Every finding on record at Lancashire Post Acute

Based on record review, interviews, and facility policy review, the facility failed to implement interventions to aid in the prevention and decline of pressure ulcers for one resident (Resident (R) R110) out of four residents reviewed for pressure ulcers. The facility's failure to implement pressure ulcer prevention interventions resulted in multiple pressure ulcers after admission, including one stage 4 and one stage 3 pressure ulcer, along with three unstageable pressure ulcers and has the potential for other residents to develop pressure ulcers.Findings include: Review of R110's Face Sheet located under the Face Sheet tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, urinary incontinence, incontinence of feces, multi-system degeneration of the autonomic nervous system, osteoarthritis of hip, pain in right hip, and generalized muscle weakness. R110 discharged from the facility on 02/22/25.Review of R110's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/22/25, located under the MDS tab of the EMR, revealed he had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated he had moderate cognitive impairment. The assessment documented R110 had no pressure injuries upon admission. The assessment also revealed that R110 required substantial/maximal assistance for bed mobility.Review of R110's admission Risk Assessments found under the Assessments tab of the EMR, revealed a Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE], which indicated R110 was at risk for developing pressure sores.Review of R110's admission assessment dated [DATE] located under the Assessments tab of the EMR revealed a skin assessment was completed with documentation No areas of discoloration or altered skin integrity identified.Review of R110's Care plan dated 01/16/25 located under the Care plans tab of the EMR, revealed R110 had the potential for altered skin integrity or had altered skin integrity with a goal R110 would not experience impaired skin integrity or would demonstrate wound healing. Interventions dated 01/16/25 included that staff were to assist R110 with positioning, encourage R110 to reposition as able, and apply skin barrier cream.Review of R110's Braden Score found under the Assessments tab of the EMR, dated 01/23/25, indicated R110 was a risk for developing pressure sores. Review of R110's Care plan located under the Care plans tab of the EMR updated on 01/24/25 with an intervention that an air mattress was applied, then changed to an air overlay on 01/28/25.Review of R110's Progress Notes, dated 01/29/25 located under the Notes tab of the EMR, revealed a purple bruise to the left forearm from a fall was noted.Review of R110's Care plan dated 01/29/25 located under the Care plans tab of the EMR, revealed R110 had the potential for or had altered skin integrity and was at risk for pressure ulcer with interventions that staff were to administered wound treatments as ordered, check skin for redness, skin tears, swelling, or pressure areas and report any signs of skin breakdown, per nutritional screening and adjust diet/supplements as indicated, use pillows, pads, or wedges, to reduce pressure on heels and pressure points, turn/reposition. Review of R110's Treatment Administration Record (TAR) dated January 2025 revealed an order for skin check two times weekly for four weeks ordered 01/16/25. The skin checks dated 01/18/25, 01/22/25, and 01/25/25 documented no new areas identified.Review of R110's TAR dated February 2025 revealed an order for skin check two times weekly for four weeks dated 01/16/25. The skin check dated 02/01/25, evenings documented there were no new areas identified.Review of R110's Progress Notes dated 02/02/25 located under the Notes tab of the EMR, revealed R110 had areas of discoloration to both heels and feet with skin intact. R110 had very poor bed mobility and frequently rested his feet on his footboard. R110's heels were repositioned and floated on pillows. The physician and wound care nurse were notified. The document did not mention the other wounds.Review of R110's Pressure Ulcer Skin Documentation/Assessment Form dated 02/02/25 and located under the Assessments tab of the EMR revealed R110 had the following wounds:Left heel - developed after admissionRight heel - developed after admissionRight ankle - developed after admissionLeft lateral foot - developed after admissionThere were no measures or assessments of the wounds documented on the 02/02/25 Pressure Ulcer Skin Documentation/Assessment Form.Review of R110's TAR dated February 2025, revealed the wound treatment, lab orders, and heel boots were implemented. Heel boots were documented as applied three times daily beginning 02/03/25.Review of R110's Physician Progress Note dated 02/04/25, located under the Documents tab of the EMR revealed documentation of skin was skin discoloration feet, bruise left forearm.Review of R110's Care plan dated 02/04/25 located under the Care plans tab of the EMR revealed R110 had pressure areas to both feet with interventions of pressure relieving boots as tolerated, nutritional screening and adjust diet/supplements as indicated, use pillows, pads, or wedges to reduce pressure on heels and pressure points, turn/reposition, pressure reducing mattress and cushion, and provide wound care per order. There was no documented evidence that the pressure reducing chair cushion or turning and repositioning of the resident was implemented.Review of R110's Pressure Ulcer Skin Documentation/Assessment Form dated 02/05/25 and, located under the Assessments tab of the EMR revealed R110 had the following wounds:Left heel - unstageable with slough and/or eschar and measured 2.5 centimeters (cm) by 2 cmRight heel - unstageable with suspected deep tissue injury (DTI) and measured 1.5 centimeters (cm) by 1 cm with EscharRight ankle- unstageable with slough and/or eschar and measured 1 cm by 1 cmLeft lateral foot - unstageable with DTI and measured 1 cm by 1 cmReview of R110's Dining Services Periodic Assessment [Nutrition assessment] dated 02/11/25 revealed recommendations for Vitamin C 500mg daily, Zinc 220mg daily, double portions protein for meals, and LiquaCel 30 milliliters (ml) 3 times daily. There was no documented evidence that these recommendations were implemented. Review of R110's Pressure Ulcer Skin Documentation/Assessment Form dated 02/12/25 and located under the Assessments tab of the EMR revealed R110 had the following Left heel- measured 2.5 cm by 1.5 cm. Right heel - measured 2.5 cm by 1.5 cmRight ankle - measured 1.5 cm by 1.2 cmLeft lateral foot - measured 1.5 cm by 1.5 cm with skin intact and maroon discolorationReview of R110's Specialty Physician Wound Evaluation & Management Summary dated 02/12/25, located under the Documents tab of the EMR, revealed documentation by the physician included the visit was conducted via telemedicine. non-pressure wound of the left, plantar heel full thickness. Dressing treatment plan: Primary Dressing(s) - Leptospermum honey apply every two days for 30 days; Alginate calcium apply every two days for 30 days. Secondary Dressing(s) - Superabsorbent gelling fiber w/ silicone bdr [border] & faced apply every two days for 30 days. Peri Wound Treatment - Skin prep apply every two days for 30 days. Plan of care reviewed and addressed. Recommendations: Off-Load Wound; Pressure Off-Loading Boot. Non-pressure wound of the right, posterior heel full thickness. Dressing treatment plan: Primary Dressing(s) - Leptospermum honey apply every two days and as needed for 30 days; Alginate calcium apply every two days and as needed for 30 days. Secondary Dressing(s) - Superabsorbent gelling fiber w/ silicone bdr & faced apply every two days and as needed soiled or loosened for 30 days. Peri Wound Treatment - Skin prep apply every two days and as needed for 30 days. Plan of care reviewed and addressed. Recommendations - Pressure Off-Loading Boot. Non-pressure wound of the right, lateral foot. Dressing treatment plan: Primary Dressing(s) - Skin prep apply once daily for 30 days. Plan of care reviewed and addressed. Recommendations - Pressure Off-Loading Boot. non-pressure wound of the right ankle full thickness. Dressing treatment plan: Primary Dressing(s) - Alginate calcium apply every two days for 30 days; Leptospermum honey apply every two days for 30 days. Secondary Dressing(s) - Superabsorbent gelling fiber w/ silicone bdr & faced apply every two days for 30 days. Peri Wound Treatment - Skin prep apply every two days for 30 days. Plan of care reviewed and addressed. Recommendations - Pressure Off-Loading Boot. RECOMMENDED (CMP) [lab order] ON 2/12/2025Review of R110's Pressure Ulcer Skin Documentation/Assessment Form dated 02/14/25 and located under the Assessments tab of the EMR revealed R110 had the following:Right buttock-developed unstageable with DTI and measured 5.6 cm long by 6 cm wide by 0.1 cm deepReview of R110's Pressure Ulcer Skin Documentation/Assessment Form dated 02/18/25 and located under the Assessments tab of the EMR revealed R110 had the following: Left heel- Stage 4 and measured 1.6 cm long by 1 cm wide by 0.1 cm deep Right heel - measured 0.9 cm by 0.5 cmRight ankle - Stage 3 and measured 1.5 cm long by 1.6 cm wide, by 0.3 cm deepLeft lateral foot - measured 2.7 cm by 4 cm with blister blood filledRight buttocks- unstageable with DTI and measured 5.6 cm long by 6 cm wide by 0.1 cm deepReview of R110's Specialty Physician Wound Evaluation & Management Summary dated 02/18/25 located under the Documents tab of the EMR revealed documentation by the physician that included: Stage 4 pressure wound of the left, posterior heel full thickness. Dressing treatment plan: Primary Dressing(s) - Leptospermum honey apply three times per week for 30 days; Methylene blue foam apply three times per week for 30 days: Hydrofera Blue Classic. Secondary Dressing(s) - Gauze sponge sterile apply three times per week for 30 days: may substitute for ABD pad.; Gauze roll (kerlix) 4.5 apply three times per week for 30 days: Wrap from toe crease to just below the knee.; Tape (retention) apply three times per week for 30 days. Peri Wound Treatment - Skin prep apply three times per week for 30 days. Plan of care reviewed and addressed. Recommendations - Off-Load Wound; Pressure Off-Loading Boot; Grippy socks only: avoid shoes with therapy; Protein supplementation and Thyroid Function Tests (TSH/Ft4); Vitamin C 500mg Twice daily PO; Zinc Sulphate 220mg Once Daily PO for 14 Day. Unstageable DTI [deep tissue injury] of the right, posterior heel full thickness . Skin prep apply three times per week for 30 days . Recommendations - Pressure Off-Loading Boot; Grippy socks only; avoid shoes w/ therapy. Unstageable DTI of the right, lateral foot undetermined thickness. Dressing treatment plan: Primary Dressing(s) - Skin prep apply three times per week for 24 days. Plan of care reviewed and addressed. Recommendations - Pressure Off-Loading Boot. Stage 3 pressure wound of the right, lateral ankle full thickness. Dressing treatment plan - Primary Dressing(s) - Leptospermum honey apply three times per week for 30 days; Methylene blue foam apply three times per week for 30 days: Hydrofera Blue Classic cutto size, wet foam with NS, then dry with gauze and place on wound already cover with primary dressing --i.e., honey paste. Secondary Dressing(s) - Gauze sponge sterile apply three times per week for 30 days: may substitute for ABD pad; Gauze roll (kerlix) 4.5 apply three times per week for 30 days: Wrap from toe crease to just below the knee; Tape (retention) apply three times per week for 30 days. Peri Wound Treatment - Skin prep apply three times per week for 30 days. Plan of care reviewed and addressed. Recommendations - Pressure Off-Loading Boot.Unstageable DTI of the right buttock undetermined thickness. Additional wound detail - Found by nursing on 1/23 and started on Triad paste for MASD [moisture associated skin damage]. Progressed to develop DTI with peri-wound dermatitis. Dressing treatment plan: Primary Dressing(s) - Hydrocolloid paste (triad) apply Q-shift [every shift] (3x/day) and as needed for 30 days: to non-intact. Peri Wound Treatment - Skin prep apply Q-shift (3xday) and as needed for 30 days: to intact/periwound. Plan of care reviewed and addressed. Recommendations - Upgrade offloading chair cushion: Roho cushion when OOB [out of bed].Review of R110's Medication Administration Record (MAR) and TAR dated February 2025, located under the Orders tab of the EMR and Care Plans under the Care Plans tab of the EMR did not reveal any documentation that the recommendations or changes in dressing treatment plans from the Specialty Physician Wound Evaluation & Management Summary dated 02/18/25, were implemented as ordered above. Review of R110's discharge MDS with an ARD of 02/22/25 located under the MDS tab of the EMR revealed a BIMS score of 99 which indicated R110 was unable to complete the interview and a staff assessment for mental status as moderately cognitively impaired. The assessment also showed documentation that R110 had one Stage 4 pressure ulcer, one Stage 3 pressure ulcer, and two unstageable pressure ulcers that were not present on admission. During an interview on 02/19/26 at 4:58 PM, the Wound Care Nurse (WCN) stated R110 developed pressure ulcers while admitted to the facility that were not present on admission. The WCN stated R110 required assistance of two staff for turning/repositioning while in bed.The WCN stated R110 was in a lot of pain and would yell a lot during Activities of Daily Living (ADL) care. The WCN stated that the typical protocol for residents with wounds were for ProStat, vitamin c, zinc, and talk with the dietician for supplements recommended.During an interview on 02/20/26 at 6:14 PM, Licensed Practical Nurse (LPN) 5 stated R110 didn't want to participate and just wanted to sleep a lot. LPN5 stated that R110 had an ulcer on his bottom but wound care was done during the day, so she didn't see his feet. LPN5 couldn't remember what pressure relieving interventions R110 had in place.During an interview on 02/20/26 at 7:42 PM, the Director of Nursing (DON) stated R110 developed pressure wounds during his stay. The DON stated the Registered Dietician (RD) conducts nutritional assessments and makes recommendations and sends them to us. The DON stated there should have been no reason the RD's recommendations were not implemented. Review of the facility's policy titled, Prevention of Pressure Injuries revised 04/01/20, indicated Nutrition: Establish and implement a nutrition care plan for any resident with or at risk of a pressure injury who is malnourished or at risk of malnutrition. Provide optimal hydration, nutrient, protein and calorie requirements as established by current practiceguidelines. include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. Mobility/Repositioning: Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. Monitoring: Evaluate, report and document potential changes in the skin.Review the interventions and strategies for effectiveness on an ongoing basis.

Based on observations, interviews, and facility policy, the facility failed to perform hand hygiene between contact with residents while serving lunch trays for 28 of 108 residents in the facility and failed to remove gloves and perform hand hygiene prior to carrying bagged dirty linen in the hall. This failure had the potential to spread infection between residents.Findings include:During an observation on 02/17/26 from 12:29 PM until 1:28 PM, Certified Nurse Assistant (CNA) 4, CNA18, and the Assistant Director of Nursing (ADON)1 were serving lunch trays to residents. The staff assisted residents with sanitizing hand wipes prior to eating. The three staff members were observed touching residents while assisting them to sit down, distracting them until their tray was served to prevent the resident from touching another resident's tray, or touching the resident's arm or shoulder. During observation, the three staff members did not perform hand hygiene between contact with residents. While assisting a resident with eating, CNA2 was observed to brush her hair out of her face with her hands and picked up her cell phone off the floor without performing hand hygiene. CNA4 was encouraging residents to eat and was observed giving one resident a bite to eat and then going to another resident and giving them a bite to eat without performing hand hygiene between residents. CNA18 was not observed going behind the nurse's station. The only wall sanitizer station was located near the exit doors of the secured unit, between the gate and the exit doors. During an observation on 02/17/26 at 3:00 PM, CNA18 carried plastic bag of dirty linen with a gloved hand down hall to dirty utility room. The CNA touched the gate to open it and then entered the code on the door of the soiled utility room. During an interview on 02/17/26 at 2:35 PM, CNA4 stated, I didn't sanitize my hands while passing lunch trays. I have no answer as to why I didn't sanitize my hands.During an interview on 02/17/26 at 2:40 PM, CNA2 stated I used the moist sanitizer napkin that was sitting on the tray after I brushed my hair and picked up my cell phone off the floor.During an interview on 02/17/26 at 2:54 PM, the ADON1 stated I had sanitizing wipes in my pocket, but I did not sanitize my hands between each resident. I should sanitize my hands between each resident.During an interview on 02/17/26 at 3:03 PM, CNA18 stated I went behind the nurse's station to wash my hands between each resident while passing lunch trays. CNA18 stated I would wash my hands in the resident's room after patient care if soiled, otherwise I would wash my hands behind the nursing station. During an interview on 02/20/26 at 7:42 PM, the DON stated my expectation is for staff to wash their hands before passing meal trays. Staff should hand sanitize between touching residents. Dirty linens should be bagged, and staff carry the bag using one gloved hand to the soiled utility. Staff should then wash their hands or perform hand hygiene. Staff should wash their hands before exiting resident rooms to carry dirty linen to soiled utility room. There are no hand sanitizer stations in the memory care unit. If staff do not wash their hands prior to exiting a resident's room, they could potentially carry transmitted infections throughout the unit.Review of the facility's policy titled, Handwashing/Hand Hygiene revised 10/01/23, indicated This facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. Indications for hand hygiene - Hand hygiene is indicated: immediately before touching resident; . after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; . immediately after glove removal. The use of gloves does not replace hand washing/hand hygiene.Review of the facility's policy titled, Standard Precautions dated 08/01/21, indicated . Gloves (clean, non-sterile) are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material. Gloves are worn when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact. Gloves are worn when handling or touching resident care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms. Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. After gloves are removed, wash hands immediately to avoid transfer of microorganisms to other residents or environments. Linen soiled with blood, body fluids, secretions, excretions are handled and processed in a mannerthat prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to other residents and environments.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure sufficient staffing to meet the needs of the 108 residents in the facility. Six residents (Resident (R) 46, R56, R4, R18, R59 and R110), five Certified Nursing Assistants (CNA5, CNA7, CNA8, CNA10 and CNA17) and the Staff Coordinator voiced concerns regarding sufficient staffing. The facility exhibited multiple failures related to a lack of sufficient staffing throughout the survey which has the potential to affect the residents quality of life. Findings include: 1.Review of the undated Facility Assessment provided by the facility indicated Staffing Guidelines: Our facility has created a base staffing pattern to ensure a sufficient number of qualified staff to meet the needs of our residents on a consistent basis. Our staffing pattern is further developed based on the assessed nursing care needs of our residents, acuity, and census. The base staffing pattern represents typical staffing based upon the average daily census of the facility. The facility adjusts staffing based upon multiple factors, including but not limited to, shifts in resident census, acuity, communicable disease outbreaks, and admission or discharge volume. Revisions to staffing based upon currently identified resident needs may be reflected in an increase or decrease in staffing from what is noted in the base staffing pattern. Registered Nurse (RN) = 2 on 7-3 and 3-11 shifts; Licensed Practical Nurse (LPN) = 2 on 7-3 and 3-11 shifts, 3 on 11-7 shift; CNAs = 11 on 7-3 shift, 8 on 3-11 shift, and 5 on 11-7 shift. Review of the Daily Staffing Sheets and Daily Nursing schedules provided by the facility for 01/15/25 through 02/28/25, revealed the average daily census was 80 residents and was unable to locate any shift that was fully staffed per the Facility Assessment – staffing guidelines 2.During an interview on 02/17/26 at 2:30 PM, R56 stated I haven't had a shower in weeks, I ask for a shower and the CNAs tell me they don't have time, they're too busy. They keep changing my shower day, then tell me I have to wait. I was supposed to get a shower this morning. They said they will get to me in the morning. Follow-up interview on 02/18/26 at 10:00AM, R56 stated, I didn't get my shower again. They said it wasn't my shower day. They have it all mixed up. 3. During an observation on 02/17/26 at 2:45 PM, R46's hair appeared oily. R46's sheet and blanket had pieces of sloppy joe meat on them. During an interview on 02/17/26 at 3:27PM, CNA7 was asked if R46 should have been left with food on her blanket following lunch. CNA7 stated, I was busy. I had to make rounds. (Refer to F677) 4.During an interview on 02/17/26 at 10:53 AM, R4 was asked if she felt there was sufficient staff to meet her needs. R4 stated, There are not enough staff working on the 3:00 PM to 11:00 PM shift and at times I feel like I am all alone here as my call light does not get answered. Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an assessment reference date (ARD) of 12/09/25 revealed R4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 was cognitively intact. 5. During an interview on 02/17/26 at 11:17 AM, R18 stated, I think nothing happens here in a timely manner. I have to wait 45 minutes to an hour for assistance. You push the light and push the light, and no one comes. Review of the admission MDS located in the MDS tab of the EMR with an ARD of 12/24/25 revealed R18 had a BIMS score of 10 out of 15 which indicated R18 was moderately impaired in cognition. 6.During an interview on 02/17/26 at 9:56 AM, R59 stated, No, there are not enough staff, especially on the 3:00 PM to 11:00 PM shift. At times you have to wait more than 30 minutes. There are a lot of staff who call off work. Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 11/14/25 revealed R59 had a BIMS score of 15 out of 15 which indicated R59 was cognitive. 7. During an interview on 02/19/26 at 9:01 AM, CNA10 stated, We are short-staffed all the time. There are a lot of people who call off work. 8.During an interview on 02/19/26 at 9:05 AM, CNA5 stated, Staffing is the biggest issue right now. There are a lot of call offs. I picked up this shift today. 9. During an interview on 02/19/26 at 9:10 AM, the Staff Coordinator (SC) stated, I have been in the role since January 2026. We are working on the call outs. I know we need more staff. We do not use agency staff, and we used to have care assistants who would ensure water was passed to the residents. 10. During an interview on 02/20/26 at 11:56 AM, CNA7 stated, No, there is not enough staff. I have more residents than I can care for in a day. 11. During an interview on 02/20/26 at 6:33 PM, CNA17 stated I don't feel we have enough staff. Sometimes we have to help out the other units. We aren't able to get our charting done because we are providing care for the residents. 12. During an interview on 02/20/2026 at 6:47 PM, CNA8 stated We are usually short aides on Fridays and weekends. There's just not enough staff, and there are issues with staff calling off. When we are short staffed, we have a hard time completing our tasks. With only two aides on the unit, we are only able to give bed baths and not showers because of safety concerns. 13. During an interview on 02/20/26 at 7:42 PM, the Director of Nursing (DON) stated There are staffing concerns with not enough aides. We've always had issues with staffing. Follow-up interview on 02/20/26 at 5:15 PM the DON stated, The management team rounds every morning, and we address issues and will pitch in and help, however, we live in an area that is hard to recruit staff as we are fairly rural, and we have other competitors in town for staff.

