ that time res refused to place O2 on once up in bed. Res in hallway and c/o SOB...Daughter called and came in..." 12/27 the resident was seen by the NP related to the shortness of breath, 3 days after the onset of the shortness of breath. Klonopin 0.25 mg twice daily and as needed. A chest x-ray was completed with no substantial findings. 1/4/12 at 10:30 AM, the resident c/o SOB, O2 at 3 L NC applied. At 1 PM, the resident "still c/o SOB. Klonopin 0.25 mg given per order." On 1/8/12, "res c/o SOB..." 1/10/12 at 8:15 AM, "Resident c/o chest pains and inability to breath. VS 120/90, 97.5, 77, 24. Resident's color is good. Moist cough and lungs congested on auscultation. Resident's daughter called and would like to have resident sent to ED for evaluation. Res refuses to each c/o chest pain mid chest. Res becomes agitated when asked questions. O2 sats 93% on 2 L NC. Call into NP for order to transfer to ED." The resident was admitted to the hospital with [REDACTED]. 3/11/12 at 9 AM, "Resident transported to (hospital) via stretcher r/t chest pain. Third shift nurse reported to this nurse stating resident c/o chest pains and her daughter wants her sent out. I've done all the paperwork and paged the doctor x4 with no call back. If he calls back can you tell him resident c/o chest pain res indicates (upper) chest sternal region. Hx of anxiety recent hosp with pneumonia. BP 120/60, P-100, O2 91-92%; had Tylenol at 6:10 AM and family requests transfer." There was not a nurse's note from the third shift nurse. No assessment, intervention, follow up or physician notification was completed. The resident was admitted to the hospital from 3/11/12 through 3/16/12. The resident was diagnosed with [REDACTED]. During an interview on 4/26/12, the Director of Nurses confirmed the weight loss between [DATE] and [DATE]. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the MAR for March 2012 revealed only one low blood sugar of "10." Review of the Nurse's Notes revealed on 3/17 at 3:40 PM, "Resident note unresponsive skin pale (unable to decipher) and clammy. FSBS 10. Pepsi cola 240 ml po given. Skin pale, (unable to decipher). 343 (3:43 PM) FSBS 90, orange juice 240 ml po given. FSB 150, skin pink and dry, speak clearly "yes." 4P RP notified of hypoglycemic episode." There was no indication the physician had been notified. 4/18 at 2 AM, "Resident noted to have labored breathing O2 sat improved from 80-84% with nebulizer treatment. VS stable will cont to monitor. O2 at 2 L via NC (nasal cannula)." There was no documentation of what the saturation increased to or evidence of the continued monitoring. 4/18 at 11:40 AM, "Res had labored breathing @ 7:30 AM, c/o throat pain. B/P 100/70, T-96.4, P-82, R-26. Breathing tx (treatment) O2 sats 97% on 2 L via O2 mask..." 4/19 at 2 PM, "Cont c labored breathing, O2 95-96%..." 4/20 the physician was notified of a nose bleed, however there was no indication the physician was notified of the labored breathing. 4/21 at 1:10 PM, "res has labored breathing noted, O2 sats 94% on 2 L via NC..." At 9 PM, "C/O inability to breath, O2 sat 94%. Family in room/HOB (head of bed up)/HHN (hand held nebulizer) administered. Res states feels better." 4/22 at 1:15 PM, Res has SOB noted, O2 sats 96% on 2 L NC. HOB up, husband by side. HHN tx cont res tolerates well." 4/23 at 1:15 PM, abd (abdominal) breathing noted..." 1:30 PM, "productive cough noted after lunch." An untimed note on 4/23 (***different nurse documented***) "N.O received for [MEDICATION NAME] and [MEDICATION NAME]. pt c SOB, O2 sat 91 % on 2-3 L via NC. Lung sounds diminished in (upper) lobes, absent c crackles in bilateral lower lobes." Another untimed note "Pt daughter in and req PRN HHN for SOB and wheezing, tx given c little effect. Pt appears somewhat lethargic and anxious, daughter insistent on sending pt to ER, MD paged." 9:20 PM, MD returned call and said send pt to ER if family refuses further tx at the facility, DON made aware of situation." 9:40 PM, Pt transported to ER via squad per family request for SOB." From 4/18 through 4/23 at 1:30 PM, there was no evidence of a nursing respiratory assessment, no evidence of interventions with follow up, or physician notification of the resident's continued reports of labored breathing, inability to breath, shortness of breath and productive cough. In addition, the resident's family requested the resident to be sent to the emergency room . The facility admitted Resident #3 with [DIAGNOSES REDACTED]. The resident was noted to have an Acute [MEDICAL CONDITION] Infarction in October 2011. In addition the resident was noted to have a Left Ventricular Apex Thrombus. Review of the Nurse's Notes revealed on 12/15/11 at 10:45 PM, "Res c/o not feeling well says it feels like his lungs are filling up again. O2 sat 98 %, lung sounds diminished. BP 102/68. Will monitor." 12/16/11 at 2 AM, "resident can't sleep at night. OOB to w/c staying at nursing station at present time. c/o SOB, SPO2 96% on RA (room air). BP 88/60, P-88, T-98.2, R-24. Denies chest pain, cont observe." 11 AM, "called to resident's room, (up) on side of bed. Resp distress noted. 3+ [MEDICAL CONDITION] bilateral lower extremities (Resident has a right [MEDICAL CONDITION])...placed resident on O2...meds given per order. 150 cc urine noted. Resident pursed lip breathing continues to be SOB and requests to be sent to the hospital..." The resident was noted to have signs and symptoms of acute changes for 11 hours before he had to request to be sent to the ER. Also, there was no evidence of a nursing assessment, intervention, follow up or timely physician notification of the change. Review of the 12/16/11 emergency room note revealed the resident had increased Troponin and had a [DIAGNOSES REDACTED]. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. "Special Instructions: <150 give Sweetened Juice and call provider." Review of the MAR (Medication Administration Record) for March 2012 revealed "<150 give sweetened juice and call MD" was lined through and "<60" was hand written above. Further review revealed on 3/5 at 6 AM, the blood sugar was 56. Review of the back of the MAR, Nurses Notes and physician's orders [REDACTED]. On 3/11 at 6 AM, the blood sugar was 50, med pass was given, however there was no recheck or physician notification. On 3/23 the blood sugar was 58, no interventions, no recheck and no notification was documented. On 3/31 at 6 AM, the blood sugar was 50, no interventions, no recheck and no notification was documented. In addition, there were 4 instances where no blood sugar was documented. April MAR indicated [REDACTED]< 60 were documented. However, at 8 AM on 4/22 the [MEDICATION NAME] was held due to a blood sugar of 43. A Telephone Order was written for Glycogen 1 mg Intramuscularly now was written. No recheck was documented and no corresponding nurses notes were located. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].<55 give sweetened juice and call provider." Review of the March 2011 MAR indicated [REDACTED]. However, review of the back of the MAR, nurse's notes and physician's orders [REDACTED]. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. In addition if the blood sugar was less than 55 give juice and call the provider. Review of the February MAR indicated [REDACTED]. On 2/25 at 4:40 PM, the blood sugar was 40, there was no evidence of an intervention, recheck or physician notification. Further record review revealed on 2/14 the resident's [MEDICATION NAME] Insulin was decreased as well as the [MEDICATION NAME]. There was no other evidence the physician or the nurse assessed, intervened or documented on the low blood sugars since 2/14/12. Review of the Nurse's Notes revealed on 1/11/12 at 9:15 PM, the resident sustained [REDACTED]. 1/12 at 4:20 AM, "...3+ [MEDICAL CONDITION] B LE, redness skin coloration c pain on touch, slightly warm. Res c/o shoulder, leg and mid back pain r/t fall on 1/11/12. No deformities, no injuries assessed r/t fall. PRN and scheduled med has been given this shift. Res has a weak, slightly dragging L leg, painful gait. CNA assisted res to the restroom c a walker." There was no evidence the physician was notified of the pain or change in gait until 8 PM on 1/12/12, approximately 16 hours after the onset of the change in condition. 1/16/12 at 1:55 PM, "CNA came and got nurse res was not verbally responding. Talked c res but she couldn't respond with appropriate answers. Called (Nurse Practitioner) gave order to send to (ER). SOB noted O2 sats 94% on 2 L via NC. BLE (bilateral lower extremities) warm, red, 2+ [MEDICAL CONDITION] noted. Res LOA via stretcher at 9:10 AM." There was no prior note to indicate the onset of the resident's shortness of breath, need for oxygen or what time the provider was contacted with the change in condition. Also, there was no evidence of a nursing respiratory assessment or interventions. The resident was admitted to the hospital for Altered Mental Status,[MEDICAL CONDITION], Infiltrate and Effusions. 1/20 at 5 PM the resident was readmitted to the facility. 1/21/12 at 5 AM slight "wheeze, HOB elevated..." At 9 PM, "...3+ [MEDICAL CONDITION] wheezes and rhonchi, dry coarse cough. HHN given as order." 1/22 2:47 AM, "[MEDICAL CONDITION] 1+ to (lower) extremities c shins red discolored, warm to touch, face and arms [MEDICAL CONDITION]. O2 sats 92%, HOB (raised). Mild wheezing observed, O2 as ordered." 1/23 at 2:20 PM, "Res c/o SOB, head of bed elevated. [MEDICAL CONDITION] noted all over body, O2 sats 92% on 3 L NC." 1/25 at 2:35 PM, "O2 sats 89% on 2 L NC...Res called nurse to room and asked if she would be better in hospital, nurse told her she was stable..." 1:11 AM, "Res has RUL (right upper lobe) crackles, O2 sat 92% on O2. Slightly labor mouth breath (sic) resp 32..." 1/26/12 at 1:26 AM, "LLL (left lower lobe) crackles, O2 sat 91% on O2, +2 [MEDICAL CONDITION] LE c deep red rash discoloration, +1 [MEDICAL CONDITION] UE (upper extremities). Slightly mouth labor breathing. Increase respir (sic) c reposition..." 1/29 at 2:30 PM, "[MEDICAL CONDITION] to B arms. SOB noted." At 6:10 PM, "O2 at 2 L via NC noted c wheezing and rales RUQ (right upper quadrant)..." 1/30 at midnight "...mouth breathing non [MEDICAL CONDITION] to (upper) extremities. Crackles lung sounds, irregular heart beat, red rash below the knee, painful on touch." 1:45 PM, SOB noted, shallow resp. O2 sat 91% on 2 L via NC. Wheezing [MEDICAL CONDITION] to B arms and face noted..." 3:15 PM, "Assessed by (provider)..." There was no indication the resident was consistently assessed, had appropriate interventions, follow up and physician notification related to the acute change in condition of her respiratory status. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. No parameters of Hypo/[MEDICAL CONDITION] were specified on the order. Review of the March 2012 orders revealed if the "blood sugar was 55 or below give sweetened juice and call provider." Review of the February 2012 MAR, Nurse's Notes and physician's orders [REDACTED]. On 2/14 at 6 AM the blood sugar was 52, there was no intervention, recheck or physician notification documented. On 2/19 at 8 PM, the blood sugar was 13. There was no evidence of any interventions, rechecks or physician notification. On 2/29 at 4 PM the blood sugar was 45, med pass was given and the "res refused recheck." However, there was no corresponding nurses notes or evidence of physician notification. In addition thee were 5 instances were the no blood sugar was documented. Further review of the Nurses Notes revealed on 2/15 the resident was "usually hypoglycemic in AM." On 2/25 the resident reported a poor appetite and low energy. On 2/26, the resident continued to have a poor appetite and was "placed in the MD book." The facility admitted Resident # 9 on 10-18-2000 with [DIAGNOSES REDACTED]. Review of the medical record on 4-25-12 revealed the Care Plan dated 2-9-12 listed a problem of "Resident is a brittle Diabetic and is at risk for hyper or hypo glycemia. He has frequent ups and downs of blood sugars. His sugar may be 20 one day and 430 the next without any changes in cognition or physical symptoms." The approaches listed included: "Give meds (medications) as ordered and insulin according to (sliding) scale. Give oj (orange juice) and sugar for low blood sugars and if needed may give glucose injection. (Blood) Sugar will be reported to MD if under 55 or over 430." Review of the MAR (Medication Administration Record) for the month of February revealed there were five (5) instances of blood sugar being over 430 and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS 2/17/12 @ 4:30 PM 474 2/22/12 @ 9:00 PM 496 2/25/12 @ 6:00 AM 477 2/28/12 @ 11:30 AM 481 2/29/12 @ 6:00 AM 452 Review of the MAR for the month of March revealed there were five (5) instances of blood sugar being over 430 and one (1) instance of blood sugar being under 55, and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS Low BS 3/4/12 @ 6:00 AM 456 3/4/12 @ 9:00 PM 434 3/7/12 @ 11:30 AM 455 3/10/12 @ 11:30 AM 450 3/18/12 @ 6:00 AM 442 3/12/12 @ 4:30 PM 43 On March 29th, at 4:30 PM the MAR indicated [REDACTED]. On the back of the MAR indicated 3/29/12 BGL (blood glucose level) checked 30 min (utes) after and its 47 , o (no) s/s (signs and symptoms) of hypo/hyper glycemia." There was no notation in the nurses notes that the Physician had been notified. During a conversation with the DON (Director of Nursing) on 4-26-12 at approximately 3:00 PM, she confirmed that the Physician had not been notified of either the "high" reading or the sudden drop to 47. The DON further confirmed that the facility had recently obtained gluometers which should read LO if the blood sugar was below 40 and HIGH if the blood sugar was above 450. Review of the MAR for the month of April revealed there were six (6) instances of blood sugar being over 430, and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS 4/1/12 @ 6:00 AM 443 4/8/12 @ 6:00 AM 434 4/14/12 @ 11:30 AM 463 4/15/12 @ 11:30 AM 498 4/16/12 @ 6:00 AM 488 4/16/12 @ 4:30 PM 445 During an interview on 4/26/12, the Director of Nurses confirmed the above residents' physician was not notified of the acute changes in condition and/or the critically low or high blood sugars. Review of the facility's policy on Physician Communication revealed "Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's condition in the medical record...In the event of a life threatening event-contact 911 immediately." During an interview on 4/25/12 at 3:10 PM, the Administrator and Director of Nurses were informed of the above residents concerns related to physician notification, nursing assessments, interventions, re assessments and documentation related to changes in condition. The Administrator and DON were informed that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility related to the failure to identify, assess, intervene and notify the physician of acute changes in condition and the failure to treat, follow up on and notify the physician of abnormally low or high blood sugars. An Allegation of Compliance (AOC) was submitted by the facility on 4/26/12. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 4/26/12 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of the regarding the notification of the physician. The Administrator was informed of this on 4/26/12. The Immediate Jeopardy at F-157 was removed but the citation at F-157 remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Survey based on record review and interview, Substandard Quality of Care and/or Immediate Jeopardy was identified related to the facility failure to ensure each resident's care plan reflected their needs and current status. Resident #1, #2, and #3's care plan failed to reflect their acute medical conditions or the resident's specific needs. Resident #6 failed to have a care plan developed related to hypo/[MEDICAL CONDITION]. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 12/24 at 9:45 AM, "Resident voicing concern of difficulty breathing. New order for O2 @ 2 L/min. O2 sat 97% on room air." 12/26 at 2 PM, "C/O inability to breath early AM lung fields have moist rales A+P (?) bilateral lower bases. O2 sat 97%." 10:30 PM, "Res c/o SOB this shift. OOB to w/c and @ that time res refused to place O2 on once up in bed. Res in hallway and c/o SOB...Daughter called and came in..." 12/27 the resident was seen by the NP related to the shortness of breath, 3 days after the onset of the shortness of breath. Klonopin 0.25 mg twice daily and as needed. A chest x-ray was completed with no substantial findings. 1/4/12 at 10:30 AM, the resident c/o SOB, O2 at 3 L NC applied. At 1 PM, the resident "still c/o SOB. Klonopin 0.25 mg given per order." 1/8/12, "res c/o SOB..." On 1/10/12 at 8:15 AM, "Resident c/o chest pains and inability to breath. VS 120/90, 97.5, 77, 24. Resident's color is good. Moist cough and lungs congested on auscultation. Resident's daughter called and would like to have resident sent to ED for evaluation. Res refuses to each c/o chest pain mid chest. Res becomes agitated when asked questions. O2 sats 93% on 2 L NC. Call into NP for order to transfer to ED." The resident was admitted to the hospital with [REDACTED]. 3/11/12 at 9 AM, "Resident transported to (hospital) via stretcher r/t chest pain. Third shift nurse reported to this nurse stating resident c/o chest pains and her daughter wants her sent out. I've done all the paperwork and paged the doctor x4 with no call back. If he calls back can you tell him resident c/o chest pain res indicates (upper) chest sternal region. Hx of anxiety recent hosp with pneumonia. BP 120/60, P-100, O2 91-92%; had Tylenol at 6:10 AM and family requests transfer." There was not a nurse's note from the third shift nurse. No assessment, intervention, follow up or physician notification was completed. The resident was admitted to the hospital from 3/11/12 through 3/16/12. The resident was diagnosed with [REDACTED]. Review of the Care Plan dated 7/10/11 revealed a problem area related to shortness of breath related to [MEDICAL CONDITION]. Approaches included monitor for shortness of breath, chest pains, weight gain, and increased [MEDICAL CONDITION], finger clubbing, [MEDICAL CONDITION] crackles, cyanosis and report to MD." Another problem area dated 3/2/11 revealed the resident had a [DIAGNOSES REDACTED]." On 4/23/12 the care plan was updated to include "res gets anxious at times especially when res feels SOB." There were no added approaches related to the complaints of shortness of breath and nursing interventions. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the MAR for March 2012 revealed only one low blood sugar of "10." Review of the Nurse's Notes revealed on 3/17 at 3:40 PM, "Resident note unresponsive skin pale (unable to decipher) and clammy. FSBS 10. Pepsi cola 240 ml po given. Skin pale, (unable to decipher). 343 (3:43 PM) FSBS 90, orange juice 240 ml po given. FSB 150, skin pink and dry, speak clearly "yes." 4P RP notified of hypoglycemic episode." There was no indication the physician had been notified. 4/18 at 2 AM, "Resident noted to have labored breathing O2 sat improved from 80-84% with nebulizer treatment. VS stable will cont to monitor. O2 at 2 L via NC (nasal cannula)." There was no documentation of what the saturation increased to or evidence of the continued monitoring. 11:40 AM, "Res had labored breathing @ 7:30 AM, c/o throat pain. B/P 100/70, T-96.4, P-82, R-26. Breathing tx (treatment) O2 sats 97% on 2 L via O2 mask..." 4/19 at 2 PM, "Cont c labored breathing, O2 95-96%..." 4/20 the physician was notified of a nose bleed, however there was no indication the physician was notified of the labored breathing. 4/21 at 1:10 PM, "res has labored breathing noted, O2 sats 94% on 2 L via NC..." 9 PM, "C/O inability to breath, O2 sat 94%. Family in room/HOB (head of bed up)/HHN (hand held nebulizer) administered. Res states feels better." 4/22 at 1:15 PM, Res has SOB noted, O2 sats 96% on 2 L NC. HOB up, husband by side. HHN tx cont res tolerates well." 4/23 at 1:15 PM, abd (abdominal) breathing noted..." 1:30 PM, "productive cough noted after lunch." An untimed note on 4/23 (***different nurse documented***) "N.O received for [MEDICATION NAME] and [MEDICATION NAME]. pt c SOB, O2 sat 91 % on 2-3 L via NC. Lung sounds diminished in (upper) lobes, absent c crackles in bilateral lower lobes." Another untimed note "Pt daughter in and req PRN HHN for SOB and wheezing, tx given c little effect. Pt appears somewhat lethargic and anxious, daughter insistent on sending pt to ER, MD paged." 9:20 PM, MD returned call and said send pt to ER if family refuses further tx at the facility, DON made aware of situation." 9:40 PM, Pt transported to ER via squad per family request for SOB." From 4/18 through 4/23 at 1:30 PM, there was no evidence of a nursing respiratory assessment, no evidence of interventions with follow up, or physician notification of the resident's continued reports of labored breathing, inability to breath, shortness of breath and productive cough. In addition, the resident's family requested the resident to be sent to the emergency room . Review of the Care Plan revealed the resident did not have a care plan developed related to Respiratory Distress/labored breathing or the resident's multiple hospitalization s. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. The resident was noted to have an Acute [MEDICAL CONDITION] Infarction in October 2011. In addition the resident was noted to have a Left Ventricular Apex Thrombus. Review of the Nurse's Notes revealed on 12/15/11 at 10:45 PM, "Res c/o not feeling well says it feels like his lungs are filling up again. O2 sat 98 %, lung sounds diminished. BP 102/68. Will monitor." 12/16/11 at 2 AM, "resident can't sleep at night. OOB to w/c staying at nursing station at present time. c/o SOB, SPO2 96% on RA (room air). BP 88/60, P-88, T-98.2, R-24. Denies chest pain, cont observe." 11 AM, "called to resident's room, (up) on side of bed. Resp distress noted. 3+ [MEDICAL CONDITION] bilateral lower extremities (Resident has a right [MEDICAL CONDITION])...placed resident on O2...meds given per order. 150 cc urine noted. Resident pursed lip breathing continues to be SOB and requests to be sent to the hospital..." Review of the 12/16/11 emergency room note revealed the resident had increased Troponin and had a [DIAGNOSES REDACTED]. Review of the Care Plan dated 11/23/11 revealed a problem area related to shortness of breath due to [MEDICAL CONDITION]. Approaches included "monitor for shortness of breath, chest pains, wt gain and increased [MEDICAL CONDITION] and report to MD. Another problem area related to MI ([MEDICAL CONDITION] infarction) was identified with approaches of "encourage questions regarding disease and treatments. Provide information freely" and "teach benefits of low-fat, low cholesterol, high fiber diet." A problem area related to cardiac dysfunction was also identified with approaches including "monitor for s/s of shortness of breath, dizziness, irregular pulse, activity intolerance and chest pain, notify MD/NP of any problems, vital signs and O2 sats as noted." There was no indication the Care Plan had been updated with the resident's hospitalization with the [MEDICAL CONDITION] infarction and pneumonia on 12/16/11 and there was no evidence of the resident's left ventricular thrombus included on the care plan. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the Care Plan revealed the resident did not have a care plan developed related to Diabetes Mellitus and Hypo/[MEDICAL CONDITION]. Review of the March 2011 MAR indicated [REDACTED]. However, review of the back of the MAR, nurse's notes and physician's orders [REDACTED]. In addition, there were 7 instances were the blood sugar was not documented. Review of the April MAR indicated [REDACTED]. During an interview on 4/26/12, the Director of Nurses confirmed the above residents' care plans did not reflect each resident's needs and current status. During an interview on 4/25/12 at 3:10 PM, the Administrator and Director of Nurses were informed of the above residents concerns related to physician notification, nursing assessments, interventions, re assessments and documentation related to changes in condition. The Administrator and DON were informed that Substandard Quality of Care and/or Immediate Jeopardy existed in the facility related to the failure to identify, assess, intervene and notify the physician of acute changes in condition and the failure to treat, follow up on and notify the physician of abnormally low or high blood sugars. An Allegation of Compliance (AOC) was submitted by the facility on 4/26/12. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 4/26/12 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable regarding the development of care plans. The Administrator was informed of this on 4/26/12. The Immediate Jeopardy at F-280 was removed but the citation at F-280 remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Survey based on observations, record review and interview, Substandard Quality of Care and/or Immediate Jeopardy was identified related to the facility nursing staffs failure to identify, assess, intervene, follow up, timely notify the provider and document acute changes in condition for 4 of 4 residents reviewed with a change in condition (Residents #1, #2, #3, and #7). The nursing staffs failed to assess, intervene, follow up and notify the physician of critically abnormal blood sugar levels for 6 of 9 residents reviewed with Sliding Scale Insulin (Residents #2, #5, #6, #7, #8 and #9). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed no indication of tooth pain, jaw pain, swelling or difficulty eating prior to 12/11/11 even though the healthcare provider had assessed the resident on 12/2 for the toothache and the resident could verbalize the location of the pain. 12/11/11 at 2:15 PM, "resident c/o sob, O2 sat 96% on room air. Daughter in @ bedside. Daughter stated she says she's having trouble breathing while she talks. Resident noted earlier in shift with no SOB, no distress. Daughter and this nurse discussed resident's condition. This nurse told daughter how resident was being treated for [REDACTED]. This nurse stated I do, then she stated can you give (Resident #1) something for pain her mouth is hurting she's getting her teeth pulled. She's in a lot of pain. Maybe you can call the doctor and get her something ordered. This nurse stated she gets Tylenol 650 mg and its scheduled for 4 PM. NAC nurse stated can you get it to her sooner. This nurse stated yes, current time 2:45 PM." 2:50 PM, "resident started on O2 at 2 L/min r/t distress at 2 PM." 12/13/11 at 12 PM, "Res seen by (NP) r/t c/o pain in mouth/teeth. Res states res tooth has hurt more and more everyday. Res has appointment to see dentist/oral surgeon on Monday 12/19/11." The resident had two teeth extracted on 12/19/11. No dental note was located during the survey. 12/24 at 9:45 AM, "Resident voicing concern of difficulty breathing. New order for O2 @ 2 L/min. O2 sat 97% on room air." 12/26 at 2 PM, "C/O inability to breath early AM lung fields have moist rales A+P (?) bilateral lower bases. O2 sat 97%." 10:30 PM, "Res c/o SOB this shift. OOB to w/c and @ that time res refused to place O2 on once up in bed. Res in hallway and c/o SOB...Daughter called and came in..." 12/27 the resident was seen by the NP related to the shortness of breath, 3 days after the onset of the shortness of breath. Klonopin 0.25 mg twice daily and as needed. A chest x-ray was completed with no substantial findings. On 1/4/12 at 10:30 AM, the resident c/o SOB, O2 at 3 L NC applied. 1 PM, the resident "still c/o SOB. Klonopin 0.25 mg given per order." 1/8/12, "res c/o SOB..." 1/10/12 at 8:15 AM, "Resident c/o chest pains and inability to breath. VS 120/90, 97.5, 77, 24. Resident's color is good. Moist cough and lungs congested on auscultation. Resident's daughter called and would like to have resident sent to ED for evaluation. Res refuses to each c/o chest pain mid chest. Res becomes agitated when asked questions. O2 sats 93% on 2 L NC. Call into NP for order to transfer to ED." The resident was admitted to the hospital with [REDACTED]. 3/11/12 at 9 AM, "Resident transported to (hospital) via stretcher r/t chest pain. Third shift nurse reported to this nurse stating resident c/o chest pains and her daughter wants her sent out. I've done all the paperwork and paged the doctor x4 with no call back. If he calls back can you tell him resident c/o chest pain res indicates (upper) chest sternal region. Hx of anxiety recent hosp with pneumonia. BP 120/60, P-100, O2 91-92%; had Tylenol at 6:10 AM and family requests transfer." There was not a nurse's note from the third shift nurse. No assessment, intervention, follow up or physician notification was completed. The resident was admitted to the hospital from 3/11/12 through 3/16/12. The resident was diagnosed with [REDACTED]. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 3/17 at 3:40 PM, "Resident note unresponsive skin pale (unable to decipher) and clammy. FSBS 10. Pepsi cola 240 ml po given. Skin pale, (unable to decipher). 343 (3:43 PM) FSBS 90, orange juice 240 ml po given. FSB 150, skin pink and dry, speak clearly "yes." 4P RP notified of hypoglycemic episode." There was no indication the physician had been notified. 4/18 at 2 AM, "Resident noted to have labored breathing O2 sat improved from 80-84% with nebulizer treatment. VS stable will cont to monitor. O2 at 2 L via NC (nasal cannula)." (There was no documentation of what the saturation increased to or evidence of the continued monitoring.) 11:40 AM, "Res had labored breathing @ 7:30 AM, c/o throat pain. B/P 100/70, T-96.4, P-82, R-26. Breathing tx (treatment) O2 sats 97% on 2 L via O2 mask..." 4/19 at 2 PM, "Cont c labored breathing, O2 95-96%..." 4/20 the physician was notified of a nose bleed, however there was no indication the physician was notified of the labored breathing. 4/21 at 1:10 PM, "res has labored breathing noted, O2 sats 94% on 2 L via NC..." 9 PM, "C/O inability to breath, O2 sat 94%. Family in room/HOB (head of bed up)/HHN (hand held nebulizer) administered. Res states feels better." 4/22 at 1:15 PM, Res has SOB noted, O2 sats 96% on 2 L NC. HOB up, husband by side. HHN tx cont res tolerates well." 4/23 at 1:15 PM, abd (abdominal) breathing noted..." 1:30 PM, "productive cough noted after lunch." An untimed note on 4/23 (***different nurse documented***) "N.O received for [MEDICATION NAME] and [MEDICATION NAME]. pt c SOB, O2 sat 91 % on 2-3 L via NC. Lung sounds diminished in (upper) lobes, absent c crackles in bilateral lower lobes." Another untimed note "Pt daughter in and req PRN HHN for SOB and wheezing, tx given c little effect. Pt appears somewhat lethargic and anxious, daughter insistent on sending pt to ER, MD paged." 9:20 PM, MD returned call and said send pt to ER if family refuses further tx at the facility, DON made aware of situation." 9:40 PM, Pt transported to ER via squad per family request for SOB." From 4/18 through 4/23 at 1:30 PM, there was no evidence of a nursing respiratory assessment, no evidence of interventions with follow up, or physician notification of the resident's continued reports of labored breathing, inability to breath, shortness of breath and productive cough. In addition, the resident's family requested the resident to be sent to the emergency room . Review of the MAR for March 2012 revealed only one low blood sugar of "10." The facility admitted Resident #3 with [DIAGNOSES REDACTED]. The resident was noted to have an Acute [MEDICAL CONDITION] Infarction in October 2011. In addition the resident was noted to have a Left Ventricular Apex Thrombus. Review of the Nurse's Notes revealed on 12/15/11 at 10:45 PM, "Res c/o not feeling well says it feels like his lungs are filling up again. O2 sat 98 %, lung sounds diminished. BP 102/68. Will monitor." 12/16/11 at 2 AM, "resident can't sleep at night. OOB to w/c staying at nursing station at present time. c/o SOB, SPO2 96% on RA (room air). BP 88/60, P-88, T-98.2, R-24. Denies chest pain, cont observe." 11 AM, "called to resident's room, (up) on side of bed. Resp distress noted. 3+ [MEDICAL CONDITION] bilateral lower extremities (Resident has a right [MEDICAL CONDITION])...placed resident on O2...meds given per order. 150 cc urine noted. Resident pursed lip breathing continues to be SOB and requests to be sent to the hospital..." (The resident was noted to have signs and symptoms of acute changes for 11 hours before he had to request to be sent to the ER. Also, there was no evidence of a nursing assessment, intervention, follow up or timely physician notification of the change.) Review of the emergency room note dated 12/16/11 revealed the resident had increased Troponin and had a [DIAGNOSES REDACTED]. Review of the telephone orders revealed an order was written on 12/16/11 at 8:45 AM for [MEDICATION NAME] 5 mg daily for 4 days, chest x-ray and a basic metabolic panel to be drawn on 12/19/11. An order to transfer the resident to the ER per the resident's request was written on 12/16/11 at 11:45 AM. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. "Special Instructions: <150 give Sweetened Juice and call provider." Review of the MAR (Medication Administration Record) for March 2012 revealed "<150 give sweetened juice and call MD" was lined through and "<60" was hand written above. 3/5 at 6 AM, the blood sugar was 56. Review of the back of the MAR, Nurses Notes and physician's orders [REDACTED]. 3/11 at 6 AM, the blood sugar was 50, med pass was given, however there was no recheck or physician notification. 3/23 the blood sugar was 58, no interventions, no recheck and no notification was documented. 3/31 at 6 AM, the blood sugar was 50, no interventions, no recheck and no notification was documented. In addition, there were 4 instances where no blood sugar was documented. Review of the April MAR indicated [REDACTED]< 60 were documented. However, at 8 AM on 4/22 the [MEDICATION NAME] was held due to a blood sugar of 43. A Telephone Order was written for Glycogen 1 mg Intramuscularly now was written. No recheck was documented and no corresponding nurses notes were located. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].<55 give sweetened juice and call provider." Review of the March 2011 MAR indicated [REDACTED]. However, review of the back of the MAR, nurse's notes and physician's orders [REDACTED]. In addition, there were 7 instances were the blood sugar was not documented. Review of the April MAR indicated [REDACTED]. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. No parameters of Hypo/[MEDICAL CONDITION] were specified on the order. Review of the March 2012 orders revealed if the "blood sugar was 55 or below give sweetened juice and call provider." Review of the February 2012 MAR, Nurses Notes and physician's orders [REDACTED]. On 2/14 at 6 AM the blood sugar was 52, there was no intervention, recheck or physician notification documented. On 2/19 at 8 PM, the blood sugar was 13. There was no evidence of any interventions, rechecks or physician notification. On 2/29 at 4 PM the blood sugar was 45, med pass was given and the "res refused recheck." However, there was no corresponding nurses notes or evidence of physician notification. In addition thee were 5 instances were the no blood sugar was documented. Review of the March MAR indicated [REDACTED]. Further review of the Nurses Notes revealed on 2/15 the resident was "usually hypoglycemic in AM." On 2/25 the resident reported a poor appetite and low energy. On 2/26, the resident continued to have a poor appetite and was "placed in the MD book." The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. In addition if the blood sugar was less than 55 give juice and call the provider. Review of the February MAR indicated [REDACTED]. On 2/25 at 4:40 PM, the blood sugar was 40, there was no evidence of an intervention, recheck or physician notification. In addition, there were 6 instances were the blood sugar was not documented. Further record review revealed on 2/14 the resident's [MEDICATION NAME] Insulin was decreased as well as the [MEDICATION NAME]. There was no other evidence the physician or the nurse assessed, intervened or documented on the low blood sugars since 2/14/12. Review of the March 2012 MAR indicated [REDACTED]. Review of the April 2012 MAR indicated [REDACTED]. Review of the Nurse's Notes revealed on 1/11/12 at 9:15 PM, the resident sustained [REDACTED]. 1/12 at 4:20 AM, "...3+ [MEDICAL CONDITION] B LE, redness skin coloration c pain on touch, slightly warm. Res c/o shoulder, leg and mid back pain r/t fall on 1/11/12. No deformities, no injuries assessed r/t fall. PRN and scheduled med has been given this shift. Res has a weak, slightly dragging L leg, painful gait. CNA assisted res to the restroom c a walker." There was no evidence the physician was notified of the pain or change in gait until 8 PM on 1/12/12, approximately 16 hours after the onset of the change in condition. 