Based on observations, interviews, record review, and review of the facility policy, the facility failed to ensure activities of daily living were provided for four residents (Residents (R)4, R18, R56, and R59) in a total sample of 32. The facility failed to provide showers per the shower schedule and resident preference for R4, R18, R56, and R59. This failure placed residents at risk for skin breakdown and a diminished quality of life.Findings include: 1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R4 was admitted to the facility on [DATE] with a diagnosis of a stroke. Review of the significant change assessment Minimum Data Set (MDS) located in the MDS tab of the EMR with an assessment reference date (ARD) of 12/09/25 revealed R4 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated R4 was cognitively intact and was dependent on staff for bathing. Review of the 04/12/21 Care Plan Report located in the Care Plan tab of the EMR revealed, R4 has the potential for health and safety concerns related to ADL [Activities of Daily Living] needs and mobility status. CVA [stroke] with left side paralysis. Interventions indicated, Assist R4 with bathing as needed. Review of a Grievance log provided by the Administrator revealed R4 had made a care concern on 10/06/25 which indicated, Resident reported she can't remember when she last had a shower. Mondays are her shower day, and her hair is to be washed on Mondays in the shower. R4 confirmed that she didn't have a shower on 09/29/25 and 10/06/25 nor was she offered a shower. The DON [Director of Nursing] did an in-service with staff about shower schedules. During an interview on 02/17/26 at 10:52 AM, R4 stated, Monday was my shower day but I did not get one. My hair was washed last Thursday because I yelled and screamed about it. I have to yell to get a shower. Review of the Tasks located in the EMR revealed R4 was to receive two showers per week on Monday and Thursday day shift. The documentation revealed R4 had only one shower which was on 02/16/26 in the last 30 days. 2. Review of the admission Record located in the Profile tab of the EMR revealed R18 was admitted to the facility on [DATE] with diagnoses that included seizures diabetes, and an irregular heart rhythm. Review of the admission MDS located in the MDS tab of the EMR with an ARD of 12/24/25 revealed that R18 had a BIMS score of 10 out of 15 which indicated R18 was moderately impaired in cognition and required moderate assistance with bathing. Review of the 12/24/25 Care Plan Report located in the Care Plan tab of the EMR revealed, R18 had the potential for health and safety concerns related to ADL needs and mobility status. Intervention indicated, Assist R18 with bathing as needed. During an interview on 02/17/26 at 11:17 AM, R18 stated, I have had at the most two showers since I have been here. Review of the Tasks tab located in EMR revealed that R18 was to receive two showers per week on Wednesday and Saturdays during the day shift. The documentation revealed that in the last 30 days R18 had a shower on 01/21/26, The 01/28/26 shower was marked no. On Saturdays, R18 had a shower on 1/24/26 and on 01/31/26 it was documented as refused. There has been no other shower documentation since 01/31/26. 3. Review of the admission Record located in the Profile tab of the EMR revealed R59 was admitted to the facility on [DATE] with diagnoses of cerebral palsy (a neurological disorder identified at birth) and paraplegia (paralysis of two limbs.) Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 11/14/25 revealed R59 had a BIMS score of 15 out of 15 which indicated R59 was cognitively intact and required substantial assistance with bathing. Review of the 08/12/26 Care Plan Report located in the Care Plan tab of the EMR revealed, Bathing-[R59] is totally dependent on the staff. Interventions indicated, Tub or Shower two times weekly. During an interview on 02/17/26 at 10:20 AM, R59 stated, I am supposed to get a shower two times a week on the afternoon shift. It's been over a month since I had a shower. Review of the Tasks tab located in the EMR revealed R59 was to receive two showers weekly on Tuesday and Friday on the afternoon shift. Documentation revealed on 02/10/26 the resident refused, however, there was no further documentation of R59 having had a shower. During an interview on 02/19/26 at 9:01 AM, Certified Nurse Aide (CNA)10 stated, We can't always get to the showers as we are short staffed all the time. During an interview on 02/20/26 at 5:15 PM, the DON acknowledged that staff are to provide the residents with showers per their shower schedule. 4. Review of R56's admission record located under the Profile tab of the EMR revealed R56 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, osteoarthritis and Type 2 Diabetes. Review of R56's quarterly MDS with an ARD of 12/19/25 and located under the MDS tab, reveal R56 has a BIMS score of 15 out of 15 which indicated R56 was cognitively intact and moderate assistance with bathing. Review of R56's undated Care Plan located in the EMR under the Care Plan tab revealed Assist resident with bathing as needed During an interview on 02/17/26 at 2:30 PM, R56 stated I haven't had a shower in weeks, I ask for a shower and the CNA tell me they don't have time, they're too busy. They keep changing my shower day, then tell me I have to wait. I was supposed to get a shower this morning. They stated that they would get to me in the morning. Interview on 02/18/26 at 10:00AM, R56 stated, I didn't get my shower again. They said it wasn't my shower day. They have it all mixed up. Review of the facility's policy titled, Activities of Daily Living, Daily Life Functions, dated 04/06/05 revealed, .To assist resident (sic) in achieving maximum function .To provide assistance to residents as necessary .To improve the quality of life . 5. The facility failed to ensure sufficient staffing to meet the needs of the 108 residents. (Refer to F725 Sufficient Staffing for additional information.)

Based on record review, interviews, and facility policy review, the facility failed to refer two residents (Resident (R)8 and R97) in a sample of 31 for Level II Pre admission Screening and Resident Review (PASARR) evaluation and determination after each was identified with a new diagnosis of mental illness. This failure created the potential for a lack of specialized and rehabilitation services to benefit the residents.Findings include:1.Review of R8's admission Record located under the profile tab of the electronic medical record (EMR) indicated an admission date of 12/11/19 with diagnoses of dementia (added 10/16/23), cognitive communication deficit (added 10/16/23), bipolar disease (added 03/21/25), major depressive disorder (added 10/16/23), and schizophrenia (added 10/16/23).Review of R8's Screening for Mental Illness, Mental Retardation/Intellectual Disability, or Related Conditions provided by the facility with a screening date of 12/06/19 indicated R8 did not have a current serious mental illness.Review of R8's quarterly Minimum Data Set (MDS) found under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/15/25 indicated diagnoses of bipolar disorder, psychotic disorder, and schizophrenia.2.Review of R97's admission Record located under the profile tab of the EMR indicated an admission date of 04/05/23 with diagnoses of depression, anxiety disorder, and nightmare disorder.Review of R97's Screening for Mental Illness, Mental Retardation/Intellectual Disability, or Related Conditions provided by the facility with a screening date of 02/28/23 indicated R97 did not have a current serious mental illness. Review of R97's MDS found under the MDS tab of the EMR with an ARD of 12/05/25 indicated a diagnosis of post-traumatic stress disorder (PTSD).During an interview on 02/18/26 at 3:43PM the Regional Director of Social Work (RDSW) stated that documentation could not be found for R8 and R97 to support a referral was made for PASARR Level II.During an interview on 02/20/26 at 6:10PM the Regional Director of Operations (RDO) stated that going forward an audit would be conducted for all new diagnoses and ensure that residents with diagnoses that meet criteria would be referred for appropriate PASARR review.Review of the facility's admission Criteria policy dated 2001 indicated that 8. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for MD, ID, or RD. b. If the level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.

Based on interviews, and record review, the facility failed to electronically transmit the Minimum Data Set (MDS) assessment withing 14 days of completing the assessment for two residents (Residents (R)89 and R117) in a total sample of 32. This failure placed residents at risk of unmet health needs.Findings include:1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R89 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic kidney disease, and heart disease.Review of the quarterly MDS located in the MDS tab of the EMR with an assessment reference date (ARD) of 10/26/25 revealed that the MDS was 15 days overdue for transmission to the Center for Medicare and Medicaid Services (CMS).During an interview on 02/19/26 at 11:34 AM, the MDS Coordinator (MDSC) confirmed that the assessment was overdue for transmission to CMS.2. Review of the admission Record located in the Profile tab of the EMR revealed R117 was admitted to the facility on [DATE] with diagnoses that included pressure ulcers.Review of the admission MDS located in the MDS tab of the EMR with an ARD of 02/03/26 revealed that the MDS was nine days overdue for transmission to CMS.During an interview on 02/19/26 at 4:53 PM, the MDSC confirmed that the admission MDS was overdue for transmission to CMS.

Based on interview, record review, and review of facility policy, the facility failed to thoroughly investigate an allegation of verbal abuse for one resident (Resident (R) 59) in a total sample of 32. This failure placed residents at risk of further abuse and a diminished quality of life.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R59 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (a neurological disorder identified at birth), paraplegia (paralysis of two limbs), and malignant colon cancer.Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an assessment reference date (ARD) of 11/14/25 revealed R59 had a Brief Interview of Mental Status (BIMS) of 15 out of 15 which indicated R59 was cognitive and was always incontinent of bowel.Review of the 05/16/25 Administrator Statement provided by the Administrator revealed, . On May 11, 2025, DON [director of nursing] received a report from a CNA [certified nurse aide] that R59 told her that another CNA, [CNA1] had used profanity while providing care for R59 on Friday, May 10, 2025 .R59 said that as he was being given a shower, he had a bowel movement in [sic] the floor while sitting on the shower chair. R59 reports that CNA1 became upset with him and called him an 'A-hole.' The team member [CNA1] was not scheduled the day report was received. Management staff has been unable to reach the team member for a statement after multiple attempts .The team member [CNA1] has been removed from the schedule and terminated .The facility investigation has been unable to determine if there was indeed profanity used by the team member [CNA1] .Residents on the same hall were interviewed with no complaints of abuse or mistreatment by any staff member .During an interview on 02/18/26 at 9:47 AM, the Administrator was asked if she had any documentation to show that she had spoken to other residents on the unit and if they had experienced any verbal abuse by CNA1 and what their response was. The Administrator stated, No. In our previous ownership we did not do this. We just talked with the residents, but I did mention this in the Administrator Statement. The Administrator was asked if she had spoken to other staff members regarding the allegation of verbal abuse and if she had documented these conversations. The Administrator stated, No.During a follow-up interview on 02/19/26 at 4:30 PM, the Administrator was asked who was the unknown CNA that reported the allegation and if she/he was interviewed for your investigation. The Administrator stated, I don't know who that was.Review of the facility's policy titled, Resident Abuse Policy and Procedure, dated 10/31/22 revealed, .All alleged violations involving mistreatment, neglect, exploitation or abuse, including injuries of an unknown source and misappropriation of resident property, must be reported immediately to the Administrator/designee of the facility. The facility must complete a thorough written investigation and must prevent further potential abuse while the investigation is in process .

Based on interview, record review, and facility policy review, the facility failed to ensure residents were free from verbal abuse by staff for one resident (Resident (R) 59) in a total sample of 32. This failure placed residents at risk of being demeaned and lower self-esteem.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R59 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (a neurological disorder identified at birth), paraplegia (paralysis of two limbs), and malignant colon cancer.Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an assessment reference date (ARD) of 11/14/25 revealed R59 had a Brief Interview of Mental Status (BIMS) of 15 out of 15 which indicated R59 was cognitive and was always incontinent of bowel.Review of the 05/16/25 Administrator Statement provided by the Administrator revealed, . On May 11, 2025, DON [director of nursing] received a report from a CNA [certified nurse aide] that R59 told her that another CNA, [CNA1] had used profanity while providing care for R59 on Friday, May 10, 2025 .R59 said that as he was being given a shower, he had a bowel movement in [sic] the floor while sitting on the shower chair. R59 reports the CNA became upset with him and called him an 'A-hole.' The team member [CNA1] was not scheduled the day report was received. Management staff has been unable to reach the team member for a statement after multiple attempts .The team member [CNA1] has been removed from the schedule and terminated .During an interview on 02/17/26 at 9:41 AM, R59 stated, CNA1 wheeled me into the shower, I had to have a bowel movement, and it went all over the floor. CNA1 called me an 'A-hole' which made me feel terrible, but when you have to go you have to go. CNA1 did clean it up and I went and told the head nurse [DON], and she told me that CNA1 will never bother me again. During the interview R31, who was R59's roommate, was in the room at the time and confirmed that CNA1 had verbally abused R59.During an interview on 02/18/26 at 09:47 AM, the Administrator stated, CNA1 was only an employee for a short time. When I spoke to R31 she stated that though she had not been verbally abused by CNA1 she confirmed that CNA1 had verbally abused R59. The Administrator was asked if she had documented this conversation. The Administrator stated, No. We just talked with residents and only documented that we did this only in the Administrator Statement.Review of the facility's policy titled, Resident Abuse Policy and Procedure, dated 10/31/22. revealed, .It is the policy of this facility to ensure the resident will be free from abuse, neglect, misappropriation of resident property, and exploitation .

Based on interview and record review, the facility failed to provide information and choices to one of one resident (Resident (R)13) family member (FM) that R13 was receiving psychiatric visits. This deficient practice has the potential to affect the resident's quality of life.Findings included.Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R13 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, atrial fibrillation and dementia.Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an assessment reference date (ARD) of 10/31/25 revealed a Brief Interview of Mental Status (BIMS) score of 99 which indicated R13 was severely impaired in cognition.Review of the psychiatric visits dated 01/27/26 and the 02/13/26 provided by the facility by the psychiatric Nurse Practitioner (NP) made no mention of consultation with FM13.Review of the Progress Notes in the EMR under the Progress Notes tab indicated no documentation that FM13 was informed of the risks and benefits or made aware that psychiatric visits were being made bi-weekly. During an interview on 02/19/26 at 10:13AM, FM13 was asked if she had been consulted about R13 having psychiatric visits. She stated, No, and we would not have agreed to that. [R13] has been completely uncommunicative for months. She [R13] babbles at times but rarely opens her eyes anymore.During an interview on 02/19/26 at 11:00 AM, the Director of Nursing (DON) was asked if FM13 should have been made aware of R13 seeing a psychiatrist. The DON stated, Yes, they should have been notified. During an interview on 02/19/26 at 11:30 AM, the Administrator was asked if FM13 should have been made aware of R13's psychiatric visits. The Administrator stated, Yes, they should have been notified. The Administrator stated, We have engaged with a mental health group, so they had more access to psychiatric treatment. They were pretty much given blanket access to see anyone on any mood-altering medications. Since [R13] was on Lorazepam the psychiatric NP saw her since [R13's name] pulled over on a list of residents on mood-altering drugs.

Based on observations, interviews, and record review, the facility failed to ensure the Fall Care Plan was updated to include interventions related to a fractured wrist for one resident (Resident (R) 20) in a total sample of 32. This failure placed residents at risk for increased complications.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R20 was admitted to the facility diabetes and congestive heart failure.Review of the annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an assessment reference date (ARD) of 12/06/25 revealed R89 had a Brief Interview of Mental Status (BIMS) score of 11 out of 15 which indicated R89 was moderately impaired in cognition, had a fall history and had one non-injury fall since the previous MDS.Review of the Nursing Note located in the Notes tab of the EMR revealed, .On 01/06/26 resident attempting to transfer from wheelchair to bed, lost her balance resident found lying on floor yelling out saying my wrist hurts. Not able to do complete ROM [range of motion] due to extreme pain to right arm. MD notified gave an order to send to ER [emergency room] for evaluation and treatment .Review of an 01/06/26 Nursing Note located in the Notes tab of the EMR revealed, .Resident returned to facility with medical transport after being seen post fall .X-ray of right elbow and right wrist. DX [diagnosis] closed fracture of right wrist .Resident is to leave splint in place until she sees ortho .Review of the Fall Care Plan located in the Care Plan tab of the EMR revealed, R20 has the potential for pain + Left femur fracture (history) + Restless leg syndrome + 1/6/26 Fracture right wrist. Interventions included: Encourage R20 to tell nurse when pain interventions are not being effective, if unable monitor for non-verbal indicators of pain .Provide therapy consult as ordered by a physician .Report to physician when medications or other interventions are not being effective .Sling to right arm as ordered .Administer pain meds as ordered .Follow up Ortho appointment as ordered .During an observation and interview on 02/17/26 at 10:46 AM, R20 stated that she broke her wrist recently. A wrist splint with Velcro ties were observed on her right wrist, however, the Velcro ties were not connected. R20 was asked why the Velcro ties were connected. R20 was unable to answer the question. During an observation on 02/17/26 at 2:51 PM, R20 had the right wrist splint on but the Velcro ties were connected. R20 was observed removing the splint and laying it on her bed. R20 stated, I remove the splint and put it back on when I want to.During an interview on 02/18/26 at 2:38 PM, Registered Nurse (RN) 1, confirmed that R20 was independent in applying and removing her wrist brace.During an interview on 02/20/26 at 5:15 PM, the Director of Nursing (DON) acknowledged that the care plan should have been updated to include R20's independent applying and removing of the right wrist brace.

Based on observations, interviews, and record review, the facility failed to provide care and services for one resident (Resident (R) 20) in a total sample of 31. The facility failed to monitor a fractured right wrist for increased swelling and bruising for R20. This failure placed the residents at risk of medical complications.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R20 was readmitted to the facility on [DATE] with a diagnosis of a right closed fractured wrist.Review of the significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an assessment reference date (ARD) of 02/12/26 revealed R20 had a Brief Interview of Mental Status (BIMS) score of nine out of 15 which indicated R20 was moderately impaired in cognition, had a fall history, and one major injury fall since the previous MDS.Review of a Nursing Note located in the Notes tab of the EMR revealed, On 01/06/26 resident attempting to transfer from wheelchair to bed, lost her balance resident found lying on floor yelling out saying my wrist hurts. Not able to do complete ROM [range of motion] due to extreme pain to right arm. MD notified gave an order to send to ER for evaluation and treatment. EMT [emergency medical technician] splinted right arm before transferring to stretcher.Review of a Nursing Note located in the Notes tab of the EMR revealed, On 01/06/26 resident returned to facility with medical transport after being seen post fall. Noted test-CT [computerized tomography-a medical imaging test], X-ray of right elbow and right wrist. Dx [diagnosis] closed fracture of right wrist. Resident is to follow up with MD and orthopedics .Resident is to leave splint in place until she sees ortho.During an interview on 02/17/26 at 10:46 AM, R20 confirmed that she broke her wrist. An observation revealed that a soft splint was on her right wrist, however, the Velcro straps were not attached. R20 had removed the splint independently. The wrist showed bruising and swelling on the back side of the wrist/forearm. R20 was asked if she was in pain. R20 stated, No. There were no signs or symptoms of non-verbal cues of pain observed.A review of the January 2025 Medication Administration Record and the Treatment Administration Record both located in the Orders tab of the EMR revealed no documentation that nursing staff were monitoring R20's right wrist for increased or decreased swelling and bruising.During an interview on 02/18/26 at 2:38 PM, Registered Nurse (RN)1 confirmed that there was no monitoring of the wrist or brace removal by R20 in the EMR.During an interview on 02/18/26 at 2:54 PM, the Director of Nursing (DON) was asked what her expectation was regarding monitoring of the wrist fracture. The DON stated, It should have been monitored.

Based on observation, record review, and interview, the facility failed to ensure an active physician order for oxygen administration for one resident (Resident (R) 9) reviewed for oxygen administration of 31sample residents. This failure had the potential for the residents to receive increased oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen).Findings include:Review of R9's admission Record located in the Profile tab of the electronic medical record (EMR) revealed admitted on [DATE] with diagnosis chronic obstructive pulmonary disease, end stage renal disease and Type 2 Diabetes. Review of R9's significant change Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/12/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact. Review of R9's Care Plan located under the Care Plan tab of the EMR dated 10/06/20 and revised on 01/08/26 revealed the resident was not care planned for oxygen. Review of R9's Physician Orders located under the Orders tab in the EMR, dated 01/08/26, revealed no current order for oxygen. During observations 02/17/26, at 1:15PM and on 02/18/26 at 8:35 AM the resident was lying in bed using a nasal cannula and the oxygen concentrator was set at four liters per minute (LPM). During an interview on 02/20/26 at 2:00PM Licensed Practical Nurse (LPN)1 confirmed R9 received oxygen and that a resident should not receive oxygen without a physician order.During an interview on 02/20/26 at 2:20PM, Registered Nurse (RN)1 confirmed R9 received oxygen and that a resident should not receive oxygen without a physician order. During an interview on 02/20/26 at 5:22 PM, the Director of Nursing (DON) stated that a resident should not receive oxygen without a physician order. That R9 had been in and out of the hospital and it must have been overlooked.No oxygen policy was provided by the facility.

Based on interview, record review, and facility policy review, the facility failed to provide documentation, when declined, that indicated that the resident and/or representative was provided education of the risks/benefits of the influenza and pneumonia vaccines for three of five residents (Residents (R)2, R19, and R20) reviewed for influenza and pneumonia vaccinations in a total sample of 31. This failure placed the residents or representatives of not knowing what the risk/benefits were of the influenza and pneumococcal vaccines before declining the vaccine.Findings included:1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnosis that included Alzheimer's disease and dementia.Review of the annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an assessment reference date (ARD) of 11/08/25 revealed R2 had a Brief Interview of Mental Status (BIMS) score of 99 which indicated R2 was severely impaired in cognition and was offered and declined the influenza vaccine.2. Review of the admission Record located in the Profile tab of the EMR revealed R19 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and major depressive disorder.Review of quarterly MDS located in the MDS tab of the EMR with an ARD of 01/04/26 revealed R19 had a BIMS score of 15 out of 15 which indicated R19 was cognitive and offered and declined both the influenza and pneumococcal vaccines.3. Review of the admission Record located in the Profile tab of the EMR revealed R20 was admitted to the facility on [DATE] with diagnoses that included diabetes and heart failure.Review of the annual MDS located in the MDS tab of the EMR with an ARD of 12/06/25 revealed R20 had a BIMS score of 10 out of 15 which indicated R20 was moderately impaired in cognition and was offered and refused the influenza and pneumococcal vaccinations.During an interview on 02/10/26 at 12:44 PM, the Infection Preventionist (IP) stated, I was not aware that there needed to documentation when a resident or representative declines the vaccines.Review of the facility's policy titled, Pneumococcal Vaccine and Influenza Vaccine, dated August 2025 revealed, .The resident (or representative) has the right to refuse vaccines. If refused, the date of and stated reason for the refusal of the vaccine are documented in the resident's medical record .

Based on Staff interview and facility documentation review, the facility staff failed to complete a skilled nursing facility (SNF) Advanced Beneficiary Notice (ABN) for two residents, (Resident #32, and #53), in a sample of 3 ABN resident reviews. 1. For Resident #32, no SNF/ABN was signed prior to discharge from skilled services. 2. For Resident #53, no SNF/ABN was signed prior to discharge from skilled services. The findings included: 1. Resident #32 was initially admitted to the skilled nursing facility on 2-5-2020. The last Medicare covered day for the Resident's most recent stay was 9-3-2021. The Resident's benefit days had not been exhausted, however, the Resident had reached a plateau, and the facility felt that she no longer required skilled nursing care and that level of care was discontinued without the Resident signing a notice of the change. 2. Resident #53 was initially admitted to the skilled nursing facility on 6-25-2021. The last Medicare covered day for the Resident's most recent stay was 1-30-2022. The Resident's benefit days had not been exhausted, however, the Resident had reached a plateau, and the facility felt that he no longer required skilled nursing care and that level of care was discontinued without the Resident signing a notice of the change. On 2-3-2022, a review of the facility's ABN/NOMNC forms issued during the last six months was conducted. Three discharged residents were chosen for review. Of the 3 chosen, two residents, (Resident #32 and # 53), did not have a signed SNF/ABN available. The facility social worker was interviewed and was asked why the Residents were not issued these documents for their signatures, and she stated I just verbally told them when their skilled time was ending. On 2-3-2022, at 4:00 p.m. the Facility Administrator was informed that the two documents for Residents #32, and #53 were not completed. The facility Administrator provided no further information.

Based on observation, staff interview and facility documentation review, the facility staff failed to properly store narcotic medications in one of two medication rooms. The findings included: On [DATE] at 11:58 AM, a review of the medication storage located in the Chesapeake unit medication room, was conducted with LPN B present. During this review, it was observed that the medication room was located behind the nursing station and was an open room. The room had a pocket door which when opened retracted into the wall. This door was observed open throughout the survey conducted [DATE]-[DATE]. LPN B unlocked the medication refrigerator which revealed a black box attached to the fridge with a silver colored, cord/wire. The black box was noted to be unlocked and able to be opened without the use of a key/combination or other mechanism. The box contained the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)]/[MEDICATION(S)] (a benzodiazepine medication), 2 mg/ml injection. Three, 1 ml, multi-dose vials were noted. 2. [MEDICATION(S)] injection 2mg/ml. Ten (10), 1 ml multi-dose vial(s), all of which were unopened, was noted. LPN B confirmed that the Resident these belonged to expired about 10 days ago. 3. [MEDICATION(S)] concentrate 2mg/ml. One unopened bottle containing 30 ml(s) was noted. 4. [MEDICATION(S)] oral concentrate 2mg/ml. One bottle containing 30 ml(s) was noted. LPN B confirmed the above contents and counts. LPN B confirmed that the box containing these medications should have been locked to create a double lock since they are narcotic medications. LPN B indicated the double lock is for safety and to restrict access. On [DATE] at 12:20 PM, LPN D was interviewed. LPN D said, Narcotics are kept under double lock and counted each shift. When asked why the double lock is necessary, LPN D said, To prevent someone from taking it. On [DATE], a review of the facility policy titled, Medication Disposition Policy was conducted. This policy read, Double lock can mean a locked cabinet in a locked room or a double locked cabinet .Controlled substances should be secured under double lock at all times until disposition is complete . On [DATE], a review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles was conducted. This policy read, .Controlled Substances Storage: Facility should ensure that Schedule II-V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by facility. After receiving controlled substances and adding to inventory, facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with applicable law). Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security. On [DATE] at approximately 5:30 PM, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed for 1 resident (Resident #30) in the survey sample of 36 residents, to ensure that the Registered Dietician's recommendation was submitted to the attending physician. The findings include: The facility staff failed to ensure that the dietary recommendation dated 12/14/21, to reduce Boost Oral liquid from twice daily to once daily, was submitted to the physician. Resident #30's diet wasn't changed until the 2/2/22. On 2/1/22 at approximately 1:50 P.M., an observation of Resident #30 was conducted. Resident #30 was clean, dressed appropriately, and well-groomed. On 2/1/22, a review was conducted of Resident #30's clinical record, revealing a Nutritional Assessment by a Registered Dietician dated 12/14/21. According to the report, Resident #30 had reached his optimal weight range. An excerpt read, Recommend decrease Boost supplements to once/day with goal of maintaining current weight. Resident #30 had not yet had a significant weight gain since December, 2021. The dietary order for January, 2022, and February, 2022 were reviewed. The order had not been changed prior to the survey. The clinical record did not contain documentation that the physician had reviewed the recommendation, or changed the order. On 2/2/22 at approximately 9:15 A.M., an interview was conducted with the Director of Nursing (Employee B). When asked about the importance of insuring that the physician reviewed the dietary recommendation, she stated, He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . If he gains weight it puts him in an overweight bracket. We don't want that. The Assistant Director of Nursing (ADON Employee P) was present. The ADON stated that she did not have documentation that she'd submitted the recommendation to the physician. She further stated, He must have given his review documentation to another nurse. The DON stated that it was the ADON's responsibility to ensure receipt and follow-up from the physician. The facility did not submit the requested policy on nutritional services. No further information was received.

Based on observation, staff interviews, and facility documentation review, the facility staff failed to maintain a safe and homelike environment for 2 Residents (Residents #6 and #31), in a survey sample of 38 Residents. For Residents #6 and #31, the facility staff failed to repair a sink cabinet located within the Resident's room, to maintain a safe and homelike environment. The findings included: On 02/01/22 at 04:21 PM, an observation was made in the room of Residents #6 and #31, which revealed the sink cabinet side support, dislodged from underneath the sink and pulled away on the side. On 2/3/22 at 9:01 AM, Resident #31 was observed ambulating in the room. The sink was still noted to be in need of repair as noted above. On 2/3/22 at approximately 9:05 AM, CNA G accompanied Surveyor C to the room of Residents #6 and #31. CNA G reported that she was unaware of how the long the sink wall had been dislodged from under the sink. CNA G said, I never noticed it. On 2/3/22 at 9:13 AM, RN D/the Assistant Director of Nursing (ADON) entered the room of Residents #6 and #31. RN D said I wasn't aware of the sink issue. On 2/3/22 at 9:22 AM, Employee P/the Maintenance Director came to the room of Residents #6 and #31. The Maintenance Director reported he has two maintenance work order books, one at each nursing station that staff use to communicate maintenance repairs needed. The maintenance director looked at the sink and said he wasn't aware of it being broken previously and acknowledged he needed to shoot some screws in it. On 2/3/22 at 9:25 AM, the maintenance director showed Surveyor C the maintenance work order book at the nursing station and said he checks the book each morning to see what repairs are needed. Review of the maintenance book revealed an entry made on 2/3/22, by RN D for the sink needing repair. On 2/3/22 at 9:28 AM, Surveyor C observed the maintenance work order book which had work orders dating 11/5/21-2/3/22. This review revealed that prior to the surveyor bringing the sink to the attention of the staff, no entry had been made into the maintenance work order book. On 2/3/22 at 5:20 PM, a telephone interview was conducted with Employee P, the maintenance director. The maintenance director confirmed that he doesn't conduct rounds, checking each Resident room for needed repairs. He relies on the staff to indicate repairs needed in his work order book. Employee P said, I only know if they write it in the book. On 2/2/22, a request for the facility policy regarding maintenance work orders/repairs was requested. This policy was not received prior to the end of survey. On the afternoon of 2/3/22, the survey team was provided with a 7 page document that read, Maintenance Request Process, New Initiative beginning 2/1/22. This document outlined how staff would submit maintenance repairs electronically. On 2/3/22 at approximately 5:30 PM, Surveyor C met with the facility Administrator and Director of Nursing and discussed the above findings. No further information was provided prior to the end of survey.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to develop and implement an accurate and complete comprehensive care plan for 1 Resident (#46) in a survey sample of 38 Residents. The findings included: For Resident # 46 the facility failed to include right hand contractures and the wearing of a soft splint on the care plan. On 2/1/21 at approximately 2:30 PM an observation was made of Resident # 46 lying in bed, asleep, her right hand was visibly contracted, and a splint fastened with the Velcro strap around the bed rail at the head of the bed and not on the resident. On 2/2/22 at approximately 2:30 PM another observation was made of Resident #46 who was in bed resting eyes closed. The splint was not on the resident but instead was fastened around the rail at the head of the bed. A review of the MAR and TAR revealed no set time for donning and doffing the splint. A review of the notes written by Occupational Therapy revealed the following note written by Employee L (Occupational Therapy Assistant) Pt will be fitted for appropriate resting hand splint for R UE and tolerate for x 6-8 hours daily in order to prevent further contractures without s/s of discomfort and skin breakdown. [Name Redacted] (Occupational Therapy Assistant) 1/26/2022 3:11 PM (Next to the above note was the box for Goal Completed was checked.) A review of Resident #46's Care plan revealed that there was no mention of the right hand contracture or the use of a soft splint. On 2/2/22 an interview with RN B was conducted and she stated that the nurses were not responsible for putting Resident # 46's splint on and taking it off. She said Physical therapy handles her splinting. On 2/3/22 at approximately 3:00 PM the DON was interviewed and she stated that Physical therapy's process to convey the donning and doffing of splints is that they tell the nurse who is assigned to the Resident and then the nurse puts the orders into the computer and adds it to the care plan. When asked if they would expect to see contractures and splinting on the care plan she agreed that it should be addressed on the Comprehensive Care Plan for nursing once PT/OT has informed instructed nursing on the hours of use and proper donning and doffing of the splint. On 2/3/22 at approximately 3:30 PM the DON provided a progress note from the Employee K that read: OT rehab has goal for pt. to tolerate 6-8 hours wearing appropriate resting R hand splint to decr. Risk of further contracture and to maintain skin integrity. Therapy is trialing different approaches such as gentle prolonged stretching, soft positioning device and built up splinting device to incr. tolerance and ROM for transition to resting hand splint as appropriate and as tolerated by pt. Pt tolerates minimal ROM and incr. tolerance / time wearing positioning device. Therapy will fit for appropriate splint as tolerated by pt. and communicate with nursing prior to establishing a care plan for wearing schedule and proper donning / doffing with skin checks.[Name redacted] OT assistant. 2/3/22 3:28 PM. On 2/3/22 at approximately 4:00 PM an interview was conducted with Employee K who stated that she wrote the progress note at 3:28 PM. She stated that Resident #46 was still working to meet her goals with splint wearing and that she could be non-compliant at times. She was asked to read Employee L's note from 1/26/22 and she stated that she was not aware the Resident had met her goal with the splint. She called Employee L and placed her on speaker phone and Employee L stated that the Resident had met the goals with regards to splint wearing for skin integrity and decreasing the risk of further contractions. She stated that she had told this to the DON the previous week and the DON was supposed to Care Plan it. On 2/3/22 during the end of day meeting the DON stated she did not recall OT telling her that Resident #46 had met her goals and that nursing should now take over donning and doffing of the splint. On 2/3/22 during the end of day meeting the Administrator was made aware of the concerns an no further information was provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to implement measures to prevent further decrease range of motion for 1 Resident (#46) in a survey sample of 38 Residents. The findings included: For Resident # 46 the facility failed to implement the donning and doffing of soft splint by nursing staff. On 2/1/21 at approximately 2:30 PM an observation was made of Resident # 46 lying in bed, asleep, her right hand was visibly contracted, and a splint fastened with the Velcro strap around the bed rail at the head of the bed and not on the resident. On 2/2/22 at approximately 2:30 PM another observation was made of Resident #46 who was in bed resting eyes closed. The splint was not on the resident but instead was fastened around the rail at the head of the bed. A review of the MAR and TAR revealed no set time for donning and doffing the splint. A review of the notes written by Occupational Therapy revealed the following note written by Employee L (Occupational Therapy Assistant) Pt will be fitted for appropriate resting hand splint for R UE [Right Upper Extremity] and tolerate for x 6-8 hours daily in order to prevent further contractures without s/s of discomfort and skin breakdown. [Name Redacted] (Occupational Therapy Assistant) 1/26/2022 3:11 PM (Next to the above note was the box for Goal Completed was checked.) A review of Resident #46's Care plan revealed that there was no mention of the right hand contracture or the use of a soft splint. On 2/2/22 an interview with RN B was conducted and she stated that the nurses were not responsible for putting Resident # 46's splint on and taking it off. She said Physical therapy handles her splinting. On 2/3/22 at approximately 4:00 PM an interview was conducted with Employee L who stated that the Resident had met the goals with regards to splint wearing for skin integrity and decreasing the risk of further contractions. She stated that she had told this to the DON the previous week and the DON was supposed to Care Plan it. On 2/3/22 during the end of day meeting the DON stated she did not recall OT telling her that Resident #46 had met her goals and that nursing should now take over donning and doffing of the splint. On 2/3/22 during the end of day meeting the Administrator was made aware of the concerns an no further information was provided.