1/16/12 at 1:55 PM, "CNA came and got nurse res was not verbally responding. Talked c res but she couldn't respond with appropriate answers. Called (Nurse Practitioner) gave order to send to (ER). SOB noted O2 sats 94% on 2 L via NC. BLE (bilateral lower extremities) warm, red, 2+ [MEDICAL CONDITION] noted. Res LOA via stretcher at 9:10 AM." There was no prior note to indicate the onset of the resident's shortness of breath, need for oxygen or what time the provider was contacted with the change in condition. Also, there was no evidence of a nursing respiratory assessment or interventions. The resident was admitted to the hospital for Altered Mental Status,[MEDICAL CONDITION], Infiltrate and Effusions. 1/20 at 5 PM the resident was readmitted to the facility. 1/21/12 at 5 AM slight "wheeze, HOB elevated..." 9 PM, "...3+ [MEDICAL CONDITION] wheezes and rhonchi, dry coarse cough. HHN given as order." 1/22 at 2:47 AM, "[MEDICAL CONDITION] 1+ to (lower) extremities c shins red discolored, warm to touch, face and arms [MEDICAL CONDITION]. O2 sats 92%, HOB (raised). Mild wheezing observed, O2 as ordered." 1/23 at 2:20 PM, "Res c/o SOB, head of bed elevated. [MEDICAL CONDITION] noted all over body, O2 sats 92% on 3 L NC." 1/25 at 2:35 PM, "O2 sats 89% on 2 L NC... Res called nurse to room and asked if she would be better in hospital, nurse told her she was stable..." 1:11 AM, "Res has RUL (right upper lobe) crackles, O2 sat 92% on O2. Slightly labor mouth breath (sic) resp 32..." 1/26/12 at 1:26 AM, "LLL (left lower lobe) crackles, O2 sat 91% on O2, +2 [MEDICAL CONDITION] LE c deep red rash discoloration, +1 [MEDICAL CONDITION] UE (upper extremities). Slightly mouth labor breathing. Increase respir (sic) c reposition..." 1/29 at 2:30 PM, "[MEDICAL CONDITION] to B arms. SOB noted." 6:10 PM, "O2 at 2 L via NC noted c wheezing and rales RUQ (right upper quadrant)..." 1/30 at midnight "...mouth breathing non [MEDICAL CONDITION] to (upper) extremities. Crackles lung sounds, irregular heart beat, red rash below the knee, painful on touch." 1:45 PM, SOB noted, shallow resp. O2 sat 91% on 2 L via NC. Wheezing [MEDICAL CONDITION] to B arms and face noted..." 3:15 PM, "Assessed by (provider)..." There was no indication the resident was consistently assessed, had appropriate interventions, follow up and physician notification related to the acute change in condition of her respiratory status. The facility admitted Resident # 9 on 10-18-2000 with [DIAGNOSES REDACTED]. Review of the medical record on 4-25-12 revealed the Care Plan dated 2-9-12 listed a problem of "Resident is a brittle Diabetic and is at risk for hyper or hypo glycemia. He has frequent ups and downs of blood sugars. His sugar may be 20 one day and 430 the next without any changes in cognition or physical symptoms." The approaches listed included: "Give meds (medications) as ordered and insulin according to (sliding) scale. Give oj (orange juice) and sugar for low blood sugars and if needed may give glucose injection. (Blood) Sugar will be reported to MD if under 55 or over 430." Review of the MAR (Medication Administration Record) for the month of February revealed there were five (5) instances of blood sugar being over 430 and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS 2/17/12 @ 4:30 PM 474 2/22/12 @ 9:00 PM 496 2/25/12 @ 6:00 AM 477 2/28/12 @ 11:30 AM 481 2/29/12 @ 6:00 AM 452 Review of the MAR for the month of March revealed there were five (5) instances of blood sugar being over 430 and one (1) instance of blood sugar being under 55, and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS Low BS 3/4/12 @ 6:00 AM 456 3/4/12 @ 9:00 PM 434 3/7/12 @ 11:30 AM 455 3/10/12 @ 11:30 AM 450 3/18/12 @ 6:00 AM 442 3/12/12 @ 4:30 PM 43 On March 29th, at 4:30 PM the MAR indicated [REDACTED]. On the back of the MAR indicated 3/29/12 BGL (blood glucose level) checked 30 min (utes) after and its 47 , o (no) s/s (signs and symptoms) of hypo/hyper glycemia." There was no notation in the nurses notes that the Physician had been notified. During a conversation with the DON (Director of Nursing) on 4-26-12 at approximately 3:00 PM, she confirmed that the Physician had not been notified of either the "high" reading or the sudden drop to 47. The DON further confirmed that the facility had recently obtained gluometers which should read LO if the blood sugar was below 40 and HIGH if the blood sugar was above 450. Review of the MAR for the month of April revealed there were six (6) instances of blood sugar being over 430, and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS 4/1/12 @ 6:00 AM 443 4/8/12 @ 6:00 AM 434 4/14/12 @ 11:30 AM 463 4/15/12 @ 11:30 AM 498 4/16/12 @ 6:00 AM 488 4/16/12 @ 4:30 PM 445 The review also revealed that there were multiple blanks on the MAR for February: 2/12/12 @11:30 AM, and 2/23/12 @ 9:00 PM; for March: 3/10 @ 9:00 PM, 3/11/12 @ 11:30 AM, 3/15/12 @ 9:00 PM, 3/16/12 @ 9:00 PM, 3/18/12 @ 9:00 PM, 3/19/12 @ 4:30 PM, and 3/28/12 @ 9:00 PM; for April; 4/19/12 at 4:30 PM. In addition on 4/8/12 there was no documentation that coverage was given for a blood sugar of 291 which should have been 4 units of insulin. During an interview on 4/26/12, the Director of Nurses (DON) confirmed the above resident's abnormal blood sugars. She confirmed the nursing staff failed to treat, follow up on, document and notify the physician of the low blood sugars. The DON confirmed Resident #1, #2, #3 and #7's acute changes in condition. She confirmed the nursing staff failed to identify potentially life threatening acute changes in condition, failed to adequately assess the residents, failed to intervene appropriately, failed to timely notify the physician and failed to thoroughly document their findings. During an interview on 4/25/12 at 3:10 PM, the Administrator and Director of Nurses were informed of the above residents concerns related to physician notification, nursing assessments, interventions, re assessments and documentation related to changes in condition. The Administrator and DON were informed that Substandard Quality of Care and/or Immediate Jeopardy existed in the facility related to the failure to identify, assess, intervene and notify the physician of acute changes in condition and the failure to treat, follow up on and notify the physician of abnormally low or high blood sugars. An Allegation of Compliance (AOC) was submitted by the facility on 4/26/12. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 4/26/12 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable regarding the identification, assessment, intervention, follow up, timely notification of the provider and documentation of acute changes in condition; and the resident with abnormal blood sugar levels. The Administrator was informed of this on 4/26/12. The Immediate Jeopardy at F-281 was removed but the citation at F-281 remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Survey based on record review and interview, Substandard Quality of Care and/or Immediate Jeopardy was identified related to the facility failure to ensure each resident received the necessary care and services in accordance with the plan of care. Resident #5, #7, #8's care plans were not followed related to the hypo/hyperglycemic protocol listed on each resident's care plan. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. "Special Instructions: <150 give Sweetened Juice and call provider." Review of the Care Plan dated 11/17/11 revealed a problem area related to "risk for hyper or [DIAGNOSES REDACTED]" with approaches including "If blood glucose is less than or equal to 60 mg/dl, follow protocol for orange juice and sugar and call MD as needed." The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the Care Plan revealed a problem area related to "risk for hyper or [DIAGNOSES REDACTED]" with approaches including "If blood glucose is less than or equal to 60 mg/dl, follow protocol for orange juice and sugar and call MD as needed." The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. In addition if the blood sugar was less than 55 give juice and call the provider. Review of the Care Plan dated 2/22/12 revealed a problem area related to "risk for hyper or [DIAGNOSES REDACTED]" with approaches including "If blood glucose is less than or equal to 60 mg/dl, follow protocol for orange juice and sugar and call MD as needed." The facility admitted Resident # 9 on 10-18-2000 with [DIAGNOSES REDACTED]. Review of the medical record on 4-25-12 revealed the Care Plan dated 2-9-12 listed a problem of "Resident is a brittle Diabetic and is at risk for hyper or hypo glycemia. He has frequent ups and downs of blood sugars. His sugar may be 20 one day and 430 the next without any changes in cognition or physical symptoms." The approaches listed included: "Give meds (medications) as ordered and insulin according to (sliding) scale. Give oj (orange juice) and sugar for low blood sugars and if needed may give glucose injection. (Blood) Sugar will be reported to MD if under 55 or over 430." Review of the MAR (Medication Administration Record) for the month of February revealed there were five (5) instances of blood sugar being over 430 and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS 2/17/12 @ 4:30 PM 474 2/22/12 @ 9:00 PM 496 2/25/12 @ 6:00 AM 477 2/28/12 @ 11:30 AM 481 2/29/12 @ 6:00 AM 452 Review of the MAR for the month of March revealed there were five (5) instances of blood sugar being over 430 and one (1) instance of blood sugar being under 55, and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS Low BS 3/4/12 @ 6:00 AM 456 3/4/12 @ 9:00 PM 434 3/7/12 @ 11:30 AM 455 3/10/12 @ 11:30 AM 450 3/18/12 @ 6:00 AM 442 3/12/12 @ 4:30 PM 43 On March 29th, at 4:30 PM the MAR indicated [REDACTED]. On the back of the MAR indicated 3/29/12 BGL (blood glucose level) checked 30 min (utes) after and its 47 , o (no) s/s (signs and symptoms) of hypo/hyper glycemia." There was no notation in the nurses notes that the Physician had been notified. During a conversation with the DON (Director of Nursing) on 4-26-12 at approximately 3:00 PM, she confirmed that the Physician had not been notified of either the "high" reading or the sudden drop to 47. The DON further confirmed that the facility had recently obtained gluometers which should read LO if the blood sugar was below 40 and HIGH if the blood sugar was above 450. Review of the MAR for the month of April revealed there were six (6) instances of blood sugar being over 430, and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS 4/1/12 @ 6:00 AM 443 4/8/12 @ 6:00 AM 434 4/14/12 @ 11:30 AM 463 4/15/12 @ 11:30 AM 498 4/16/12 @ 6:00 AM 488 4/16/12 @ 4:30 PM 445 During an interview on 4/26/12, the Director of Nurses confirmed the above resident's abnormal blood sugars. The DON confirmed the residents' care plans were not followed related to low blood sugars. During an interview on 4/25/12 at 3:10 PM, the Administrator and Director of Nurses were informed of the above residents concerns related to physician notification, nursing assessments, interventions, re assessments and documentation related to changes in condition. The Administrator and DON were informed that Substandard Quality of Care and/or Immediate Jeopardy existed in the facility related to the failure to identify, assess, intervene and notify the physician of acute changes in condition and the failure to treat, follow up on and notify the physician of abnormally low or high blood sugars. An Allegation of Compliance (AOC) was submitted by the facility on 4/26/12. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 4/26/12 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable regarding following care plans. The Administrator was informed of this on 4/26/12. The Immediate Jeopardy at F-282 was removed but the citation at F-282 remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Survey based on record review and interview, Substandard Quality of Care and/or Immediate Jeopardy was identified related to the facility failure to provide the necessary care and services to maintain the highest practicable physical well-being related to the identification, assessment, intervention, follow up and documentation for 4 or 4 residents with an acute change in condition (Residents #1, #2, #3 and #7). The facility failed to assess, intervene, follow up on and notify the physician of critically low or high blood sugars for 6 or 9 residents reviewed for blood sugars (Residents #2, #5, #6, #7, #8 and #9). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Provider Progress Notes dated 12/2/11 revealed the resident was assessed for "cough and congestion and she continues to have a little bit of irritation in her peri area." The Provider noted "she indicates she has a sore tooth in her lower arch, which is a first bi cuspid. It is not loose. She states it hurts just a little bit when she eats. She does have mild gingivitis noted...brush her teeth with a soft toothbrush bid in the am and the pm, after that she can have 15 ml [MEDICATION NAME] to swish and spit in the morning and HS." On 12/30 the provider assessed the patient due to "pain." "She will be seeing the dentist and that appointment is pending." (The appointment was scheduled for 12/19/11). "She points to the left lower incisor and indicates that these areas are sore. She does have mild gingivitis noted throughout. Tongue is stippled. She has broken teeth in the upper central incisor with caries obvious. She also some swelling along the jaw angle left and she states it is somewhat sore in this area...We will start Pen V K 500 mg PO bid x 7 days and [MEDICATION NAME] 5/500 every 4 hours as needed and every 12 hours scheduled. Consult with dentist or oral surgeon associated with need for dental extractions." Review of the Nurse's Notes revealed no indication of tooth pain, jaw pain, swelling or difficulty eating prior to 12/11/11 even though the healthcare provider had assessed the resident on 12/2 for the toothache and the resident could verbalize the location of the pain. 12/11/11 at 2:15 PM, "resident c/o sob, O2 sat 96% on room air. Daughter in @ bedside. Daughter stated she says she's having trouble breathing while she talks. Resident noted earlier in shift with no SOB, no distress. Daughter and this nurse discussed resident's condition. This nurse told daughter how resident was being treated for [REDACTED]. This nurse stated I do, then she stated can you give (Resident #1) something for pain her mouth is hurting she's getting her teeth pulled. She's in a lot of pain. Maybe you can call the doctor and get her something ordered. This nurse stated she gets Tylenol 650 mg and its scheduled for 4 PM. NAC nurse stated can you get it to her sooner. This nurse stated yes, current time 2:45 PM." 2:50 PM, "resident started on O2 at 2 L/min r/t distress at 2 PM." 12/13/11 at 12 PM, "Res seen by (NP) r/t c/o pain in mouth/teeth. Res states res tooth has hurt more and more everyday. Res has appointment to see dentist/oral surgeon on Monday 12/19/11." The resident had two teeth extracted on 12/19/11. No dental note was located during the survey. 12/24 at 9:45 AM, "Resident voicing concern of difficulty breathing. New order for O2 @ 2 L/min. O2 sat 97% on room air." On 12/26 at 2 PM, "C/O inability to breath early AM lung fields have moist rales A+P (?) bilateral lower bases. O2 sat 97%." 10:30 PM, "Res c/o SOB this shift. OOB to w/c and @ that time res refused to place O2 on once up in bed. Res in hallway and c/o SOB...Daughter called and came in..." 12/27 the resident was seen by the NP related to the shortness of breath, 3 days after the onset of the shortness of breath. Klonopin 0.25 mg twice daily and as needed. A chest x-ray was completed with no substantial findings. 1/4/12 at 10:30 AM, the resident c/o SOB, O2 at 3 L NC applied. 1 PM, the resident "still c/o SOB. Klonopin 0.25 mg given per order." On 1/8/12, "res c/o SOB..." 1/10/12 at 8:15 AM, "Resident c/o chest pains and inability to breath. VS 120/90, 97.5, 77, 24. Resident's color is good. Moist cough and lungs congested on auscultation. Resident's daughter called and would like to have resident sent to ED for evaluation. Res refuses to each c/o chest pain mid chest. Res becomes agitated when asked questions. O2 sats 93% on 2 L NC. Call into NP for order to transfer to ED." The resident was admitted to the hospital with [REDACTED]. On 3/11/12 at 9 AM, "Resident transported to (hospital) via stretcher r/t chest pain. Third shift nurse reported to this nurse stating resident c/o chest pains and her daughter wants her sent out. I've done all the paperwork and paged the doctor x4 with no call back. If he calls back can you tell him resident c/o chest pain res indicates (upper) chest sternal region. Hx of anxiety recent hosp with pneumonia. BP 120/60, P-100, O2 91-92%; had Tylenol at 6:10 AM and family requests transfer." There was not a nurse's note from the third shift nurse. No assessment, intervention, follow up or physician notification was completed. The resident was admitted to the hospital from 3/11/12 through 3/16/12. The resident was diagnosed with [REDACTED]. Review of the Medication Administration Records revealed in December 2011 the resident did not receive any "as needed" doses of Klonopin for shortness of breath or anxiety. In January 2012, the resident received an "as needed" dose of Klonopin on 1/4, 1/8. 1/21 and 1/22. Review of the additional documentation revealed on 1/4 at 1:30 PM, the resident c/o SOB, restless. [MEDICATION NAME] 0.25 mg given. There was no indication of follow up for effectiveness or physician notification. On 1/20 (no medication was signed out on this date), the nurse documented "[MEDICATION NAME] 0.25 mg given related to panic disorder. effect +." No other documentation was located related to assessment, follow up and physician notification. Review of the March 2012 MAR indicated [REDACTED]. No Klonopin was administered prior to 3/23/12 for anxiety or shortness of breath. Review of the Care Plan dated 7/10/11 revealed a problem area related to shortness of breath related to [MEDICAL CONDITION]. Approaches included monitor for shortness of breath, chest pains, weight gain, and increased [MEDICAL CONDITION], finger clubbing, [MEDICAL CONDITION] crackles, cyanosis and report to MD." Another problem area dated 3/2/11 revealed the resident had a [DIAGNOSES REDACTED]." On 4/23/12 the care plan was updated to include "res gets anxious at times especially when res feels SOB." There were no added approaches related to the complaints of shortness of breath and nursing interventions. Review of the Weight Record revealed in December 2011 that the resident weighed 179 pounds. In January 2012 the resident weighed 163.5 pounds. A 15.5 pound loss in one month or an 8.7% significant weight loss in one month. The resident's weight for the second week of January was 166, a 2.5 pound gain. The next week the resident was 166 pounds, a loss of 6 pounds. During the next 3 months the resident's weight fluctuated up and down between 153.5 and 169.5 pounds. The fluctuation of the residents weight was not addressed related to possible fluid overload. During an interview on 4/26/12, the Director of Nurses (DON) confirmed the delay in obtaining the dental appointment. She also confirmed that the nursing staff failed to appropriately assess, intervene and document the resident's mouth pain. The DON stated that the facility contracted with an out sourced dentist. She stated that the dentist comes into the facility for assessments of the residents but all treatments were done at the dental clinic. The DON was asked how long an appointment usually took to obtain, she stated that for extractions the dentist usually can fit in that day or the next day. The DON also confirmed the weight loss between December 2011 and January 2012. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 3/17 at 3:40 PM, "Resident note unresponsive skin pale (unable to decipher) and clammy. FSBS 10. Pepsi cola 240 ml po given. Skin pale, (unable to decipher). 343 (3:43 PM) FSBS 90, orange juice 240 ml po given. FSBS 150, skin pink and dry, speak clearly "yes." 4P RP notified of hypoglycemic episode." There was no indication the physician had been notified. Further review of the Nurses Notes revealed on 4/18 at 2 AM, "Resident noted to have labored breathing O2 sat improved from 80-84% with nebulizer treatment. VS stable will cont to monitor. O2 at 2 L via NC (nasal cannula)." There was no documentation of what the saturation increased to or evidence of the continued monitoring. 4/18 at 11:40 AM, "Res had labored breathing @ 7:30 AM, c/o throat pain. B/P 100/70, T-96.4, P-82, R-26. Breathing tx (treatment) O2 sats 97% on 2 L via O2 mask..." On 4/19 at 2 PM, "Cont c labored breathing, O2 95-96%..." 4/20 the physician was notified of a nose bleed, however there was no indication the physician was notified of the labored breathing. 4/21 at 1:10 PM, "res has labored breathing noted, O2 sats 94% on 2 L via NC..." 9 PM, "C/O inability to breath, O2 sat 94%. Family in room/HOB (head of bed up)/HHN (hand held nebulizer) administered. Res states feels better." 4/22 at 1:15 PM, Res has SOB noted, O2 sats 96% on 2 L NC. HOB up, husband by side. HHN tx cont res tolerates well." On 4/23 at 1:15 PM, abd (abdominal) breathing noted..." 1:30 PM, "productive cough noted after lunch." An untimed note on 4/23 (***different nurse documented***) "N.O received for [MEDICATION NAME] and [MEDICATION NAME]. pt c SOB, O2 sat 91 % on 2-3 L via NC. Lung sounds diminished in (upper) lobes, absent c crackles in bilateral lower lobes." Another untimed note "Pt daughter in and req PRN HHN for SOB and wheezing, tx given c little effect. Pt appears somewhat lethargic and anxious, daughter insistent on sending pt to ER, MD paged." 9:20 PM, MD returned call and said send pt to ER if family refuses further tx at the facility, DON made aware of situation." 9:40 PM, Pt transported to ER via squad per family request for SOB." From 4/18 through 4/23 at 1:30 PM, there was no evidence of a nursing respiratory assessment, no evidence of interventions with follow up, or physician notification of the resident's continued reports of labored breathing, inability to breath, shortness of breath and productive cough. In addition, the resident's family requested the resident to be sent to the emergency room . Review of the MAR for March 2012 revealed only one low blood sugar of "10." Further record review revealed the last documented physician note was 3/30/12 (a readmission history and physical). The last telephone order was 4/20/12 related to a lab draw for a PT/INR and no change in [MEDICATION NAME] orders. Review of the Care Plan revealed a problem area related to "risk for hyper or [DIAGNOSES REDACTED]" with approaches including "If blood glucose is less than or equal to 60 mg/dl, follow protocol for orange juice and sugar and call MD as needed." Further review revealed the resident did not have a care plan developed related to Respiratory Distress/labored breathing or the resident's multiple hospitalization s. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. The resident was noted to have an Acute [MEDICAL CONDITION] Infarction in October 2011. In addition the resident was noted to have a Left Ventricular Apex Thrombus. Review of the Nurse's Notes revealed on 12/15/11 at 10:45 PM, "Res c/o not feeling well says it feels like his lungs are filling up again. O2 sat 98 %, lung sounds diminished. BP 102/68. Will monitor." 12/16/11 at 2 AM, "resident can't sleep at night. OOB to w/c staying at nursing station at present time. c/o SOB, SPO2 96% on RA (room air). BP 88/60, P-88, T-98.2, R-24. Denies chest pain, cont observe." At 11 AM, "called to resident's room, (up) on side of bed. Resp distress noted. 3+ [MEDICAL CONDITION] bilateral lower extremities (Resident has a right [MEDICAL CONDITION])...placed resident on O2...meds given per order. 150 cc urine noted. Resident pursed lip breathing continues to be SOB and requests to be sent to the hospital..." The resident was noted to have signs and symptoms of acute changes for 11 hours before he had to request to be sent to the ER. Also, there was no evidence of a nursing assessment, intervention, follow up or timely physician notification of the change. Review of the emergency room note dated 12/16/11 revealed the resident had increased Troponin and had a [DIAGNOSES REDACTED]. Review of the telephone orders revealed an order was written on 12/16/11 at 8:45 AM for [MEDICATION NAME] 5 mg daily for 4 days, chest x-ray and a basic metabolic panel to be drawn on 12/19/11. An order to transfer the resident to the ER per the resident's request was written on 12/16/11 at 11:45 AM. Review of the Care Plan dated 11/23/11 revealed a problem area related to shortness of breath due to [MEDICAL CONDITION]. Approaches included "monitor for shortness of breath, chest pains, wt gain and increased [MEDICAL CONDITION] and report to MD. Another problem area related to MI ([MEDICAL CONDITION] infarction) was identified with approaches of "encourage questions regarding disease and treatments. Provide information freely" and "teach benefits of low-fat, low cholesterol, high fiber diet." A problem area related to cardiac dysfunction was also identified with approaches including "monitor for s/s (signs/symptoms) of shortness of breath, dizziness, irregular pulse, activity intolerance and chest pain, notify MD/NP of any problems, vital signs and O2 sats as noted." There was no indication the Care Plan had been updated with the resident's hospitalization with the [MEDICAL CONDITION] infarction and pneumonia on 12/16/11 and there was no evidence of the resident's left ventricular thrombus included on the care plan. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. "Special Instructions: <150 give Sweetened Juice and call provider." Review of the Care Plan dated 11/17/11 revealed a problem area related to "risk for hyper or [DIAGNOSES REDACTED]" with approaches including "If blood glucose is less than or equal to 60 mg/dl, follow protocol for orange juice and sugar and call MD as needed." Review of the MAR (Medication Administration Record) for March 2012 revealed "<150 give sweetened juice and call MD" was lined through and "<60" was hand written above. Further review revealed on 3/5 at 6 AM, the blood sugar was 56. Review of the back of the MAR, Nurses Notes and physician's orders [REDACTED]. On 3/11 at 6 AM, the blood sugar was 50, med pass was given, however there was no recheck or physician notification. On 3/23 the blood sugar was 58, no interventions, no recheck and no notification was documented. On 3/31 at 6 AM, the blood sugar was 50, no interventions, no recheck and no notification was documented. In addition, there were 4 instances where no blood sugar was documented. Review of the April MAR indicated [REDACTED]< 60 were documented. However, at 8 AM on 4/22 the [MEDICATION NAME] was held due to a blood sugar of 43. A Telephone Order was written for Glycogen 1 mg Intramuscularly now was written. No recheck was documented and no corresponding nurses notes were located. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].<55 give sweetened juice and call provider." Review of the Care Plan revealed the resident did not have a care plan developed related to Diabetes Mellitus and Hypo/[MEDICAL CONDITION]. Review of the March 2011 MAR indicated [REDACTED]. However, review of the back of the MAR, nurse's notes and physician's orders [REDACTED]. In addition, there were 7 instances were the blood sugar was not documented. Review of the April MAR indicated [REDACTED]. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the Care Plan revealed a problem area related to "risk for hyper or [DIAGNOSES REDACTED]" with approaches including "If blood glucose is less than or equal to 60 mg/dl, follow protocol for orange juice and sugar and call MD as needed." Review of the physician's orders [REDACTED]. No parameters of Hypo/[MEDICAL CONDITION] were specified on the order. Review of the March 2012 orders revealed if the "blood sugar was 55 or below give sweetened juice and call provider." Review of the February 2012 MAR, Nurses Notes and physician's orders [REDACTED]. On 2/14 at 6 AM the blood sugar was 52, there was no intervention, recheck or physician notification documented. On 2/19 at 8 PM, the blood sugar was 13. There was no evidence of any interventions, rechecks or physician notification. On 2/29 at 4 PM the blood sugar was 45, med pass was given and the "res refused recheck." However, there was no corresponding nurses notes or evidence of physician notification. In addition there were 5 instances where no blood sugar was documented. Review of the March MAR indicated [REDACTED]. Further review of the Nurse's Notes revealed on 2/15 the resident was "usually hypoglycemic in AM." On 2/25 the resident reported a poor appetite and low energy. On 2/26, the resident continued to have a poor appetite and was "placed in the MD book." Review of the Progress Notes and Telephone Orders revealed on 2/20 the resident was noted to have an altered mental status and was refusing to eat or drink. The provider noted "FSBS on the lower side." An order was written to decrease the [MEDICATION NAME] from 10 mg to 5 mg due to "concerns about blood sugar." On 3/1 the provider saw the resident, with no mention of the low blood sugars. On 3/5 and order was written to decrease the finger stick blood sugar checks from four times daily to twice daily. On 3/10 the [MEDICATION NAME] was decreased again to 2.5 mg and the blood sugar checks were increased to four times daily again due to hypoglycemic episodes on 3/10. On 3/13 the provider assessed the resident and noted that the blood sugars were low and to "continue to monitor." The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. In addition if the blood sugar was less than 55 give juice and call the provider. Review of the Care Plan dated 2/22/12 revealed a problem area related to "risk for hyper or [DIAGNOSES REDACTED]" with approaches including "If blood glucose is less than or equal to 60 mg/dl, follow protocol for orange juice and sugar and call MD as needed." Review of the February MAR indicated [REDACTED]. On 2/25 at 4:40 PM, the blood sugar was 40, there was no evidence of an intervention, recheck or physician notification. In addition, there were 6 instances were the blood sugar was not documented. Further record review revealed on 2/14 the resident's [MEDICATION NAME] Insulin was decreased as well as the [MEDICATION NAME]. There was no other evidence the physician or the nurse assessed, intervened or documented on the low blood sugars since 2/14/12. Review of the March 2012 MAR indicated [REDACTED]. Review of the April 2012 MAR indicated [REDACTED]. Review of the Nurse's Notes revealed on 1/11/12 at 9:15 PM, the resident sustained [REDACTED]. 1/12 at 4:20 AM, "...3+ [MEDICAL CONDITION] B LE, redness skin coloration c pain on touch, slightly warm. Res c/o shoulder, leg and mid back pain r/t fall on 1/11/12. No deformities, no injuries assessed r/t fall. PRN and scheduled med has been given this shift. Res has a weak, slightly dragging L leg, painful gait. CNA assisted res to the restroom c a walker." There was no evidence the physician was notified of the pain or change in gait until 8 PM on 1/12/12, approximately 16 hours after the onset of the change in condition. 1/16/12 at 1:55 PM, "CNA came and got nurse res was not verbally responding. Talked c res but she couldn't respond with appropriate answers. Called (Nurse Practitioner) gave order to send to (ER). SOB noted O2 sats 94% on 2 L via NC. BLE (bilateral lower extremities) warm, red, 2+ [MEDICAL CONDITION] noted. Res LOA via stretcher at 9:10 AM." There was no prior note to indicate the onset of the resident's shortness of breath, need for oxygen or what time the provider was contacted with the change in condition. Also, there was no evidence of a nursing respiratory assessment or interventions. The resident was admitted to the hospital for Altered Mental Status,[MEDICAL CONDITION], Infiltrate and Effusions. 1/20 at 5 PM the resident was readmitted to the facility. 1/21/12 at 5 AM slight "wheeze, HOB elevated..." 9 PM, "...3+ [MEDICAL CONDITION] wheezes and rhonchi, dry coarse cough. HHN given as order." 1/22 at 2:47 AM, "[MEDICAL CONDITION] 1+ to (lower) extremities c shins red discolored, warm to touch, face and arms [MEDICAL CONDITION]. O2 sats 92%, HOB (raised). Mild wheezing observed, O2 as ordered." 1/23 at 2:20 PM, "Res c/o SOB, head of bed elevated. [MEDICAL CONDITION] noted all over body, O2 sats 92% on 3 L NC." 1/25 at 2:35 PM, "O2 sats 89% on 2 L NC...Res called nurse to room and asked if she would be better in hospital, nurse told her she was stable..." 1:11 AM, "Res has RUL (right upper lobe) crackles, O2 sat 92% on O2. Slightly labor mouth breath (sic) resp 32..." 1/26/12 at 1:26 AM, "LLL (left lower lobe) crackles, O2 sat 91% on O2, +2 [MEDICAL CONDITION] LE c deep red rash discoloration, +1 [MEDICAL CONDITION] UE (upper extremities). Slightly mouth labor breathing. Increase respir (sic) c reposition..." 1/29 at 2:30 PM, "[MEDICAL CONDITION] to B arms. SOB noted." 6:10 PM, "O2 at 2 L via NC noted c wheezing and rales RUQ (right upper quadrant)..." 1/30 at midnight "...mouth breathing non [MEDICAL CONDITION] to (upper) extremities. Crackles lung sounds, irregular heart beat, red rash below the knee, painful on touch." 1:45 PM, SOB noted, shallow resp. O2 sat 91% on 2 L via NC. Wheezing [MEDICAL CONDITION] to B arms and face noted..." 3:15 PM, "Assessed by (provider)..." There was no indication the resident was consistently assessed, had appropriate interventions, follow up and physician notification related to the acute change in condition of her respiratory status. The facility admitted Resident # 9 on 10-18-2000 with [DIAGNOSES REDACTED]. Review of the medical record on 4-25-12 revealed the Care Plan dated 2-9-12 listed a problem of: "Resident is a brittle Diabetic and is at risk for hyper or hypo glycemia. He has frequent ups and downs of blood sugars. His sugar may be 20 one day and 430 the next without any changes in cognition or physical symptoms." The approaches listed included: "Give meds(medications) as ordered and insulin according to (sliding) scale. Give oj (orange juice)and sugar for low blood sugars and if needed may give glucose injection. (Blood) Sugar will be reported to MD if under 55 or over 430." Review of the MAR (Medication Administration Record) for the month of February revealed there were five (5) instances of blood sugar being over 430 and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS 2/17/12 @ 4:30 PM 474 2/22/12 @ 9:00 PM 496 2/25/12 @ 6:00 AM 477 2/28/12 @ 11:30 AM 481 2/29/12 @ 6:00 AM 452 Review of the MAR for the month of March revealed there were five (5) instances of blood sugar being over 430 and one (1) instance of blood sugar being under 55, and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS Low BS 3/4/12 @ 6:00 AM 456 3/4/12 @ 9:00 PM 434 3/7/12 @ 11:30 AM 455 3/10/12 @ 11:30 AM 450 3/18/12 @ 6:00 AM 442 3/12/12 @ 4:30 PM 43 On March 29th, at 4:30 PM the MAR indicated [REDACTED]. On the back of the MAR indicated 3/29/12 BGL (blood glucose level) checked 30 min (utes) after and its 47 , o (no) s/s (signs and symptoms) of hypo/hyper glycemia." There was no notation in the nurses notes that the Physician had been notified. During a conversation with the DON (Director of Nursing) on 4-26-12 at approximately 3:00 PM, she confirmed that the Physician had not been notified of either the "high" reading or the sudden drop to 47. The DON further confirmed that the facility had recently obtained gluometers which should read LO if the blood sugar was below 40 and HIGH if the blood sugar was above 450. Review of the MAR for the month of April revealed there were six (6) instances of blood sugar being over 430, and there was no documentation on the MAR indicated [REDACTED]. Date/time High BS 4/1/12 @ 6:00 AM 443 4/8/12 @ 6:00 AM 434 4/14/12 @ 11:30 AM 463 4/15/12 @ 11:30 AM 498 4/16/12 @ 6:00 AM 488 4/16/12 @ 4:30 PM 445 The review also revealed that there were multiple blanks on the MAR for February: 2/12/12 @11:30 AM, and 2/23/12 @ 9:00 PM; for March: 3/10 @ 9:00 PM, 3/11/12 @ 11:30 AM, 3/15/12 @ 9:00 PM, 3/16/12 @ 9:00 PM, 3/18/12 @ 9:00 PM, 3/19/12 @ 4:30 PM, and 3/28/12 @ 9:00 PM; for April; 4/19/12 at 4:30 PM. In addition on 4/8/12 there was no documentation that coverage was given for a blood sugar of 291 which should have been 4 units of insulin. The facility admitted Resident # 12 on 2-21-02 with [DIAGNOSES REDACTED]. Review of the MAR indicated [REDACTED]@ 8:00 PM, 2/11/12 @ 8:00 PM, 2/17/12 @ 12:00 PM, 2/24/12 @ 8:00 PM, and 2/28/12 @ 8:00 PM; March, 3/9/12 @ 4:00 PM and 8:00 PM, 3/11/12 @ 4:00 PM and 8:00 PM, 3/19/12 @ 8:00 PM, 3/22/12 @ 8:00 PM, 3/23/12 @ 8:00 PM. The facility admitted Resident # 11 on 3/23/11 with [DIAGNOSES REDACTED]. Review of the MAR indicated [REDACTED]@ 6:00 AM, 2/7/12 at 11:30 AM, 2/9/12 at 6:00 AM, 2/11/12 @ 11:30, 2/16/12 @ 9:00 PM, and 2/17/12 @ 11:30 AM. The facility admitted Resident # 10 on 1-14-11 with [DIAGNOSES REDACTED]. Review of the MAR indicated [REDACTED]@ 8:00 PM. and in the month of March there were 2 blanks indicating that the FSBS had not been done: 3/11/12 @ 8:00 PM, and 3/25/12 @ 8:00 PM. During an interview on 4/25/12 at 3:35 PM, the Medical Director stated that he expected the nursing staff to follow up on, recheck and document after an intervention was initiated. He stated that he also expected the nursing staff to notify the physician according to the defined parameters for abnormal blood sugars or changes in condition. The Medical Director stated that