Based on observations, staff interviews, and facility documentation review, the facility staff failed to maintain one mechanical lift in a safe operational manner, in a sample of 4 mechanical lifts observed. The facility staff failed to ensure the sling bar safety latches were present on one mechanical lift. The findings included: On 02/01/22 at 02:31 PM, Surveyor C observed the mechanical lift (Viking lift) in the storage room, plugged in and charging. The lift bar was observed to be missing the clips on both side of the bar, which the lift sling attach to. A sticker was observed on the lift that indicated an electrical safety test/inspection date of 4/28/21. Two other lifts were observed in the storage room also available for facility staff to use. All lifts within the facility were observed and the Viking lift noted above was the only one noted to not have the safety clips. On 2/2/22 at 5:16 PM, the mechanical Viking lift was observed in the storage room, plugged in and charging, available for use. The safety clips were not in place on the lift bar/they were missing. Two other mechanical lifts were observed in the storage room also available for staff use. On 2/3/22 at 8:58 AM, the mechanical Viking lift was observed in the storage room, plugged in and charging available for use. The safety clips were not in place on the lift bar. Other mechanical lifts were also in the storage room available for staff use. On 2/3/22 at 9:25 AM, the maintenance director showed Surveyor C the maintenance work order book at the nursing station and said he checks the book each morning to see what repairs are needed. On 2/3/22 at 9:28 AM, Surveyor C observed the maintenance work order books located at both nursing stations. Maintenance work orders dating from 8/30/21-2/3/21, were reviewed. Only one entry regarding mechanical lifts was noted, which read, 10/2/21- old lift needs new battery for scale. On 2/3/22 at 9:39 AM, the maintenance director was asked if he performs any type of repairs to the mechanical lifts, preventative maintenance or safety inspections. The maintenance director/Employee P said, I don't work on them other than like if a screw comes out. He (the maintenance director) also confirmed he doesn't perform any inspection or preventative maintenance of the mechanical lifts. On 2/3/22 at 3:40 PM, an interview was conducted with CNA H. CNA H accompanied Surveyor C to the storage room where the mechanical lift was stored. CNA H confirmed that she currently has 6 Residents who require a mechanical lift. CNA H stated she does use the mechanical lift in question. When asked why the holes on the lift bar were there, CNA H said, I believe there is a metal clip that goes here. CNA H continued to state, The clip is for safety, it holds the straps inside. I've never seen the clips and I've been here 2 years. On 2/3/22 at approximately 3:55 PM, an interview was conducted with CNA F. CNA F accompanied Surveyor C to the storage room where the mechanical lifts are stored. CNA F confirmed that she has one Resident currently in her assignment that she uses a mechanical lift for. CNA F confirmed that the holes on the lift bar are For clamps that used to be here. CNA F confirmed that she hadn't seen the clips for months. When asked what the purpose of the clips are, CNA F said, To keep the sling in. CNA F confirmed during the interview that she uses the lift in question. During the 3 days of survey, the survey team did not observe the lift in question being utilized with any Residents. On 2/3/22 at approximately 4:05 PM, the Maintenance Director/Employee P and the Director of Nursing (DON) accompanied Surveyor C to the storage room where the lift was located. The DON acknowledged that she noted the hooks were missing. When asked what the purpose of the hooks are, the DON said, They hold the strap in. The DON stated they (the facility) purchased new lifts and expects staff to use the new lifts and not the one in question which is much older. When asked if she had any documentation to show that staff were told to not use the lift with the missing clips, the DON said she did not. On 2/3/22, during the interview with the DON and Maintenance director, they were asked to confirm if the lift is able to be used. The maintenance director used the remote of the lift to check and the lift was operational and available for use. Surveyor C asked how staff would know not to use the lift in question. Both the DON and Maintenance director acknowledge that they do not use a lock out/tag out system for equipment that is not to be used. The DON asked the maintenance director to remove the battery so that the lift could not be used and to put a note on it to alert staff not to use that lift. On 2/3/22 at approximately 4:10 PM, the DON was asked if the facility had any incidents in the past year involving a Resident while using the mechanical lift and she said no. On 2/3/22 at 4:18 PM, the Vice President of Nursing Services (VPNS)/Employee M was observed in the mechanical lift storage room with the DON. Surveyor C entered the room. The VPNS confirmed that the clips were missing on the lift bar and the lift should not be used. The VPNS further confirmed that the mechanical lift in question has now been removed from service and they were conducting in-services with all staff at that time to advise them to no longer use the lift in question. On 2/3/22 at 5:05 PM, the Vice President of Nursing Services entered the conference room with the survey team to provide in-services of the new mechanical lifts the facility purchased. The in-service records had a date of 7/24/17 and 10/3/17. There was an additional in-service sheet that was dated 10/21/19, that read, subject matter covered: mechanical lifts. The VPNS said, she was demonstrating that the training on mechanical lifts is ongoing and staff had been trained to use the new lifts purchased. She also provided the survey team with a skills checklist that the staff are signed off on. This skills checklist stated, Safety Check- visually inspect lift for external damage or excessive wear, - check that exposed fasteners are tight especially those of the sling bar, - check that sling bar safety latches are present and will freely swing closed . During the above noted interaction with the VPNS and survey team, the VPNS was asked about the clips not being present. She said, They are called safety clips for a reason it's a feature that is supposed to be there. When we get our safety check they say they are to be there. A review of the facility policy titled, Mechanical Lifts was conducted. This policy read, .Perform a basic safety check before use: check that the sling bar safety latches are present and will freely swing closed . A review of the manufacturer Instructions for Use booklet for the mechanical lift was reviewed. The Director of Clinical Support/Employee J, confirmed this booklet was for the mechanical lift in question. This booklet read, .Warning; this situation requires extra care and attention .Before lifting, always make sure that: o The lifting accessories are not damaged; o The lifting accessory is correctly attached to the lift; o The lifting accessory hangs vertically and can move freely; o The lifting accessory is selected appropriately, in terms of type, size, material and design, with regard to the patient's needs; o The lifting accessory is correctly and safely applied to the patient in order to prevent injuries; o the latches are intact; missing or damaged latches must always be replaced . On 2/3/22 at approximately 5:30 PM, the facility Administrator and DON were made aware of the above concerns. No further information was provided.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation, the facility staff failed to A) remove known hazards (long cords) from a resident's private room after a suicide attempt by strangulation and during active verbalizations of suicidal ideation for one Resident (Resident #12) in a sample of 27 residents and; B) the facility staff failed to supervise and monitor Resident #12 after he expressed recurring thoughts of death that resulted in a suicide attempt resulting in psychosocial harm. On [DATE] at 4:20 PM, immediate jeopardy was called. On [DATE] at 5:00 PM, immediate jeopardy was abated and was lowered to a level 3 isolated due to the failure of staff to supervise and monitor Resident #12 prior to his suicide attempt on [DATE]. The findings include: Resident #12, a [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident's #12's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of [DATE]. Resident #12 was coded with a Brief Interview of Mental Status (BIMS) score of 13 out of 15 indicative of intact cognition. Total severity score for mood was 15 out of possible 27 indicative of moderately severe depression. Psychotic behavior was coded as not occurring. Behavioral symptoms such as scratching self was coded as occurring 1 to 3 days. Psychotherapy by any licensed mental health professional was coded as being administered 1 day out of 7. Comparatively, the total severity score for mood dated [DATE] demonstrated increased depressive symptoms (sleep disturbances) from MDS quarterly assessment with an ARD of [DATE] which was just prior to documented [MEDICAL CONDITION] and suicide attempt on [DATE]. The most recent quarterly MDS assessment for functional status for locomotion on unit in a wheelchair was coded as requiring oversight, encouragement, or cueing from staff and support from staff for set up only. Functional status for bed mobility was coded as requiring extensive assistance from staff. Toileting and personal hygiene activities were coded as total dependence and full staff performance. Functional status for eating was coded as requiring limited assistance from staff indicating Resident was highly involved in the eating activity. Functional status for dressing was coded as Resident involvement in activity but requiring extensive assistance from staff for support. On [DATE] at 12:17 PM, Resident #12 was observed in dining area seated upright in his wheelchair. When asked about any concerns regarding the care received at the facility, the Resident stated I don't want to be here anymore. The Resident had a kerlix wrap covering his left forearm from the elbow to the wrist. When asked about the dressing, the Resident stated the staff put it there because I'm scratching. The Resident's fingers on right hand were in a flexed position consistent with contractures. On [DATE] at approximately 2:00 PM, Resident #12 was observed in the hall propelling self in wheelchair, with his left foot on the floor, to the dining room and stated he was available for an interview. The kerlix wrap was no longer on Resident #12's left forearm and when asked about it, the Resident stated the staff removed it to let it open to air. There were open areas on the left lateral forearm consistent with nail scratches. At the base of the scratch marks, there were approximately 4 red, open wounds with an estimated diameter of 1 cm and no perceivable depth. Resident #12 re-stated he did not want to be at the facility anymore. When asked why, Resident #12 stated I'm not happy here. I can't walk anymore and they stopped working with me. Resident #12 also stated they have to feed me because the right hand and arm don't work. Resident #12 demonstrated partially moving right arm in an upward motion but limited distance. The fingers on his right hand were flexed and, when asked, Resident #12 was able to demonstrate the ability to actively, partially extend fingers on his right hand away from palm. Resident #12 stated he could feed himself with the left hand if he had a special fork. Resident #12 was asked if he could move his left arm and he demonstrated ability to fully extend fingers on the left hand and Resident #12 lifted his left arm to the level of his chin. Resident #12's nails appeared trimmed and skin on bilateral palms was intact. When asked if he had been hospitalized recently, Resident #12 stated he was sent to the hospital because he tried to kill himself. When asked how he tried to kill himself, Resident #12 stated he tried to strangle himself with the call bell cord. Resident #12 also stated he does not feel happy; he feels depressed and the medication for depression isn't working. When asked if he still had thoughts of suicide, Resident #12 stated he always thinks about killing himself, even today but does not have a plan of how to carry it out. On [DATE] at approximately 2:45 PM, Resident #12's room was quickly surveyed for ligature risk. It was a private room. The furniture in the room consisted of two wardrobes and one dresser with a TV on it against the right wall. There was one bed in the room positioned near the window. On the left wall of the room, there were two wall lights and one of them had a long light cord (accessible to the Resident when he was up in his wheelchair) hanging down and nearly touching the floor. The wall light directly behind Resident #12's bed did not have a light cord attached to it. The window blinds had 2 sets of cords. The function of the cords on the left were for blind tilt control and appeared inaccessible to the Resident. The lift cords on the right side of the blinds were beyond the foot of the bed and accessible to Resident #12 while he was in his wheelchair. On [DATE] at approximately 2:50 PM, the provider notes were reviewed. An Admission History & Physical form completed by an MD (medical doctor) dated [DATE] documented, This is a 56yrs (sic) old man, a (facility) resident with hx (history) significant for [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder tried to kill himself by strangulating his head with his call bell cord on [DATE] morning and was admitted to a hospital for suicidal attempt. He is back at facility on [DATE]. On this same form under Family History, it was documented, mother had depression died of suicide The nurse's notes were reviewed. A nurse's note dated [DATE] at 12:28 PM documented, Resident was extremely irritable. Aides asked he (sic) if he wanted to get up and he declined their care and still proceeded to yell that he needed help and he wanted to get out of bed. Resident hollered help I went into the resident room and found him on the floor halfway under his bed with his head facing at the end of the bed. I asked resident what happened and how he got there. Resident stated I threw myself down here, if you put me back in that goddamn bad I will do it again. Resident has no apparent injuries from fall and vital signs obtained. Blood pressure: 165 / 75 pulse 83 respirations 19 oxygen saturation 95% on room air temperature 97.4 orally. Resident has calmed down now is in a more rational state of mind. I encourage resident to call for assistance using the call bell provided and explained to him the potential risk factors of his behaviors such as injuries related to him purposely falling from his bed. MD aware and resident is self representative. A nurse's note dated [DATE] at 7:32 PM documented, Resident has been having angry outbursts since 3 p.m. Resident screaming as loud as possible help, help, help because he stated he wanted to get in bed. The CNA and I put him in the bed at 4 pm. Resident began screaming again help, help, help at 5:30 p.m. Resident now stated he wanted to get back up and then his chair. Resident stated if you don't get me the hell out of this bed I will get out of my goddamn self I don't give a damn if I get hurt I will fall. To avoid him trying to purposely fall out of bed I got him out of bed and back into the wheelchair and brought him in the dining area near the nurses station so he could eat his dinner. Resident started hollering and yelling at staff calling them names. Resident repeatedly pushed the dining room table with his wheelchair almost tipping his chair over with him in it. Resident then proceeded to go up the hallway to the main dining room looking for the receptionist and hollering her name. I explained she had went home for the day. He stated She better not have, I need my money, she has my money, I don't give a damn. Leave me the hell alone. Resident then starts screaming help again and literally threw himself out of his wheelchair onto the floor where he hit his head. I asked resident why did he do this? Resident stated because I can who gives a damn it's my goddamn head. Resident has a 0.5cm by 2 cm lesion to the forehead which I cleaned and dressed. Resident was picked up off the floor with the Hoyer lift after complete physical assessment was performed. Resident asked to go to bed so we put him in bed. Neuro checks implemented and initial vitals obtained after fall at 6:15 p.m. Blood pressure: ,[DATE] pulse: 80 respirations: 19 oxygen saturation: 97% on room air temperature: 97.1 orally. Pain level: 4. Resident states his head hurts. Resident had been given his 6 p.m. pain medication and [MEDICATION NAME] which were effective at pain relief of head pain. A nurse's note on [DATE] at 11:37 p.m. documented, Resident refused all neuro check vital signs. Continue to holler help and threatened to throw himself in the floor. Performed dressing change three times to the open lesion on the forehead substained (sic) from the fall and each time resident rips off dressing cussing and scratches open the lesion making it bleed then wiping his hands all over his face and onto blankets. Resident attempted to wipe blood on me. A nurse's note on [DATE] at 2:06 PM documented, Resident having crying episodes-stating he wanted to die. Stated he wanted to kill himself. Telephoned NP (nurse practitioner)- NP gave new order for [MEDICATION NAME] 50 mg (an antipsychotic). Resident representative aware. The next nurse's note entry on Resident #12 is 6 days later dated [DATE] at 1:09 AM documented, resident very restless and agitated scratching at forehead cursing and yelling at staff attempting to get out of bed with no assist medications given as ordered resident continues with behaviors. There were no nursing note entries between [DATE] 2:06 PM and [DATE] 07:52 AM that showed assessing, monitoring for [MEDICAL CONDITION], or determining if Resident #12 had a plan to commit suicide. A nurse's note on [DATE] at 07:52 AM documented, At about 6:10 AM this morning, staff reported to this nurse that resident was actively trying to kill himself by strangulation. Resident was seen with the call bell wrapped around his neck tightly. I removed the call bell from around his neck. Resident stated, 'I want to die' & 'I wanted to get out of this place.' 1 on 1 given to resident at the time of the incident & repeated 1 on 1 and close observation since then. Resident was assisted up into wheelchair & has been calm with bouts of crying noted when asked about the incident. Resident is on continued monitoring. Resident has visible redness around his neck. Resident expressed a personal tragedy that occurred in his family. Oncoming staff made aware. Close monitoring will continue. A nurse's note on [DATE] at 8:21 AM documented, Given in report that resident attempted suicide by attempting to strangle himself with his call bell cord. Resident reportedly had a bluish tent (sic) to skin tone when found. Resident has been given one on one care since the incident occurred at 6:10 AM. Resident very upset visibly crying. Attempted to console resident and provided emotional support. Resident sent to (hospital) for psychiatric evaluation. Resident left in ambulance via stretcher at 8:12 AM. On [DATE] at 3:30 PM, the Administrator was asked to provide any service concerns, incident reports, or any investigations regarding Resident #12 from (MONTH) (YEAR) to (MONTH) 2019. The Administrator presented a copy of a facility-reported incident dated [DATE] and stated that was the only investigation he had for Resident #12. The attempted suicide by this Resident on [DATE] was not reported to the state agency. On [DATE] at approximately 3:45 PM, Surveyor D made the following observation. Surveyor D went to Resident #12's room to observe the environment for any ligature risks. Resident #12 was observed sitting in his wheelchair in his room. He was dressed in sweat pants and shirt. The sweat pants were visibly wet in the front. Resident #12 had, in his hands a fanny Pack with a plastic clip on it. Resident #12 held one part of the clip in his left hand and maneuvered the other part into the clip with his right hand. Resident #12 was able to clip the belt of the fanny pack and place it over the end of the bed rail. His left arm was exposed and there were scabbed areas with reddened open areas from wrist to elbow. When asked what happened to his left arm he stated I scratch it until it bleeds. When asked do they put a bandage on it, he responded 'They wrap it sometimes but they leave it open sometimes too. The blinds in Resident #12's room had double cords on each side, and the overbed light on the opposite side of room hand plastic coated cord with metal tabs at the end hanging from the light. On [DATE] at 4:15 PM, the state agency supervisor was notified. After consultation with the state agency supervisor, on [DATE] at 4:20 PM, immediate jeopardy was called. On [DATE] at 4:40 PM, the Administrator was notified of immediate jeopardy for Resident #12 due to ongoing accessibility to ligatures in the Resident's room that could be used for strangulation. On [DATE] at approximately 4:45 PM, Surveyor D and this surveyor entered the Resident's room for closer examination of ligatures. The cord hanging from the wall light was unobstructed and accessible to Resident #12 when he was in his wheelchair. It measured 57 inches long (144.78 cm) and ,[DATE] inch (0.15 cm) thick. According to product description provided by the Administrator, the cord is made from a nylon center core and encased in ABS ([MEDICATION NAME] butadiene styrene) plastic. There was a hard, plastic, bell-shaped cuff at the terminal end of this pliable cord suitable for anchoring a knot in the ligature. The diameter of the bell measured 0.55 inches (1.4 cm). The other end of the light cord had a metal device on it that fastened to a metal chain hanging down from the wall light. The window blinds had 2 sets of cords. The function of the cords on the left were for blind tilt control and appeared inaccessible to Resident #12. The lift cords on the right side of the blinds were beyond the foot of the bed and accessible to Resident #12. When the blinds were partially opened, the lift cords measured 53 inches (134.62 cm) long and ,[DATE] inch (0.15 cm) thick. The lift cords were connected by a hard plastic-appearing bead to create a loop in the upper portion of the cords. The bead could not advance down to the terminal end of the cords due to a knot in the connection. The knot was 17 inches (43.18 cm) from the terminal end of the cords. The diameter of the hard plastic-type bells at the ends of the lift cords measured 0.70 inches (1.8 cm). On [DATE] at 4:53 PM, the Administrator stated that staff removed the call bell from the room when it happened but they did not remove other items in the room that were ligatures. On [DATE] at 5:00 PM, the blinds and light cord and stated all cords were removed from the Resident's room. On [DATE] at 5:00 PM, immediate jeopardy was abated. On [DATE] at approximately 5:30 PM, the review of the clinical record continued. A nurse's note entry dated [DATE] at 5:05 PM documented, New order received from MD to send resident to ER (emergency room ) for eval and treatment for [REDACTED]. 911 phones at this time. A nurse's note dated [DATE] at 5:13 PM documented, Resident interviewed. In regards to self harm, resident stated, I always have had thoughts of suicide, but I'm not actually going to do it. Throughout the conversation, resident denied having an active plan for self harm. Initiated one-to-one sitter. Primary nurse notified. NP notified. New order received to send to ER for evaluation of [MEDICAL CONDITION]. On [DATE] at approximately 6:00 PM, a Resident Transfer Form was given to Surveyor B by Employee H. It was the Transfer Form (for Resident #12) completed by the nurse on day shift that documented on [DATE] at 8:21 AM Resident left in ambulance via stretcher at 8:12 AM The vital signs on the form on [DATE] at 7:56 AM were blood pressure: ,[DATE] Pulse: 68 Respirations: 18 Temperature: 97.2 Oxygen saturation: 98%. This form had a date on the top left corner of [DATE] 6:00 PM. On [DATE] at 6:10 PM, Surveyor A, Surveyor C, and this Surveyor were present when Surveyor B and the DON were looking together at Resident #12's Vital Sign Report on the computer. The DON stated that This program pulls all of the vital signs from any and all vital signs in the clinical record that were documented on [DATE]. If it was documented on that day, it is in this report. The DON was then asked by Surveyor B, Why is the Resident Transfer Form given to me by Employee H a few minutes ago have a blood pressure on it and this doesn't? The DON stated, I don't know why that is. The Resident Vital Sign Report, with a print date of [DATE] 6:09 PM, documents vital signs report was completed by the same nurse on day shift with a capture date/time of [DATE] at 6:52 AM. The Pulse: 68, Pulse oximetry 98%, Respirations: 18, Temperature: 97.2. No blood pressure was recorded on the report. The nurse on night shift that removed the call bell from around Resident #12's neck on [DATE] did not document vital signs in the narrative note, the Vital Signs Record, or the Resident Transfer Form. The oncoming nurse documented on the clinical notes, Vital Sign Record, and the Resident Transform Form but there is a discrepancy in the record with the time and blood pressure. On [DATE] at 6:30 PM, the care plan was reviewed. An intervention for the problem of history of falls documented, Keep call bell and personal items within reach. When the DON was asked about still having a call bell for the Resident on the care plan, she stated, It could mean the chime. On [DATE] at 8:30 AM, Employee G from the maintenance department was asked about the blinds, he stated they look like a metal composite with a nylon rope. Employee G carried blinds and walked with this surveyor to the facility scale. Employee G placed blinds on scale and CNA B weighed blinds at 16 pounds. The length of the blinds measured 70.25 inches and the slats are 2 inches wide. With the blinds fully retracted, the lift cords measured 60 inches from where they exited the headrail to the terminal end of the cords at the bottom of the bells. On [DATE] at 10:20 AM, CNA A was asked about Resident #12's feeding activities. CNA A stated Resident was able to feed himself finger foods. Also stated Resident used a special fork and spoon to feed himself but would also need staff to help with eating. On [DATE] at 10:22 AM, LPN C was asked about the open areas on Resident #12's left forearm. LPN C stated the open areas are self-inflicted scratch marks. When asked why he scratches himself, LPN C stated Resident said he did it when he felt nervous and when he felt itchy. On [DATE] at 10:25 AM, the first Plan of Correction (P[NAME]) by the facility was received, reviewed, and discussed among survey team members. On [DATE] at 10:52 AM, survey team met with Administrator and corporate staff to inform them the P[NAME] was rejected, why it was rejected, and to record their questions. On [DATE] at 11:35 AM, an interview with Staff B, a licensed clinical social worker (LCSW), was conducted. Surveyors A, B, C, D, and this surveyor were present. Staff B stated she has worked with Resident #12 for close to a year and that Resident #12 is seen weekly to offer therapy for depression. When asked if she assesses Resident #12 for thoughts of suicide during the visits, she stated, I gauge him for suicidal ideation on a scale from 1 to 5 where 5 is the worst, and I ask him 'how depressed are you?' Staff B stated she does not put are you suicidal? and does not ask Resident #12 if he has a plan in place to carry out a suicide. Staff B stated she uses the Geriatric Depression Scale and will get the psychologist involved as necessary. Staff B stated that all the sessions were held in the dining room and that she does not know what his room looks like. When asked if she made any recommendations to the facility regarding Resident #12, she stated, no. When asked if she was aware there were long ligatures accessible to Resident #12 in his room, she stated Resident #12's environment should have been evaluated for safety and the cords should have been removed from his room. She also stated it would have been prudent for her to look at the Resident #12's environment. When asked if she attends care plan meetings, she stated she does not usually attend care plan meeting unless there are behavior problems but never here at this facility. Staff B went on to say that as a result of this meeting, she was going to totally change what I am doing. She stated she will be going to residents' rooms, she will be asking if (residents) are suicidal, and she will ask them if they have a plan. On [DATE] at 2:10 PM, the 2nd P[NAME] was received, reviewed, and discussed among the survey team members. On [DATE] at 2:46 PM, the survey team met with Administrator and corporate staff to inform them the 2nd P[NAME] was rejected, why it was rejected, and to record their questions. The meeting ended at 3:03 PM. On [DATE] at 3:54 PM, the revised (3rd) P[NAME] was received, reviewed, and discussed among survey team members. On [DATE] at 4:06 PM, the final P[NAME] was accepted. On [DATE] at approximately 9:40 AM, CNA D was asked what Resident #12 kept in his fanny pack and CNA stated sometimes he would keep his glasses or his money/loose change in there. She also stated that Resident #12 was able to feed himself finger foods such as chicken nuggets, a sandwich, or French fries. On [DATE] at 9:47 AM, Staff C, an occupational therapy assistant that has worked at the facility for five years, was interviewed. Staff C stated she has worked with Resident #12 in relation to wheelchair positioning and how to move better in the wheelchair. She also worked with Resident #12 with the gorilla grip build up fork, spoon, and big washcloth so he can wash his face. She also stated in the past year, she has seen Resident #12 use his upper extremities to wheel himself in the wheelchair at will. When asked if the Resident's strength and dexterity has declined over the past year, she stated she thinks he has maintained the same strength and dexterity. On [DATE] at approximately 11:00 AM, the kitchen staff provided a sample plate of frozen french fries typically served at this facility. The Administrator provided the two types of call bells used at the facility. The call bell cords measured a thickness of 0.23 inches (0.6 cm). Comparatively, the call bell cords are thinner than the diameter of the bell at the terminal end of the light cord (1.4 cm), the bells on the terminal end of the lift cords (1.8 cm), and the French fries (1 cm) that Resident #12 is able to pick up and feed himself. On [DATE] at 12:45 PM, an interview with the facility's social worker was conducted. Staff A has worked at the facility for [AGE] years and has her Bachelor's degree in Psychology. When asked if she was aware Resident #12 expressed he wanted to kill himself, she stated not in recent times. When asked to share what she knows about him, she stated, I talk to him routinely, at least every quarter. She stated he likes to be involved in activities; he prefers to get up early. When asked about the cause for his current condition, she stated, I'm not sure if he had a stroke in the past. When asked about what should be done when a resident verbalizes [MEDICAL CONDITION], she stated nursing should report it to her so she would be aware of it. When asked who is responsible for making referrals to psychiatry, she stated it was the DON's responsibility. When asked if she saw Resident #12 between [DATE] and [DATE] (the time frame when the Resident verbalized [MEDICAL CONDITION] to the morning he attempted suicide), Staff A looked at the electronic health record during the interview and verified she did not see him in that time period. Her first visit with Resident #12 when he returned to the facility was [DATE] at 5:27 AM. When asked if she received an in-service on the topic of suicide recently, she stated she receive training on [DATE] about the process of what to do, to monitor resident, and who to notify. When asked what she thinks should have been done (when Resident #12 verbalized [MEDICAL CONDITION]), she stated, Staff should be monitoring, he has ongoing depression. When asked to define 'monitoring, Staff A stated visiting consistently, frequently. Staff A stated Resident #12 would go to the lobby to get change to purchase snacks such as chips or diet soda. Staff A also stated Resident #12 can get money into his fanny pack independently and zip it back up. When asked about the suicide attempt on [DATE], Staff A stated she was surprised by it. She stated, He was turning blue when found and it was looped around his neck a few times. Staff A stated she was aware the call bell cord releases from the wall when it's pulled. When asked if she made any recommendations to the facility about room safety, Staff A stated, not specifically. When asked for the Social Work department policy concerning behaviors, Staff A stated she didn't know if there was a written policy and added, I just do my job. A copy of her job description was requested. On [DATE] at 2:10 PM, the facility DON was interviewed. When asked about what she would expect to see on the care plan of a Resident who expressed [MEDICAL CONDITION], she stated she would expect to see mood, if they were expressing depressive symptoms and thoughts and feelings of harming self. The DON stated interventions would include psychiatry consult, meds if applicable, and one-to-one therapeutic communication as needed. She stated there should also be resident-specific interventions such as activities to encourage. When asked about her expectation when a Resident verbalizes [MEDICAL CONDITION], she states she would provide one-to-one monitoring and notify MD (medical doctor). This surveyor and the DON reviewed the nursing note entry dated [DATE] at 2:06 PM. When asked what her expectation is of staff when a Resident verbalizes thoughts of suicide, she stated she would expect to see vital signs and more details about what was going on. She also stated that after the assessment and caring for the Resident, she would expect that EMS (emergency medical services) would be called. She stated she would also expect she would be notified as well as ADON and the Administrator. When asked if she was notified about the attempted suicide, she stated she didn't remember but she's sure she was. When asked what she would have done in the event she was notified, she stated she would refer Resident #12 to psychiatry. She also stated that if she would make a referral to psychiatry, she would write a note about it in the clinical record. However, after reviewing the electronic record, the DON did not find evidence of her referral or that the psychiatrist was notified of Resident #12's [MEDICAL CONDITION] from [DATE]. The DON stated she could not see it in the computer and would check the hard chart. She also stated that, in general, it's a good idea for social worker to be notified when residents make depressive statements. On [DATE] at 2:30 PM, the corporate DON stated, The official title is 'social worker' in reference to Staff A. A copy of Resident Coordinator Job Description was presented. Responsibilities listed include but not limited to, develops social histories on residents through information obtained from referral sources, appropriate social agencies, residents and family members or friends. Documents same, and updates as needed. Evaluates resident's social situation; incorporates into the resident's overall care plan as assessment of resident needs, goals, and progress. Helps resident understand his need for the Center's care and assists in dealing with fears, resentments, loneliness. Assists resident in acceptance of placement. Works closely with other services involved in total health care of the resident in assisting with restoration of health, slowing disease process and preventing complications. On [DATE] at 3:40 PM, the Administrator was interviewed. When asked about the investigation pertaining to Resident #12's suicide attempt on [DATE], he stated he did not have an investigation and added there was nothing to investigate because we knew what happened. When asked if he thinks an investigation should have been done, he stated, Looking back, I should have - it would be the thing to do. When asked why he thinks it's important to do investigations, he stated to be able to look back at the cause and the notes. A copy of the ombudsman notification was requested. On [DATE] at 4:05 PM, the Administrator stated the ombudsman was not notified when Resident #12 was transferred to the hospital for attempted suicide on [DATE]. The physician's orders [REDACTED]. There were no orders for behavior monitoring pertaining to [MEDICAL CONDITION]/plans found from [DATE] to [DATE]. Orders from the Nurse Practitioner (NP) for behavior monitoring the day Resident #12 returned to the facility dated [DATE] (discontinued on [DATE]) documented target behaviors to be monitored were verbally abusive towards staff, crying outbursts and withdrawn. There were no orders for monitoring for [MEDICAL CONDITION]/plans or assessing/monitoring environment for safety risks. Orders from an internist MD for behavior monitoring for Resident #12 dated [DATE] (still active) documented target behaviors to be monitored were verbally abusive towards staff, crying outbursts, and withdrawn. There were no orders for assessing/monitoring for [MEDICAL CONDITION]/plans or environmental safety checks. A psychological services form completed by Staff B (LCSW), listed the date of service as [DATE] and time was 12:55 PM to 1:15 PM (the service time was less than one hour prior to nursing entry of resident crying and verbalizing wanting to die and wanting to kill himself). Under Current Risk Factors: Suicidal/Self Injury, the entry documented none. The LCSW documented, Pt was crying during session. Pt appeared upset re not getting his new wheelchair yet. Plan for next session: Clinician will utilize modified CBT (cognitive behavioral therapy) techniques to address pt's (patient's) ongoing depression. Staff B visited with Resident #12 two more times since the Resident verbalized [MEDICAL CONDITION] and prior to the attempted suicide event on [DATE] ([DATE] and [DATE]). Both visits documented none for Suicidal/Self Injury Risk Factors. After Resident #12 returned to the facility on [DATE], Staff B had documented 21 visits with the Resident. For those visits under Current Risk Factors: Suicidal/Self Injury, the entry documented, history. <br (TRUNCATED)

Based on observations, Resident interview, staff interview, clinical record review, and facility documentation, the facility saff failed to develop and implement a comprehensive care plan after Resident verbalized [MEDICAL CONDITION] resulting in a suicide attempt on [DATE] for one Resident (Resident #12) in a sample size of 27 residents. This resulted in harm. The findings include: Resident #12, a [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident's #12's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of [DATE]. Resident #12 was coded with a Brief Interview of Mental Status (BIMS) score of 13 out of 15 indicative of intact cognition. Total severity score for mood was 15 out of possible 27 indicative of moderately severe depression. Psychotic behavior was coded as not occurring. Behavioral symptoms such as scratching self was coded as occurring 1 to 3 days. Psychotherapy by any licensed mental health professional was coded as being administered 1 day out of 7. Comparatively, the total severity score for mood dated [DATE] demonstrated increased depressive symptoms (sleep disturbances) from MDS quarterly assessment with an ARD of [DATE] which was just prior to documented [MEDICAL CONDITION] and suicide attempt on [DATE]. The most recent quarterly MDS assessment for functional status for locomotion on unit in a wheelchair was coded as requiring oversight, encouragement, or cueing from staff and support from staff for set up only. Functional status for bed mobility was coded as requiring extensive assistance from staff. Toileting and personal hygiene activities were coded as total dependence and full staff performance. Functional status for eating was coded as requiring limited assistance from staff indicating Resident was highly involved in the eating activity. Functional status for dressing was coded as Resident involvement in activity but requiring extensive assistance from staff for support. On [DATE] at 12:17 PM, Resident #12 was observed in dining area seated upright in his wheelchair. When asked about any concerns regarding the care received at the facility, the Resident stated I don't want to be here anymore. The Resident had a kerlix wrap covering his left forearm from the elbow to the wrist. When asked about the dressing, the Resident stated the staff put it there because I'm scratching. The Resident's fingers on right hand were in a flexed position consistent with contractures. On [DATE] at approximately 2:00 PM, Resident #12 was observed in the hall propelling self in wheelchair, with his left foot on the floor, to the dining room and stated he was available for an interview. The kerlix wrap was no longer on Resident #12's left forearm and when asked about it, the Resident stated the staff removed it to let it open to air. There were open areas on the left lateral forearm consistent with nail scratches. At the base of the scratch marks, there were approximately 4 red, open wounds with an estimated diameter of 1 cm and no perceivable depth. Resident #12 re-stated he did not want to be at the facility anymore. When asked why, Resident #12 stated I'm not happy here. I can't walk anymore and they stopped working with me. Resident #12 also stated they have to feed me because the right hand and arm don't work. Resident #12 demonstrated partially moving right arm in an upward motion but limited distance. The fingers on his right hand were flexed and, when asked, Resident #12 was able to demonstrate the ability to actively, partially extend fingers on his right hand away from palm. Resident #12 stated he could feed himself with the left hand if he had a special fork. Resident #12 was asked if he could move his left arm and he demonstrated ability to fully extend fingers on the left hand and Resident #12 lifted his left arm to the level of his chin. Resident #12's nails appeared trimmed and skin on bilateral palms was intact. When asked if he had been hospitalized recently, Resident #12 stated he was sent to the hospital because he tried to kill himself. When asked how he tried to kill himself, Resident #12 stated he tried to strangle himself with the call bell cord. Resident #12 also stated he does not feel happy; he feels depressed and the medication for depression isn't working. When asked if he still had thoughts of suicide, Resident #12 stated he always thinks about killing himself, even today but does not have a plan of how to carry it out. On [DATE] at approximately 2:45 PM, Resident #12's room was quickly surveyed for ligature risk. It was a private room. The furniture in the room consisted of two wardrobes and one dresser with a TV on it against the right wall. There was one bed in the room positioned near the window. On the left wall of the room, there were two wall lights and one of them had a long light cord (accessible to the Resident when he was up in his wheelchair) hanging down and nearly touching the floor. The wall light directly behind Resident #12's bed did not have a light cord attached to it. The window blinds had 2 sets of cords. The function of the cords on the left were for blind tilt control and appeared inaccessible to the Resident. The lift cords on the right side of the blinds were beyond the foot of the bed and accessible to Resident #12 while he was in his wheelchair. On [DATE] at approximately 2:50 PM, the provider notes were reviewed. An Admission History & Physical form completed by an MD (medical doctor) dated [DATE] documented, This is a 56yrs (sic) old man, a (facility) resident with hx (history) significant for [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder tried to kill himself by strangulating his head with his call bell cord on [DATE] morning and was admitted to a hospital for suicidal attempt. He is back at facility on [DATE]. On this same form under Family History, it was documented, mother had depression died of suicide The nurse's notes were reviewed. A nurse's note dated [DATE] at 12:28 PM documented, Resident was extremely irritable. Aides asked he (sic) if he wanted to get up and he declined their care and still proceeded to yell that he needed help and he wanted to get out of bed. Resident hollered help I went into the resident room and found him on the floor halfway under his bed with his head facing at the end of the bed. I asked resident what happened and how he got there. Resident stated I threw myself down here, if you put me back in that goddamn bad I will do it again. Resident has no apparent injuries from fall and vital signs obtained. Blood pressure: 165 / 75 pulse 83 respirations 19 oxygen saturation 95% on room air temperature 97.4 orally. Resident has calmed down now is in a more rational state of mind. I encourage resident to call for assistance using the call bell provided and explained to him the potential risk factors of his behaviors such as injuries related to him purposely falling from his bed. MD aware and resident is self representative. A nurse's note dated [DATE] at 7:32 PM documented, Resident has been having angry outbursts since 3 p.m. Resident screaming as loud as possible help, help, help because he stated he wanted to get in bed. The CNA and I put him in the bed at 4 pm. Resident began screaming again help, help, help at 5:30 p.m. Resident now stated he wanted to get back up and then his chair. Resident stated if you don't get me the hell out of this bed I will get out of my goddamn self I don't give a damn if I get hurt I will fall. To avoid him trying to purposely fall out of bed I got him out of bed and back into the wheelchair and brought him in the dining area near the nurses station so he could eat his dinner. Resident started hollering and yelling at staff calling them names. Resident repeatedly pushed the dining room table with his wheelchair almost tipping his chair over with him in it. Resident then proceeded to go up the hallway to the main dining room looking for the receptionist and hollering her name. I explained she had went home for the day. He stated She better not have, I need my money, she has my money, I don't give a damn. Leave me the hell alone. Resident then starts screaming help again and literally threw himself out of his wheelchair onto the floor where he hit his head. I asked resident why did he do this? Resident stated because I can who gives a damn it's my goddamn head. Resident has a 0.5cm by 2 cm lesion to the forehead which I cleaned and dressed. Resident was picked up off the floor with the Hoyer lift after complete physical assessment was performed. Resident asked to go to bed so we put him in bed. Neuro checks implemented and initial vitals obtained after fall at 6:15 p.m. Blood pressure: ,[DATE] pulse: 80 respirations: 19 oxygen saturation: 97% on room air temperature: 97.1 orally. Pain level: 4. Resident states his head hurts. Resident had been given his 6 p.m. pain medication and [MEDICATION NAME] which were effective at pain relief of head pain. A nurse's note on [DATE] at 11:37 p.m. documented, Resident refused all neuro check vital signs. Continue to holler help and threatened to throw himself in the floor. Performed dressing change three times to the open lesion on the forehead substained (sic) from the fall and each time resident rips off dressing cussing and scratches open the lesion making it bleed then wiping his hands all over his face and onto blankets. Resident attempted to wipe blood on me. A nurse's note on [DATE] at 2:06 PM documented, Resident having crying episodes-stating he wanted to die. Stated he wanted to kill himself. Telephoned NP (nurse practitioner)- NP gave new order for [MEDICATION NAME] 50 mg (an antipsychotic). Resident representative aware. The next nurse's note entry on Resident #12 is 6 days later dated [DATE] at 1:09 AM documented, resident very restless and agitated scratching at forehead cursing and yelling at staff attempting to get out of bed with no assist medications given as ordered resident continues with behaviors. There were no nursing note entries between [DATE] 2:06 PM and [DATE] 07:52 AM that showed assessing, monitoring for [MEDICAL CONDITION], or determining if Resident #12 had a plan to commit suicide. A nurse's note on [DATE] at 07:52 AM documented, At about 6:10 AM this morning, staff reported to this nurse that resident was actively trying to kill himself by strangulation. Resident was seen with the call bell wrapped around his neck tightly. I removed the call bell from around his neck. Resident stated, 'I want to die' & 'I wanted to get out of this place.' 1 on 1 given to resident at the time of the incident & repeated 1 on 1 and close observation since then. Resident was assisted up into wheelchair & has been calm with bouts of crying noted when asked about the incident. Resident is on continued monitoring. Resident has visible redness around his neck. Resident expressed a personal tragedy that occurred in his family. Oncoming staff made aware. Close monitoring will continue. A nurse's note on [DATE] at 8:21 AM documented, Given in report that resident attempted suicide by attempting to strangle himself with his call bell cord. Resident reportedly had a bluish tent (sic) to skin tone when found. Resident has been given one on one care since the incident occurred at 6:10 AM. Resident very upset visibly crying. Attempted to console resident and provided emotional support. Resident sent to (hospital) for psychiatric evaluation. Resident left in ambulance via stretcher at 8:12 AM. On [DATE] at approximately 5:30 PM, the review of the clinical record continued. A nurse's note entry dated [DATE] at 5:05 PM documented, New order received from MD to send resident to ER (emergency room ) for eval and treatment for [REDACTED]. 911 phones at this time. A nurse's note dated [DATE] at 5:13 PM documented, Resident interviewed. In regards to self harm, resident stated, I always have had thoughts of suicide, but I'm not actually going to do it. Throughout the conversation, resident denied having an active plan for self harm. Initiated one-to-one sitter. Primary nurse notified. NP notified. New order received to send to ER for evaluation of [MEDICAL CONDITION]. On [DATE] at 6:30 PM, the care plan was reviewed. An intervention for the problem of history of falls documented, Keep call bell and personal items within reach. When the DON was asked about still having a call bell for the Resident on the care plan, she stated, It could mean the chime. On [DATE] at 11:35 AM, an interview with Staff B, a licensed clinical social worker (LCSW), was conducted. Surveyors A, B, C, D, and this surveyor were present. Staff B stated she has worked with Resident #12 for close to a year and that Resident #12 is seen weekly to offer therapy for depression. When asked if she assesses Resident #12 for thoughts of suicide during the visits, she stated, I gauge him for suicidal ideation on a scale from 1 to 5 where 5 is the worst, and I ask him 'how depressed are you?' Staff B stated she does not put are you suicidal? and does not ask Resident #12 if he has a plan in place to carry out a suicide. Staff B stated she uses the Geriatric Depression Scale and will get the psychologist involved as necessary. Staff B stated that all the sessions were held in the dining room and that she does not know what his room looks like. When asked if she made any recommendations to the facility regarding Resident #12, she stated, no. When asked if she was aware there were long ligatures accessible to Resident #12 in his room, she stated Resident #12's environment should have been evaluated for safety and the cords should have been removed from his room. She also stated it would have been prudent for her to look at the Resident #12's environment. When asked if she attends care plan meetings, she stated she does not usually attend care plan meeting unless there are behavior problems but never here at this facility. Staff B went on to say that as a result of this meeting, she was going to totally change what I am doing. She stated she will be going to residents' rooms, she will be asking if (residents) are suicidal, and she will ask them if they have a plan. On [DATE] at 12:45 PM, an interview with the facility's social worker was conducted. Staff A has worked at the facility for [AGE] years and has her Bachelor's degree in Psychology. When asked if she was aware Resident #12 expressed he wanted to kill himself, she stated not in recent times. When asked to share what she knows about him, she stated, I talk to him routinely, at least every quarter. She stated he likes to be involved in activities; he prefers to get up early. When asked about the cause for his current condition, she stated, I'm not sure if he had a stroke in the past. When asked about what should be done when a resident verbalizes [MEDICAL CONDITION], she stated nursing should report it to her so she would be aware of it. When asked who is responsible for making referrals to psychiatry, she stated it was the DON's responsibility. When asked if she saw Resident #12 between [DATE] and [DATE] (the time frame when the Resident verbalized [MEDICAL CONDITION] to the morning he attempted suicide), Staff A looked at the electronic health record during the interview and verified she did not see him in that time period. Her first visit with Resident #12 when he returned to the facility was [DATE] at 5:27 AM. When asked if she received an in-service on the topic of suicide recently, she stated she receive training on [DATE] about the process of what to do, to monitor resident, and who to notify. When asked what she thinks should have been done (when Resident #12 verbalized [MEDICAL CONDITION]), she stated, Staff should be monitoring, he has ongoing depression. When asked to define 'monitoring, Staff A stated visiting consistently, frequently. Staff A stated Resident #12 would go to the lobby to get change to purchase snacks such as chips or diet soda. Staff A also stated Resident #12 can get money into his fanny pack independently and zip it back up. When asked about the suicide attempt on [DATE], Staff A stated she was surprised by it. She stated, He was turning blue when found and it was looped around his neck a few times. Staff A stated she was aware the call bell cord releases from the wall when it's pulled. When asked if she made any recommendations to the facility about room safety, Staff A stated, not specifically. When asked for the Social Work department policy concerning behaviors, Staff A stated she didn't know if there was a written policy and added, I just do my job. A copy of her job description was requested. On [DATE] at 2:10 PM, the facility DON was interviewed. When asked about what she would expect to see on the care plan of a Resident who expressed [MEDICAL CONDITION], she stated she would expect to see mood, if they were expressing depressive symptoms and thoughts and feelings of harming self. The DON stated interventions would include psychiatry consult, meds if applicable, and one-to-one therapeutic communication as needed. She stated there should also be resident-specific interventions such as activities to encourage. When asked about her expectation when a Resident verbalizes [MEDICAL CONDITION], she states she would provide one-to-one monitoring and notify MD (medical doctor). This surveyor and the DON reviewed the nursing note entry dated [DATE] at 2:06 PM. When asked what her expectation is of staff when a Resident verbalizes thoughts of suicide, she stated she would expect to see vital signs and more details about what was going on. She also stated that after the assessment and caring for the Resident, she would expect that EMS (emergency medical services) would be called. She stated she would also expect she would be notified as well as ADON and the Administrator. When asked if she was notified about the attempted suicide, she stated she didn't remember but she's sure she was. When asked what she would have done in the event she was notified, she stated she would refer Resident #12 to psychiatry. She also stated that if she would make a referral to psychiatry, she would write a note about it in the clinical record. However, after reviewing the electronic record, the DON did not find evidence of her referral or that the psychiatrist was notified of Resident #12's [MEDICAL CONDITION] from [DATE]. The DON stated she could not see it in the computer and would check the hard chart. She also stated that, in general, it's a good idea for social worker to be notified when residents make depressive statements. On [DATE] at 2:30 PM, the corporate DON stated, The official title is 'social worker' in reference to Staff A. A copy of Resident Coordinator Job Description was presented. Responsibilities listed include but not limited to, develops social histories on residents through information obtained from referral sources, appropriate social agencies, residents and family members or friends. Documents same, and updates as needed. Evaluates resident's social situation; incorporates into the resident's overall care plan as assessment of resident needs, goals, and progress. Helps resident understand his need for the Center's care and assists in dealing with fears, resentments, loneliness. Assists resident in acceptance of placement. Works closely with other services involved in total health care of the resident in assisting with restoration of health, slowing disease process and preventing complications. The physician's orders [REDACTED]. There were no orders for behavior monitoring pertaining to [MEDICAL CONDITION]/plans found from [DATE] to [DATE]. Orders from the Nurse Practitioner (NP) for behavior monitoring the day Resident #12 returned to the facility dated [DATE] (discontinued on [DATE]) documented target behaviors to be monitored were verbally abusive towards staff, crying outbursts and withdrawn. There were no orders for monitoring for [MEDICAL CONDITION]/plans or assessing/monitoring environment for safety risks. Orders from an internist MD for behavior monitoring for Resident #12 dated [DATE] (still active) documented target behaviors to be monitored were verbally abusive towards staff, crying outbursts, and withdrawn. There were no orders for assessing/monitoring for [MEDICAL CONDITION]/plans or environmental safety checks. A psychological services form completed by Staff B (LCSW), listed the date of service as [DATE] and time was 12:55 PM to 1:15 PM (the service time was less than one hour prior to nursing entry of resident crying and verbalizing wanting to die and wanting to kill himself). Under Current Risk Factors: Suicidal/Self Injury, the entry documented none. The LCSW documented, Pt was crying during session. Pt appeared upset re not getting his new wheelchair yet. Plan for next session: Clinician will utilize modified CBT (cognitive behavioral therapy) techniques to address pt's (patient's) ongoing depression. Staff B visited with Resident #12 two more times since the Resident verbalized [MEDICAL CONDITION] and prior to the attempted suicide event on [DATE] ([DATE] and [DATE]). Both visits documented none for Suicidal/Self Injury Risk Factors. After Resident #12 returned to the facility on [DATE], Staff B had documented 21 visits with the Resident. For those visits under Current Risk Factors: Suicidal/Self Injury, the entry documented, history. A Medical Provider Acute Care note completed by the NP on [DATE] (five days after being notified by nursing of resident crying and verbalizing wanting to die and wanting to kill himself and ordering [MEDICATION NAME] 50 mg (an antipsychotic)). The Physical exam documentation includes, able to self-propel w/c (wheelchair) grabbing for door. (Up arrows signifying increased) increased anxiety; increased agitation; increased impulsive; difficult to redirect; anger towards (family member). The Plan included but not limited to [MEDICATION NAME] 25 mg three times a day, [MEDICATION NAME] 50 mg at bedtime, [MEDICATION NAME] 1 mg four times a day, and [MEDICATION NAME] (no dose written). The NP saw the Resident again on [DATE]. For chief complaint, the NP documented episodes yelling, impatient, arguing with other residents; agitated. The Plan included but not limited to Borderline personality - psych eval (psychiatric evaluation). There was no documentation of an assessment, interventions, monitoring, or evaluating for [MEDICAL CONDITION]/plans by the NP on [DATE] or [DATE] prior to the suicide attempt on [DATE]. There were no recommendations for suicide precautions or environmental safety checks. A psychiatric evaluation was recommended by the NP 19 days after the Resident verbalized [MEDICAL CONDITION] but it was for borderline personality, not [MEDICAL CONDITION]. The NP documented 9 visits with Resident since he returned from the hospital on [DATE]. Each visit documented no [MEDICAL CONDITION]. The Discharge Summary from the hospital back to the facility by a psychiatrist dated [DATE] documented, Improved, stable from a psychiatric perspective to return to his nursing home. Suicide risk assessment completed and patient deemed to be of low risk for suicide at this time. The psychiatrist's consultation notes were reviewed. A consultation note dated [DATE] documented reason for consultation Routine follow up and addressing post hospitalization medications. The psychiatrist documented. (Resident) is known to me from previous consultations at this facility. Last consult was on [DATE]. At that time, I had advised changes to medications as after hospitalization much of his medications were discontinued in spite of him being suicidal. Today I am seeing him as part of a routine consult for follow up. No new complaints today, much calmer than before, does not want any medication changes, does not engage well with the interview process as well. He agreed to increasing [MEDICATION NAME]. A consultation note dated [DATE] documented that Resident #12 was being seen for evaluation and treatment of [REDACTED]. Unable to reason out behavior. Unable to complete MMSE (mini-mental state examination). No EPS/TD (extrapyramidal symptoms/tardive dyskinesia) noted. Noted duplicate doses of [MEDICATION NAME]. The Plan included changes in medications. A consultation note dated [DATE] documented that Resident #12 was being seen for continues to yell out Help! Help! for non-emergencies. The psychiatrist documented not as agitated, continues to yell out when he needs to get out of the wheelchair instead of signing or asking for help. This is his baseline behavior. The Plan included initiating a medication to address impulsivity and aggressive yelling out behaviors. The nurse's notes with a date range of [DATE] to [DATE] were reviewed. Excerpts from an entry dated [DATE] at 10:29 PM documented, Resident returned to facility at 3:55 PM via stretcher from (hospital). Resident was orientated to his new room and ring bell to call for assistance since the traditional call bell is not allowed to be used with this resident. Resident's [DIAGNOSES REDACTED]. An entry dated [DATE] at 5:37 PM documented, Resident is showing evidence of not adjusting well today. When first started shift Resident was in a good mood and participating in activities with other residents. Resident has verbalized today that he wants to hurt himself, that he's depressed, and that I will kill myself. 1:1 was offered with resident in length and he agreed to a verbal contract not to hurt himself tonight but rounds will be done q30 minutes (every 30 minutes) to ensure resident safety. (Company) has been contacted to speak to the on-call provider for orders. Resident is still seeming very down, says he's frustrated and doesn't want to be here anymore. He is requesting his old call bell back with the cord that goes into the wall and patient teaching was done on how it isn't safe for him to have it and his ring bell was placed within his reach, residents seem dissatisfied with this answer. Residents seemed to respond well to 1:1 and went from agitated and upset to calm but still seemingly depressed. MD notified. This showed that Resident #12 was verbalizing [MEDICAL CONDITION], asking for his old call bell back, and left unsupervised. A nursing note dated [DATE] at 6:49 PM documented, The on-call doctor recommended to send resident out for evaluation to hospital and provide 1:1 until resident leaves the facility. 1:1 was given by nursing assistive staff until transportation was acquired and officers were dispatched to come speak to resident, from that point 1:1 was carried out by myself. Resident agreed to go talk to the counselor at hospital. Resident left facility at 6:30 p.m. brother and sister and law notified (listed as family contacts). MD notified. A nursing note dated [DATE] at 10:41 AM documented, spoke to (name) at the in regards to resident stating he wanted to kill himself. Reviewed nurses notes. Made her aware resident went to ER, reviewed medication to include new order to increase [MEDICATION NAME]. (name, company) asked this nurse to ask resident if he would be willing to go outside of facility voluntarily for psych Services. Resident stated that he did not want to leave. I was not going to kill myself. I was only saying how I felt not what I was going to do. Made resident aware that he needed to make absolutely sure of his choice of words in regards to this type of statement. Reminded him of recent outpatient stay. He stated that he did feel like he wants to die but he will try not to kill himself. Returned to the phone and relayed information to (person) and stated that if resident makes statements that he wants to kill himself again to call her back or call COPE (phone number). A nurses note dated [DATE] at 11:19 a.m. documented, Attempted telephone consultation with psychiatrist regarding resident to review medications and discuss behaviors. Unable to reach her at this time, left message to contact - awaiting return call. Will attempt to reach out again today if no call received. Meanwhile spoke with NP she has discontinued [MEDICATION NAME] 50 mg BID (Twice a day) and new order received for [MEDICATION NAME] 100 mg BID (two times a day). Resident up in wheelchair wheeling himself around this area tonight wanting to harm himself and states that he says that out of frustration and anger. Discussed alternative coping skills with him which he states he understands. A nurse's note dated [DATE] at 4:23 p.m. documented, Resident pleasant and cooperative with staff and other residents. No statements of wanting to kill self this shift, charge nurse talked with resident today. A nurse's note dated [DATE] at 5:01 a.m. documented, On [DATE] resident returned from ER via Medical Transport at 2:40 AM resident in good mood, making jokes with transport team. Resident had a restful night. Resident had no complaints of pain or discomfort. Resident had no verbalization is suicidal thoughts or actions. Resident slept through the night with no complaints of pain discomfort or suicidal ideation on this night as well. Bed low, call bell within reach. According to this nurse's note, the call bell was within reach after returning from the emergency room . A nurse's note dated [DATE] at 1:42 p.m. documented, Received return call from (psychiatrist) this afternoon for telephone conference regarding resident recent history, behaviors, medications, and proposed plan of care. Doctor made the following recommendations [MEDICATION NAME] 15 mg at bedtime, DC [MEDICATION NAME], initiate [MEDICATION NAME] 200 mg daily, [MEDICATION NAME] 0.5 mg twice-daily and [MEDICATION NAME] 25 mg once-daily. Spoke with NP after conference with MD regarding recommendations. NP ordered [MEDICATION NAME] 15 mg at bedtime, DC (discontinue) [MEDICATION NAME] 50 mg daily, [MEDICATION NAME] 0.5 mg twice a day, and [MEDICATION NAME] TID. Resident representative aware. The nurse's notes with a dated range of [DATE] to [DATE] were reviewed. There were 62 nursing note entries during that date range. One entry dated [DATE] at 1:20 PM documented, no s/s (signs/symptoms) depression or suicidal thoughts. No crying or shouting noted. An entry dated [DATE] at 4:01 PM documented, pleasant and cooperative, no [MEDICAL CONDITION] at this time. There were no other nurse's notes from [DATE] to [DATE] that documented assessments or monitoring of [MEDICAL CONDITION]/plans. The care plan before the Resident's suicide attempt on [DATE] with a date range of [DATE] - [DATE] was reviewed. An active problem identified with an effective date of [DATE] documented, (Resident) has been observed to make statements that life isn't worth living, wishes for death, or attempts to harm self. Active interventions documented for this problem are Monitor side effects of medication (mental slowness, altered unsteady gait, abnormally high drug levels). Notify physician if side effects noted. Plan with (Resident) and the physician for a trial period of dose reduction. Record behavior on Behavior Tracking Form. Observe for agitation, [MEDICAL CONDITION], combativeness, and altered perceptions. Provide quiet atmosphere/reduce stimulation when behaviors observed. Secure personal items that might be used to injure self. Increase monitoring, and notify provider if symptoms persist. A problem identified with an effective date of [DATE] documented, (Resident) has physical behavioral symptoms directed at self and others. Active interventions documented are, Provide medications as ordered. Record behaviors on Behavior Tracking Form. Monitor pattern of behavior (time of day, precipitating factors, sp(TRUNCATED)