it was not acceptable practice to give an unresponsive resident liquids by mouth for low blood sugars. He stated that Glycogen IM should have been administered and the physician should have been notified within 10-30 minutes. The Medical Director stated that he expected the providers to review the blood sugars during their routine assessments and adjust medications accordingly. The Medical Director also stated that new onset shortness of breath, chest pains or other symptoms should be reported to the physician within the hour. He also stated that if the symptoms constituted a medical emergency then the staff should not wait on the physician and should call 9-1-1 and send the resident to the ER. The Medical Director also stated that anxiety that manifested as shortness of breath, needed to be treated and assessed as well notifying the physician. The above residents were shared with the Medical Director. During an interview on 4/26/12, the Director of Nurses (DON) confirmed the above residents abnormal blood sugars. She confirmed the nursing staff failed to treat, follow up on, document and notify the physician of problems related to blood sugars. The DON confirmed Resident #1, #2, #3 and #7's acute changes in condition. She confirmed the nursing staff failed to identify potentially life threatening acute changes in condition, failed to adequately assess the residents, failed to intervene appropriately, failed to timely notify the physician and failed to thoroughly document their findings. The DON confirmed the residents' care plans were not followed related to low blood sugars and confirmed that the care plans did not reflect each residents needs and current status. Review of the Physician's Communication Grid revealed the Physician notification was required for treatment within one hour for "chest pain-new onset or not relieved by physician orders [REDACTED]." Shortness of breath required treatment within one hour if there was an "acute onset or with chest pain, change in VS, labored breathing, O2 saturation <95%." Treatment was required within 4 hours if "gradual onset of SOB, O2 saturation >95%." treatment for [REDACTED].>450 mg/dl or machine reading HI in diabetic patient using sliding scale insulin or < 70 mg/dl in diabetic patient or < 50 mg/dl in non diabetic patient or high or low blood sugar accompanied by change from usual LOC or responsiveness." treatment for [REDACTED].< 70 or > 350 in a diabetic patient on oral hypoglycemic or insulin unless consistent with usual pattern." During an interview on 4/25/12 at 3:10 PM, the Administrator and

On the days of the Complaint and Extended Survey based on record review and interview, Substandard Quality of Care and/or Immediate Jeopardy was identified. The facility's Administration failed to utilize it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure each resident's change in condition was appropriately identified, assessed, interventions initiated, the physician notified and the appropriate documentation was in place for 4 of 4 resident (#1, #2, #3 and #7) with acute changes in condition and 6 of 9 residents (#2, #5, #6, #7, #8 and #9) reviewed with sliding scale insulin. The findings included: Cross Refer to F 309 as it relates to the failure of the facility to provide the necessary care and services to maintain the highest practicable physical well-being related to the identification, assessment, intervention, follow up and documentation for 4 or 4 residents with an acute change in condition (Resident #1, #2, #3 and #7). The facility failed to assess, intervene, follow up on and notify the physician of critically low or high blood sugars for 6 or 9 residents reviewed for blood sugars (Residents #2, #5, #6, #7, #8 and #9). During an interview on 4/26/12, the Director of Nurses (DON) confirmed the above resident's abnormal blood sugars. She confirmed the nursing staff failed to treat, follow up on, document and notify the physician of the low blood sugars. The DON confirmed Resident #1, #2, #3 and #7's acute changes in condition. She confirmed the nursing staff failed to identify potentially life threatening acute changes in condition, failed to adequately assess the residents, failed to intervene appropriately, failed to timely notify the physician and failed to thoroughly document their findings. During an interview on 4/25/12 at 3:10 PM, the Administrator and Director of Nurses (DON) were informed of the above residents concerns related to physician notification, nursing assessments, interventions, re assessments and documentation related to changes in condition. The Administrator and DON were informed that Substandard Quality of Care and/or Immediate Jeopardy existed related to the facility failure to identify, assess, intervene and notify the physician of acute changes in condition and the failure to treat, follow up on and notify the physician of abnormally low or high blood sugars. An Allegation of Compliance (AOC) was submitted by the facility on 4/26/12. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 4/26/12 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator had been educated and was knowledgeable regarding the AOC and administration of the facility. The Administrator was informed of this on 4/26/12. The Immediate Jeopardy at F-490 was removed but the citation at F-490 remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Survey the facility Medical Director failed to ensure resident care policies were implemented related to acute changes in condition and critically abnormal blood sugars. The findings included: Cross Refer to F 309 as it relates to the failure of the facility to provide the necessary care and services to maintain the highest practicable physical well-being related to the identification, assessment, intervention, follow up and documentation for 4 or 4 residents with an acute change in condition (Resident #1, #2, #3 and #7). The facility failed to assess, intervene, follow up on and notify the physician of critically low or high blood sugars for 6 or 9 residents reviewed for blood sugars (Residents #2, #5, #6, #7, #8 and #9). During an interview on 4/25/12 at 3:35 PM, the Medical Director stated that he expected the nursing staff to follow up on, recheck and document after an intervention was initiated. He stated that he also expected the nursing staff to notify the physician according to the defined parameters for abnormal blood sugars or changes in condition. The Medical Director stated that it was not an acceptable practice to give unresponsive residents liquids by mouth for low blood sugars. He stated that Glycogen IM should have been administered and the physician should have been notified within 10-30 minutes. The Medical Director stated that he expected the providers to review the blood sugars during their routine assessments and adjust medications accordingly. The Medical Director also stated that new onset shortness of breath; chest pains or other symptoms should be reported to the physician within the hour. He also stated that if the symptoms constituted a medical emergency then the staff should not wait on the physician and should call 9-1-1 and send the resident to the ER. The Medical Director also stated that anxiety that manifested as shortness of breath, needed to be treated and assessed as well notifying the physician. The above residents were shared with the Medical Director. During an interview on 4/26/12, the Director of Nurses (DON) confirmed the above resident's abnormal blood sugars. She confirmed the nursing staff failed to treat, follow up on, document and notify the physician of the low blood sugars. The DON confirmed Resident #1, #2, #3 and #7's acute changes in condition. She confirmed the nursing staff failed to identify potentially life threatening acute changes in condition, failed to adequately assess the residents, failed to intervene appropriately, failed to timely notify the physician and failed to thoroughly document their findings. The DON confirmed the residents' care plans were not followed related to low blood sugars and confirmed that the care plans did not reflect each resident's needs and current status. During an interview on 4/25/12 at 3:10 PM, the Administrator and Director of Nurses were informed of the above residents concerns related to physician notification, nursing assessments, interventions, re assessments and documentation related to changes in condition. The Administrator and DON were informed that Substandard Quality of Care and/or Immediate Jeopardy existed in the facility related to the failure to identify, assess, intervene and notify the physician of acute changes in condition and the failure to treat, follow up on and notify the physician of abnormally low or high blood sugars. An Allegation of Compliance (AOC) was submitted by the facility on 4/26/12. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 4/26/12 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Medical Director was knowledgeable regarding the AOC. The Administrator was informed of this on 4/26/12. The Immediate Jeopardy at F-501was removed but the citation at F-501 remained at a lower scope and severity of "E".

On the days of the Complaint and Extended Survey the facility failed to identify, assess, intervene, treat, follow up, notify and document acute changes in condition and critically abnormal blood sugars. The facility failed to audit and implement an action plan related to an identified concern of changes in condition and care plan revisions. The facility failed to identify concerns related to critically abnormal blood sugars. The findings included: Cross Refer to F 309 as it relates to the failure of the facility to provide the necessary care and services to maintain the highest practicable physical well-being related to the identification, assessment, intervention, follow up and documentation for 4 or 4 residents with an acute change in condition (Resident #1, #2, #3 and #7). The facility failure to assess, intervene, follow up on and notify the physician of critically low or high blood sugars for 6 or 9 residents reviewed for blood sugars (Residents #2, #5, #6, #7, #8 and #9). During an interview on 4/26/12, the Director of Nurses (DON) confirmed the above resident's abnormal blood sugars. She confirmed the nursing staff failed to treat, follow up on, document and notify the physician of the low blood sugars. The DON confirmed Resident #1, #2, #3 and #7's acute changes in condition. She confirmed the nursing staff failed to identify potentially life threatening acute changes in condition, failed to adequately assess the residents, failed to intervene appropriately, failed to timely notify the physician and failed to thoroughly document their findings. During an interview on 4/25/12 at 3:10 PM, the Administrator and Director of Nurses were informed of the above residents concerns related to physician notification, nursing assessments, interventions, re assessments and documentation related to changes in condition. The Administrator and DON were informed that Substandard Quality of Care and/or Immediate Jeopardy existed related to the failure of the facility to identify, assess, intervene and notify the physician of acute changes in condition and the failure to treat, follow up on and notify the physician of abnormally low or high blood sugars. The DON stated that on 4/16/12 the facility identified a concern related to the failure to identify changes in condition. No audit had been completed as of 4/25/12. A formal action plan had not been implemented as of 4/25/12. Review of the "POC" revealed the plan was for the facility to "review all hot box charting in the clinical morning meeting, track changes in condition on the monitoring board and the DON and Unit Managers to assess patients with changes in condition to ensure proper follow up is being managed." No target or completion dates had been included. In addition, the facility identified a concern related to the revision of care plans, however no action plan had been put in place and only 10 charts had been audited as of 4/25/12. Observations, interviews, and review of policy, education and signature sheets on 4/26/12 revealed the Allegation of Compliance submitted by the facility on 4/26/12 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator was informed of this on 4/26/12 at 3:50 PM. The citations at F-157, F-280, F-281, F-282, F-309, F-490, F-501 and F-520 remained at a lower scope and severity of "E".