Based on staff interview, facility documentation review and clinical record review, the facility staff failed for 1 resident (Resident #8) of 26 residents in the survey sample to provide supervision to prevent a fall resulting in harm. Staff observed Resident #8 inappropriately using her walker while ambulating to a bathroom on the unit hallway. Staff did not correct Resident #8's inappropriate use of the walker. Resident #8 fell and fractured her right hip. The findings included: Resident #8, an [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) assessment was a significant change assessment with an assessment reference date (ARD) of 8/1/14. She was coded with a Brief Interview of Mental Status score of 4 indicating severe cognitive impairment. She required assistance with her activities of daily living. Resident #8 ' s care plan was reviewed. The care plan titled " Quality of Life-Cognition, Communication, and Vision " was dated 7/13/12. It read " Resident is at risk for compromised quality of life secondary to: impaired cognition. " The " Approaches " section read " Provide step-by-step cueing as needed to complete tasks. " An additional approach read " Provide verbal cueing to help resident negotiate environment. " The care plan titled " Fall Prevention/ Reduction " dated 7/13/12 was reviewed. The care plan read " Resident has risk for falls, recent falls, and/or history of falls related to: unsteady gait, loss of balance, short term memory loss, requires staff assistance for transfers, sensory impairment, impaired sensation, health condition- hypertension. " The " Approaches " section read " keep bed in lowest position, keep bed wheels locked, obtain labs as ordered by physician; report abnormal findings, keep frequently used items in reach and/or close proximity, obtain vital signs per physician order; check vital signs at time of fall, keep eye glasses clean and ensure use., assess resident ' s response to pain, keep corridors and areas of resident use uncluttered, keep call bell in reach, provide rest periods as needed and/or tolerated, report changes in health condition to physician. " Resident #8 was observed on 8/20/14 at 9:00 a.m. in the common area on the unit. She was dressed and sitting in a wheelchair at this time. On 7/20/14, Resident #8 had a fall resulting in a fractured right hip. Nursing notes documented the fall. The notes read: 7/20/14, 9:50 AM- "Resident fell in resident bathroom injury to R (right) hip noted- MD (doctor) in house to assess- VS (vital signs) 132/78-63-24-97-97%-ROM (range of motion) completed-lower extremities limited." 7/20/14, 10:10 AM- "MD (doctor) in to assess patient" 7/20/14, 10:15 AM- "RP (responsible party) called to inform of fall and orders" 7/20/14, 10:20 AM- "911 called" 7/20/14, 10:30 AM- "EMTs (emergency medical technicians) in to transport" 7/20/14, 11:15 AM- "Resident transported to ER (emergency room )" 7/20/14, 2:45 PM- "(hospital) called with report resident to be admitted with right hip fracture." A physician progress notes [REDACTED]. The note read "Pt w hx (history) of dementia; 1+ BP- 10:20 AM now w fall in shower- c/o (complain of) R (right) LQ (lower quadrant) pain w externally rotated R leg + pain w ROM (range of motion)- Prob pt- send to hospital for possible fx (fracture) R (right) hip." An interview was held with Resident #8's family on 8/20/14 at 2:35 p.m. The family was asked if they were notified of Resident #8's 7/20/14 fall. The family stated that they were called and told that Resident #8 had fallen. The family asked the facility staff what happened and were told that the resident was observed dragging her walker behind her and fell . The family asked the facility staff why no one corrected Resident #8 when she was observed using the walker incorrectly. The facility staff informed the family that she didn't know and she was just telling them what she was told. Resident #8's fall was witnessed by Licensed Practical Nurse J (LPN J). LPN J's witness statement was reviewed. The statement read "7/20/14 Resident stated to the nurse that she had to use the bathroom. I told her to go back and get her walker, she did. She came to the med cart and asked 'do I go in there?' (Pointing to the bathroom) I said yes. Resident went towards the door and couldn't get it open, so I asked her to wait, as I had medication on my cart. While she was waiting, another resident passed by and said that she would hold the door, she did. Resident had the walker using it inappropriately. Walker wheel hit the back of her foot, and the resident fell . She did not hit her head, and fell on her right side. VS (vitals signs)-132/78-63-24-97-97%-ROM completed with upper extremities. Completed partial ROM (range of motion) with lower extremities." According LPN (Licensed Practical Nurse) J's statement, she allowed Resident #8 to proceed to the bathroom alone. It was only when Resident #8 could not open the door on her own, did LPN J ask her to wait. Resident #8 informed LPN J two different times prior to the fall that she needed to use the bathroom. According LPN J's witness statement, Resident #8's requests were ignored on both occasions. On 8/21/14 at 10:20 a.m., LPN J's witness statement was reviewed with the DON (Director of Nursing). The DON stated that the incident took place at the unit hallway bathroom. The DON stated that the nurse was passing medications at the time of the incident. The DON was asked if it was acceptable for a nurse to watch a resident use a piece of assistive equipment inappropriately. The DON stated that she would expect immediate intervention from the nurse. It was requested of the Director of Nursing (DON) that she provide LPN J's phone number or that she have LPN J to call the facility and speak to the survey team. On 8/21/14 at 2:30 p.m., the DON stated that she had missed LPN J's call. The DON stated that LPN J had left a message stating that she was not coming into work for her 8/21/14 shift because she had a test she forgot about. Resident #8's most recent MDS (minimum data set) assessment prior to the fall was reviewed. This MDS had an ARD (assessment reference date) of 7/1/14. It was coded as follows: G0110 (D) Walk in corridor: 1/1 (supervision -oversight, encouragement or cueing with set up help only). G0110 (I) Toilet Use: 3/2 (Extensive assistance- resident involved in activity, staff provide weight bearing support with one person physical assist). H0400 Bowel Continence: 9 (Not rated, resident had an ostomy or did not have a bowel movement for entire 7 days). On 8/21/14 at 2:45 p.m., the 7/1/14 MDS was reviewed with Licensed Practical Nurse A (LPN A). LPN A completed the MDS. LPN A was asked why H0400 Bowel Continence was coded as a 9, as Resident #8 did not have an ostomy. LPN A provided a written statement that read, "Resident during this time frame was ambulatory- would toilet self unable to recall when asked if she had a BM (bowel movement) due to dementia." On the same 7/1/14 assessment where Resident #8 was coded as 9, not having a bowel movement because she toileted herself, her "Toilet Use" was coded as requiring "Extensive assistance- resident involved in activity, staff provide weight bearing support with one person physical assist." On 8/21/14 at 2:15 p.m. an interview was held with Certified Nursing Assistant B (CNA B). CNA B stated that she had worked with Resident #8 in September 2013. CNA B stated that Resident #8 used a walker at that time. CNA B stated that Resident #8 was also confused at that time, having good and bad days. She stated that Resident #8 required toileting help at that time. CNA B stated that the the staff that worked with Resident #8 around the time of her July 2014 fall were not available. She stated that one had resigned and one was on maternity leave. Resident #8's fall was discussed with the DON and Administrator on 8/21/14 at 2:30 p.m. The Administrator stated that the incident occurred while LPN J was passing medications. He stated that the staff had not observed Resident #8 using her walker inappropriately prior to the incident. Concerns regarding the incident were reviewed with the DON and Administrator. The first concern was that LPN J instructed Resident #8 to return to her room to get her walker. Resident #8 was unsafe at this time without the walker and was instructed to continue to move about with out it. The second concern was that once Resident #8 had her walker, LPN J allowed her to use it inappropriately without correction. The last concern is that LPN J allowed Resident #8 to enter the bathroom alone when her MDS prior to the fall coded Resident #8's toileting as extensive assistance, defined as "resident involved in activity, staff provide weight bearing support with one person physical assist." According to the interview conducted with LPN A, it was facility practice to allow Resident #8 to toilet alone. Resident #8 was allowed by LPN J to enter the bathroom while using her walker inappropriately. As a result, she fell and fractured her right hip.

Based on observation, staff interview, clinical record review and facility documentation, the facility failed for five residents (Resident #7, Resident #2, Resident #12, Resident #3 and Resident #4) in a survey sample of 26 residents, to provide care and services to promote the highest practicable well being. 1. Resident #7's pain was not managed appropriately after a fall with fracture, resulting in harm. 2. For Resident #2, the facility staff failed, on three different occasions, to attempt non-pharmacological interventions prior to the administration of [MEDICATION NAME] (an anti-anxiety medication) and failed to assess and monitor the effectiveness of the [MEDICATION NAME] after it was administered. 3. For Resident #12, the facility staff failed to administer as ordered [MEDICATION NAME] from 8/16/14 through 8/20/14. 4. For Resident #3, the facility staff administered [MEDICATION NAME] without a physician's order and failed to administer sliding scale per physician's orders; and 5. For Resident #4, the facility staff failed to obtain a hip x-ray, after a fall and with symptoms of pain for 6 hours. The findings included: 1. Resident #7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #7's most recent MDS (minimum data set) assessment was a significant change in status assessment with an ARD (assessment reference date) of 7/22/14. She was coded with moderate cognitive impairment with long and short term memory problems. She required extensive total assistance with her activities of daily living and was coded for extensive staff assistance for hygiene. The resident was coded as having no pain in the lookback period. On 8/20/14 at 9:20 AM, Resident #7 was observed being repositioned in bed by two CNA's (certified nursing assistants). The privacy curtain was pulled closed, the resident was informed of repositioning. The resident did not demonstrate any facial grimacing or voiced any pain. Review of the clinical records revealed on 6/21/14 at 8:15 PM, Resident #7 "fell out of the wheelchair. Hit head on door. Neurochecks initiated. RP (responsible party) aware. Assessed - ROM (range of motion) good, some pain to right leg expressed, c/o (complained of pain to forehead." A nurses note was written 6/21/14 at 11:00 PM, :Resident remained at nurses station for remainder of shift. No complaints voiced." There were no further notes until 3:30 PM the next day (6/22/14). There was no documentation of the physician being notified. Neurochecks were documented with BP (blood pressures were done, with a rise from 108/59 (immediately after fall) to 138/70. Pulses were 69 per minute (immediately after fall) to 84 at 6:15 AM. On 6/22/14 at 3:45 PM, the nurse's note read: "Follow up full assessment. Resident c/o right leg pain. Tylenol given." (at 2:00 PM) On 6/22/14 at 3:30 PM (note out of sequence): This nurse went in room to observe resident. Right hip to right knee swollen. Bruise noted to right hip 5 cm (centimeters) X 4 cm. Resident cries in pain when trying to do care." Review of the MAR (medication administration record) revealed that Tylenol 650 mg (milligrams) was given at 4:00 PM for hip/knee pain. No documentation of effectiveness. On 6/22/14 at 4:00 PM, the nurse's note read: "MD (medical doctor) returned call. New order: Stat X-Ray to right hip and right femur. Call results to MD. Medicated with Tylenol 650 mg po (by mouth) for pain." Review of the MAR revealed a one time order for Tylenol 650 mg, given at 6:00 PM. There was documentation that the medication was "not effective." On 6/22/14 at 7:45 PM, a note revealed the X-Ray company was in to do the X-Ray. The note read: "Resident in severe pain when positioning for X-Ray." The X-Ray was positive for a fractured right hip. On 6/22/14 at 8:30 PM, the nurse's note read: "New order given to send to (---name of hospital) for treatment and evaluation. RP (responsible party) notified." The nurse's notes went on to state the resident left the facility at 8:45 PM. There was no documentation that the physician was notified of continued severe pain unrelieved by Tylenol. On 8/20/14 at 10:45 AM, LPN (licensed practical nurse) B was interviewed as she was the 7-3 nurse on 6/22/14. She stated, "They told me in report she didn't have much pain, but she was in severe pain." She went on to state that she gave the resident Tylenol at 4:00 PM, "it was not effective." LPN (B) stated, "She was moaning and groaning- she did not usually do that." She also stated that she attempted to call the MD, but the MD did not call back. The attempted call was approximately 2:30 PM. On 8/20/14 at 2:15 PM, the DON (director of nursing) stated, "If a resident is in distress, send the resident to the ER (emergency room ) and get an order later." She went on to state "if pain medication is on board and pain is not relieved, would send to the ER." On 8/20/14 at 2:45 PM, LPN (C) was interviewed as she was the 3-11 nurse on 6/22/14. She stated that around 2-2:30 PM, the aide went to the 7-3 nurse to "tell her the resident was in a lot of pain- was hollering out." She went on to state that her right knee was swollen with bruising as well as her thigh. LPN (C) stated, "She was screaming." She went on to state she had only Tylenol ordered, which she gave at 6:00 PM after talking to the nurse on call (an LPN), who told her to give an extra dose of Tylenol." LPN (C) stated she was fine until you touched her, " then begged to be left alone." LPN (C) went through the on call MD process as followed: "We call the answering system and talk to the nurse on call. The nurse on call talks to the MD and the nurse will call us back. It takes a while." LPN (C) was asked if she notified the MD of continued pain after the third dose of Tylenol was ineffective. LPN (C) stated, "Apparently I didn't." She went on to state, "it took them forever to call me back." The facility policy on pain management included the following: "Assessments should include the onset, location, frequency, quality and intensity of pain with the resident's self report as the primary indicator of pain. Pain assessments should be ongoing, and if interventions are not effective, the treatment plan should be revised accordingly." The facility policy of notification of changes included the following: "If the attending/ on call physician is unable to be reached by the nursing staff, the Medical Director/Assistant Medical Director may be called after a reasonable attempt has been made." On 8/20/14 at the end of the day exit, the Administrator, DON and the Corporate Nurse Consultant were notified of the above findings. 2. For Resident #2, the facility staff failed, on three different occasions, to attempt non-pharmacological interventions prior to the administration of [MEDICATION NAME] (an anti-anxiety medication) and failed to assess and monitor the effectiveness of the [MEDICATION NAME] after it was administered. Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a significant change assessment with an Assessment Reference Date (ARD) of 7/1/14. The MDS coded Resident #2 with short and long term memory problems and moderately impaired cognitive skills for daily decision making ; trouble falling asleep was coded under mood; required extensive assistance from staff for bed mobility, eating, toileting and hygiene; total dependency on staff for transfers and bathing; and incontinent of bowel and bladder. Under Active Diagnoses, Resident #2 was not coded for an Anxiety Disorder and under Medications, Resident #2 was coded as not having received an Antianxiety Medication in the last 7 days of the review period. On 8/19/14 at 3:15 p.m., Resident #2 was observed lying on her back in bed. Resident #2 was alert and pleasantly confused as she reached over to the left hand side of her bed. There were elbow protectors in place on both arms and Resident #2 showed no signs of anxiety, pain or discomfort. Resident #2's clinical record was reviewed including the Medication Administration Record (MAR). The review revealed a physician's order dated 6/22/14, for [MEDICATION NAME] .5 mg (milligram) every 12 hours as needed for Anxiety. The July MAR revealed [MEDICATION NAME] was administered on 7/8 at 9 p.m.; 7/9 at 9 p.m.; and 7/10 at 6 p.m. Further review of the clinical record revealed there was no follow up monitoring of the effectiveness of the anti-anxiety medication on the MAR or in the progress notes for those dates. Non-pharmacological interventions prior to administration of the anti-anxiety medication were not documented in the clinical record. Review of the Behavior Monitoring Records for July 8,9 and 10 did not reveal any targeted behaviors on the [MEDICATION NAME] behavior monitoring record. Resident #2's care plan for psychoactive medication use read: " Assess for other causes for mood or behavior disturbances prior to use of PRN (as needed) medications. Offer non-pharmacological interventions prior to increasing medications or giving PRN medications." Review of facility's Medication Administration Guidelines, under PRN (as needed) Medications read, "When PRN medications are administered, the following documentation is provided - Results achieved from giving the dose and the time results were noted." On 8/19/14 at 4:20 p.m. an interview was conducted with Admin. B., the Director of Nursing. Admin B stated, "The nurses are expected to document the effectiveness of the administered medication on the back of the MAR or in the nurse's notes." On 8/20/14 at 4:45 p.m. the Administrator and Director of Nursing were informed of the findings. The facility staff did not present any further information regarding the findings. 3. For Resident #12, the facility staff failed to administer [MEDICATION NAME] from 8/16/14 through 8/20/14. [MEDICATION NAME] is a medication administered to treat [MEDICAL CONDITION] reflux disease (GERD). Resident #12, a male, was initially admitted [DATE] after a hospitalization and discharged home 4/3/14. He was readmitted to the facility after another hospitalization [DATE]. His [DIAGNOSES REDACTED]. As Resident #12 had just been admitted to the facility, no MDS assessment had been completed. His admitting nursing assessment documented he was alert and oriented. Resident #12 was observed and interviewed, 8/21/14 at 3:45 p.m. He was out of bed and sitting in a wheelchair. Resident #12 was alert, oriented, and verbally responsive. Review of Resident #12's clinical record revealed the following physician's order, "8/14/14 [MEDICATION NAME] 20 mg (milligram) i (one) PO (by mouth) daily." The order was included with Resident #12's admission set of orders. An accompanying entry was noted on the MAR (medication administration record) with nurse's initials indicating it was only administered on 8/15/14 at 6 a.m. No notations were evident to indicate Resident #12 had refused the medication from 5/16-5/20/14, when the record review was conducted. Resident #12's medications were observed in the medication cart, 8/20/14 at 2:20 p.m. 8 tablets of [MEDICATION NAME] were in the medication cart with a delivery date on the medication of 8/14/14. A delivery manifest was presented indicating 8 tablets of [MEDICATION NAME] had been delivered to the facility during the evening of 8/14/14. The corporate consultant stated the pharmacy included one extra tablet of all medications in the event a medication was dropped, 8/20/14 at 4:30 p.m. The corporate consultant also stated the pharmacy does not bill for the one extra medication, so it was not accounted for on the manifest. The corporate consultant could not account for why the medication had not been administered. Review of the MAR and nursing notes revealed Resident #12 had not complained of chest or pain related [MEDICAL CONDITION] 8/16-8/20/14. Review of the facility's policy entitled, "Medication Administration Guidelines" included: "Medications are administered in accordance with written orders of attending physicians, manufacturer's specifications, and professional standards of practice. *Only the licensed or legally authorized personnel who prepares a medication may administer it. This individual records the administration on the resident's MAR/TAR (medication administration record/treatment administration record) to ascertain that all necessary doses were administered and all administered doses were documented. *The resident's MAR/TAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration. *If a dose of regularly scheduled medication is with held, refused, or given at other than the scheduled time (e.g. resident not in facility at scheduled dose time, initial dose of medication), the space provided on the front the MAR/TAR for the dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. If several doses of a vital medication are withheld or refused, the physician and responsible party are notified and documentation of notification is made." The administrator, DON, and corporate consultant were advised of the failure of the staff to administer [MEDICATION NAME], 8/16-20/14 (6 days), 8/21/14 at 3:20 p.m. 4. For Resident #3, the facility staff administered [MEDICATION NAME] without a physician ' s order. Resident #3, a female, was admitted to the facility 5/14/14. Her [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) with an ARD (assessment reference date) of 5/21/14 was coded as an admission, five day assessment. Resident #3 was coded as having no memory deficits and was able to make her own daily life decisions. She was also coded as needing extensive to total assistance with her activities of daily living. She was coded, in Section J1700 as having no falls in the month prior to admission. Review of Resident #3's clinical record revealed the following entry on her MAR: "[MEDICATION NAME] give 5 units sq (subcutaneously) at 7 a.m. and 9 p.m. for dm (diabetes mellitus)." Nurses initials were evident indicating Resident #3 had been administered 5 units of [MEDICATION NAME] twice daily since 6/23/14. On the most recently signed "Physician's Orders" dated 8/5/14, no order was evident for the administration of [MEDICATION NAME] 5 units twice daily. A previous order, that had been marked out, was evident for [MEDICATION NAME] 4 units sq (subcutaneous) at 7 a.m. and 9 p.m. A thorough review of the Physician's orders for July and August, 2014, both of which had been signed on 8/5/14 revealed no order for [MEDICATION NAME] 5 units twice daily. When interviewed, the DON presented a signed physician's order dated 6/23/14 that increased the [MEDICATION NAME] dosage from 4 units to 5 units. The order had not been evident within the clinical record. The DON also stated the "Physician's Orders" signed on 8/5/14 were the most recent physician's orders and would have superceded the order written on 6/23/14. The administrator, DON, and corporate consultant were advised of the failure of the staff to obtain a physician's order prior to administering [MEDICATION NAME] to Resident #3, 8/21/14 at 3:20 p.m. The corporate consultant stated when the "Physician's Orders" are received from the pharmacy, a nurse was responsible for reviewing the new order sheet and ensuring any orders that had been obtained or changed were captured on the order form prior to the physician signing it. 5. For Resident #4, the facility staff failed to obtain a hip x-ray, after a fall with symptoms of pain after the fall, for 6 hours. Resident #4, a female, was initially admitted to the facility 4/30/14 and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) with an ARD (assessment reference date) of 6/6/14 was coded as a significant change assessment. Resident #4 was coded as having short and long term memory deficits and required assistance with making daily life decisions. She was coded as needing extensive assistance of one to two staff members to perform her activities of daily living. Resident #4 was observed 8/19/14 at 4:10 p.m. She was lying in her bed, with the head of the bed elevated. Pillows were observed under her legs. Resident #4 was alert and verbally responsive. Review of Resident #4's clinical record revealed an entry on "Skilled Nursing Daily Progress Notes:" "2:10 p (p.m.) Resident FOF (found on floor) @ 2:00 pm ROM (range of motion) completed x (times) 3. (L) hip noted to only move during passive ROM. no other apparent injuries. RP (responsible party)/MD aware... 2:30 pm N.O. (new order) rec'd. (name of xray provider) called. RP aware... 4:15 P 136/61 94 97.9 20 97% c/of (complained of) (L) leg pain, (L) leg with [MEDICAL CONDITION] +1 from ankle to knee, +pedal pulse... 8 P (name or xray provider) arrives... 8:30 P Paged (physician's name) ... 9:10 P N.O. received RP notified... 9:15 P EMS (emergency medical services) notified, Report call to ED (emergency department)... 9:35 P EMS transferred resident to (hospital name)." Review of the clinical record revealed that Resident #4's physician had been notified at 2:30 p.m. and ordered for an xray of her left hip to be obtained via the company that provided xray services at the facility. After receiving the xray report, indicating Resident #4's hip was fractured, the clinician was again contacted and ordered her to be sent to the hospital, approximately 7 hours after the fall. When interviewed regarding the length of time it took for the xray to be obtained (5 1/2 hours), the DON said 8/20/14 at 3:10 p.m., that was not an unusual time for an xray to be obtained. She said unless the physician ordered the xray to be done "stat" (immediately), it was not uncommon for it to take several hours due to the remote location of the facility. She further related if the MD wanted the tests to be done immediately, the clinicians would order for the Resident to go to the hospital for testing. When called, Other D a representative from the xray company, said 8/20/14 at 4:10 p.m., she had pulled the information and interviewed staff that would have worked during the time of the call for Resident #4. Other D stated she was part owner of the company and took issues that had been identified very seriously. Other D stated the facility had notified the company of the need for a hip xray 5/25/14 at 3 p.m. A technician arrived at the facility around 8 p.m. and obtained the xray. Other D stated the caller had not indicated the need for the xray was emergent and Resident #4 was put in the queue for the xray to be obtained. If the caller had stated the xray was needed "stat" the technician would have come to the facility as soon as possible to obtain the xray. The DON stated, 8/20/14 at 3:10 p.m., the physician's order did not indicate the xray needed to be done "stat." The DON did state Resident #4 was complaining of pain from the time of the fall, however no indication was evident the staff informed the clinician that Resident #4 was symptomatic (pain, swelling, etc) when the order was obtained. Documentation was evident Resident #4 received medication for pain during the time period between the fall and when she was transported to the ER. The administrator, DON, and corporate consultant were advised of the failure of the staff to ensure a hip xray was obtained in a timely manner for Resident #4, 8/21/14 at 3:25 p.m.