On the days of the survey based on record review and interview the facility failed to ensure a resident's care plan was updated with new and appropriate interventions after each fall to prevent falls from occurring again. Resident #3's care plan was not updated with new interventions after a fall to prevent further falls. (One of five sampled residents reviewed for care plan revisions). The findings included: The facility admitted Resident #3 on 5/3/2011 with [DIAGNOSES REDACTED]. Review of the Nurses Notes on 8/16/201 revealed an entry dated 8/12/2011 at 7 AM that documented "CNA found resident sitting on floor next to bed...spoke with resident re: (regarding) importance of using call light and not walking sock footed or barefooted. Resident not receptive to using call light and does not want to and is then reinforced on the importance of both. " Further review revealed an entry dated 8/13/2011 at 12:10 PM that documented: "CNA called this nurse to residents room, upon arriving noted resident on back c (with) L (left) shoulder against door frame and head through bedroom door. Resident stated I'm OK, help me get up. Resident was moving all extremities s (without) distress no complaints of pain. This nurse and 2 CNAs assisted resident to feet. No external rotation or length discrepancies were seen. Upon lifting resident noted resident dragging left leg so placed resident in wc (wheelchair) and took to bed, full body lifted resident c assistance of 2 CNAs in to bed. @ (at) this time resident said his hip was hurting, requested that resident stay in bed until x-rays were obtained." At 4:00 PM, " received results of hip x-rays. There is a right sub capital fx (fracture) with slight displacement. " Resident #3 was transferred to hospital with a right [MEDICAL CONDITION]. Review of the Incident Report dated 8/12/2011 revealed "CNA was walking on hall and saw resident was sitting on floor next to bed... " Steps taken to prevent re occurrence were "educated res(ident) to use call light. " Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 received a BIMS (Brief Interview for Mental Staus) score of "4". Review of the Fall Risk Evaluation revealed on 5/3/2011 Resident #3 scored an "18". Review of the evaluation revealed "a resident who scores a 10 of higher is at risk. If resident scored a 10 or above interventions should be initiated." Interventions added were "top ? of side rails up when in bed for mobility." Review of the Care Plan revealed a problem area related to falls was identified with approaches including "assure the floor is free of glare, liquids, foreign objects; encourage me to call for help; keep personal items and frequently used items within reach; make sure my call light is in reach,; orient to changes in environment such as new furniture, room change etc." On 8/12/2011 the care plan was updated with the fall. An intervention was added for "reinforced to resident the importance of using call light." The intervention to reinforce the importance of using the call light was not appropriate for Resident #3 with a BIMS score of 4. No additional interventions were added to prevent further falls. During an interview on 8/15/2011 at 12:30 PM, the Director of Nurses (DON) confirmed the care plan was not updated with new and appropriate interventions to prevent further falls. The DON confirmed the use of the call light was an intervention that was in place since the resident's admission. The DON stated new interventions were not put in place because the facility did not want to restrict the resident. The DON then stated that other non restrictive interventions could have been put in place such as a toileting program and fall mats. The DON confirmed Resident #3 fell again on 8/13/2011 and sustained a [MEDICAL CONDITION].

On the days of the survey based on record review and interviews the facility failed to ensure two of five sampled residents received the necessary supervision and interventions necessary to prevent accidents. Resident #1 was transferred using the wrong lift that resulted in a fall with injury on 6/26/2011. Resident #1 was also transferred incorrectly from 6/9/2011 through 6/30/2011. Resident #3 did not have new and appropriate interventions put in place after a fall and Resident #3 fell again resulting in a hip fracture. The facility also failed to assure Therapy recommendations were acted upon and followed. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident was coded as requiring total dependence with two person assistance for transfers. Review of the Care Plan dated 1/18/2011 revealed Resident #1 was to be transferred with a Hoyer Lift with a two person assist. Review of the CNAs Care Plan revealed Resident #1 was transferred with a Hoyer lift. Review of the ADL (Activities of Daily Living) Tracking Form for June 2011 first shift revealed the staff was documenting Resident #1 required total one person assistance with transfers from 6/9/2011 through 6/13/2011. Staff then documented that Resident #1 required extensive one person assist with transfers from 6/13 through 6/30/2011. Review of the Nurse's Notes revealed an entry dated 6/26/2011 at 8:15 AM, Certified Nursing Assistant (CNA#1) called for assistance in resident's room; upon entering room noted resident c (lift) pad attached to resident; resident laying on right side on floor and lift laying tilted over to left side resting against bedside table; resident's head and shoulders still suspended in air; disconnected lift from resident c assistance from other staff members...(CNA#1) reported resident was up in wc and while using stand up lift to change resident, resident's left leg started jerking and came off lift causing lift to become unbalanced and tip over...noted pink/purple area 2 inches in diameter round shape on R(ight) mid back... " Review of the Physical Therapy assessment dated [DATE] revealed Resident #1 was to be transferred with a Hoyer lift and 2 people. During an interview on 8/16/2011 at 11:30 AM, CNA#1 stated that she was assigned to Resident #1 on 6/26/2011. She stated that third shift usually got Resident #1 up in the mornings. CNA#1 stated that she had been caring for the resident for over a year and never checked the CNAs Care Plan. CNA#1 stated that she always used a stand up lift for the resident and was never informed that he was a total lift for transfers. CNA#1 stated that Resident #1 did not have a total lift sling that was required for use with the Hoyer lift. CNA#1 stated again that Resident #1 transferred with a stand up lift or with two people and a gait belt. CNA#1 stated that she was going to change Resident #1 and he was standing up in the stand up lift when his leg gave way and the lift tipped over. CNA#1 stated that CNA#2 had left the room to get a towel and was not in the room when the resident tipped over. Multiple attempts were made to contact CNA#5 (third shift Nursing Assistant routinely assigned to Resident #1) without success. During an interview on 8/16/2011 at 11:45 AM, CNA#2 stated that she was in another resident's room feeding him breakfast when she heard a loud boom. She walked down the hall and heard CNA#1 screaming. CNA#2 entered Resident #1's room and saw Resident #1 still suspended in the stand up lift that had fallen over. CNA#2 stated that she called for more assistance. CNA#2 stated that she was not in Resident #1's room and did not assist CNA#1 during a transfer on 6/26/2011. CNA#2 stated that she had assisted CNA#1 on previous occasions with the stand up lift for Resident #1. CNA#2 stated that she was aware all lifts required two staff members to assist. CNA#2 also stated that if a resident required a Hoyer lift then the sling would be under the resident. During an interview on 8/15/2011 at 12:30 PM, the Director of Nurses (DON) and Administrator confirmed Resident #1 was transferred with a stand up lift on 6/26/2011. Both stated that the Resident was a two person transfer with a Hoyer Lift. The Administrator stated that CNA#1 transferred the resident by herself with the wrong lift. The Administrator also stated that CNA#1 did not check the care plan. Both confirmed that CNA#1 was terminated. The Administrator stated an in-service was conducted on 6/29/2011 related to Abuse and Neglect and the importance of the CNAs Care Plan. The Administrator confirmed CNAs documentation was identified as a concern in May 2011. She stated that an in-service was conducted on 6/22/2011 related to the proper coding for documentation. The Administrator stated that no action plan was put in place. She also stated that no other audits or follow up was completed related to the documentation errors. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 received a BIMS score of "4". Resident #3 was also coded as requiring limited supervision for transfers and locomotion in the room. Resident #3 was coded as independent for toilet needs but required one person limited assist for hygiene. Review of the Nurses Notes on 8/16/2011 revealed an entry dated 8/12/2011 at 7 AM that documented "CNA found resident sitting on floor next to bed... spoke with resident re: (regarding) importance of using call light and not walking sock footed or barefooted. Resident not receptive to using call light and does not want to and is then reinforced on the importance of both." Further review revealed an entry dated 8/13/2011 at 12:10 PM that documented "CNA called this nurse to residents room, upon arriving noted resident on back c (with) L (left) shoulder against door frame and head through bedroom door. Resident stated I'm OK, help me get up. Resident was moving all extremities s (without) distress no complaints of pain. This nurse and 2 CNAs assisted resident to feet. No external rotation or length discrepancies were seen. Upon lifting resident noted resident dragging left leg so placed resident in wc (wheelchair) and took to bed, full body lifted resident c assistance of 2 CNAs in to bed. @ (at) this time resident said his hip was hurting, requested that resident stay in bed until x-rays were obtained. " At 4:00 PM, " received results of hip x-rays. There is a right sub capital fx (fracture) with slight displacement. " Resident #3 was transferred to hospital with a right hip fracture. Review of the Incident Report dated 8/12/2011 revealed "CNA was walking on hall and saw resident was sitting on floor next to bed..." Steps taken to prevent re occurrence were "educated res(ident) to use call light." Review of the Incident Report dated 8/13/2011 revealed "Res(ident) noted on floor lying on back c shoulder propped up on room door. Res was ambulating to BR (bathroom). Res assisted to wc and then assisted to bed. NP (nurse practitioner) on call notified for R (right) hip xray." Step taken to prevent re occurrence were "Explained to res to use call light when needing assistance to BR. Res verbalized understanding. " Review of the Fall Risk Evaluation revealed on 5/3/2011 Resident #3 scored an "18". Review of the evaluation revealed "a resident who scores a 10 of higher is at risk. If resident scored a 10 or above interventions should be initiated." Interventions added were "top ? of side rails up when in bed for mobility." Review of the Care Plan revealed a problem area related to falls was identified with approaches including "assure the floor is free of glare, liquids, foreign objects, encourage me to call for help, keep personal items and frequently used items within reach, make sure my call light is in reach, orient to changes in environment such as new furniture, room change etc." On 8/12/2011 the care plan was updated with the fall. An intervention was added for "reinforced to resident the importance of using call light." To reinforce to the resident the importance of using the call light was no an appropriate intervention for a resident with a BIMS score of 4. Review of the Certified Nursing Assistant Care Plan revealed the resident was "Independent" with transfers. Review of the Therapy Discharge Note dated 7/3/2011 revealed Resident #3 upon discharge could only recall 3/5 steps related to safety awareness. Resident #3 required hand held assist with ambulation and required supervision with transfers. The note indicated that the staff was provided education related to the residents needs. During an interview on 8/15/2011 at 12:30 PM, the Director of Nurses (DON) and Administrator confirmed the use of the call light was an intervention that was in place since the resident's admission. The DON stated new interventions were not put in place because the facility did not want to restrict the resident. The DON then stated that other non restrictive interventions could have been put in place such as a toileting program and fall mats. The DON confirmed Resident #3's poor safety awareness and confirmed the therapy discharge note that documented the resident's transfer requirements as well as ambulation requirements. The DON confirmed that the Physical Therapist did not recommend that Resident #3 was independent in transfers or ambulation. The Administrator also confirmed that Resident #3 did not have decisional capacity per the Psychiatrist and confirmed that the resident was not alert and oriented per the BIMS score. During a telephone interview on 8/16/2011 at 2 PM, the Physical Therapist stated that all modes of transfers were assessed by the Therapy Department at least quarterly or when there was a change. He stated that all recommendations should be followed. The PT stated that he gives the RAC (Resident Assessment Coordinator) Nurse the transfer screen. The PT then stated that there was no follow up on the recommendations to assure that they were followed. He stated that he would provide education for the staff if requested. The PT stated that after he gives the Screens to the RAC nurse it was then nursing's responsibility to disperse the information to the staff. During an interview on 8/16/2011 at 2:10 PM, the RAC Nurse stated that she did not receive the screens from Therapy and that they were put into the residents' charts. She stated that the Rehab Manager would discuss the resident needs in the morning stand up meetings. She stated that the Unit Managers attended the morning meeting and would take the information and then update the CNAs' care plans, inform the charge nurse and place the resident in the "hot box" charting. The RAC nurse stated that it was the Unit Manager's or the Charge Nurses' responsibility to assure the recommendations were followed. During an interview on 8/16/2011 at 3:35 PM, the Unit Manager stated that she did not actually see the therapy screens but was aware they were in the resident's charts. She also stated that during the morning meetings she would be informed by the Rehab Manager of the recommendations. The Unit Manager stated that she would then update the CNAs' care plans and would verbally tell the CNAs if she saw them. The Unit Manager also stated that she would "sometimes" place the residents in the hot box charting. The Unit Manager stated that she did not check to make sure the CNAs were following the recommendations assessed by the Physical Therapist. Five CNAs were interviewed during the Complaint Survey, three of the five CNAs stated that they did not check the care plan daily. All five stated that the resident care needs were located on the care plan. CNA#1 stated that she did not check the care plan at all. CNA#2 stated that she would only check the care plan if there was a change in the resident's condition. CNA#3 stated that she would check the care plan once or twice a week. CNA#4 and CNA#6 stated that they checked the care plan daily. The DON and Administrator confirmed there was no written policy regarding how Therapy recommendations were dispersed and how the recommendations were to be followed accordingly.