Based on observation, staff interview, clinical record and facility documentation review, the facility staff failed for one resident, Resident #7 in a survey sample of 26 residents, to timely notify the physician, resulting in unrelieved pain and harm. Resident #7's physician was not timely notified of unrelieved pain from a fractured right hip (three doses of Tylenol was given with continued severe pain). The findings included: Review of the clinical records revealed on 6/21/14 at 8:15 PM, Resident #7 "fell out of the wheelchair. Hit head on door. Neurochecks initiated. RP (responsible party) aware. Assessed - ROM (range of motion) good, some pain to right leg expressed, c/o (complained of pain to forehead." A nurses note was written 6/21/14 at 11:00 PM, :Resident remained at nurses station for remainder of shift. No complaints voiced." There were no further notes until 3:30 PM the next day (6/22/14). There was no documentation of the physician being notified. Neurochecks were documented with BP (blood pressures were done, with a rise from 108/59 (immediately after fall) to 138/70. Pulses were 69 per minute (immediately after fall) to 84 at 6:15 AM. On 6/22/14 at 3:45 PM, the nurse's note read: "Follow up full assessment. Resident c/o right leg pain. Tylenol given." (at 2:00 PM) On 6/22/14 at 3:30 PM (note out of sequence): This nurse went in room to observe resident. Right hip to right knee swollen. Bruise noted to right hip 5 cm (centimeters) X 4 cm. Resident cries in pain when trying to do care." Review of the MAR (medication administration record) revealed that Tylenol 650 mg (milligrams) was given at 4:00 PM for hip/knee pain. No documentation of effectiveness. On 6/22/14 at 4:00 PM, the nurse's note read: "MD (medical doctor) returned call. New order: Stat X-Ray to right hip and right femur. Call results to MD. Medicated with Tylenol 650 mg po (by mouth) for pain." Review of the MAR indicated [REDACTED]. There was documentation that the medication was "not effective." On 6/22/14 at 7:45 PM, a note revealed the X-Ray company was in to do the X-Ray. The note read: "Resident in severe pain when positioning for X-Ray." The X-Ray was positive for a fractured right hip. On 6/22/14 at 8:30 PM, the nurse's note read: "New order given to send to (---name of hospital) for treatment and evaluation. RP notified." The nurse's notes went on to state the resident left the facility at 8:45 PM. There was no documentation that the physician was notified of continued severe pain unrelieved by Tylenol. On 8/20/14 at 10:45 AM, LPN (licensed practical nurse) B was interviewed as she was the 7-3 nurse on 6/22/14. She stated, "They told me in report she didn't have much pain, but she was in severe pain." She went on to state that she gave the resident Tylenol at 4:00 PM, "it was not effective." LPN (B) stated, "She was moaning and groaning- she did not usually do that." She also stated that she attempted to call the MD, but the MD did not call back. The attempted call was approximately 2:30 PM. On 8/20/14 at 2:15 PM, the DON (director of nursing) stated, "If a resident is in distress, send the resident to the ER (emergency room ) and get an order later." She went on to state "if pain medication is on board and pain is not relieved, would send to the ER." On 8/20/14 at 2:45 PM, LPN (C) was interviewed as she was the 3-11 nurse on 6/22/14. She stated that around 2-2:30 PM, the aide went to the 7-3 nurse to "tell her the resident was in a lot of pain- was hollering out." She went on to state that her right knee was swollen with bruising as well as her thigh. LPN (C) stated, "She was screaming." She went on to state she had only Tylenol ordered, which she gave at 6:00 PM after talking to the nurse on call (an LPN), who told her to give an extra dose of Tylenol." LPN (C) stated she was fine until you touched her, " then begged to be left alone." LPN (C) went through the on call MD process as followed: "We call the answering system and talk to the nurse on call. The nurse on call talks to the MD and the nurse will call us back. It takes a while." LPN (C) was asked if she notified the MD of continued pain after the third dose of Tylenol was ineffective. LPN (C) stated, "Apparently I didn't." She went on to state, "it took them forever to call me back." The facility policy on pain management included the following: "Assessments should include the onset, location, frequency, quality and intensity of pain with the resident's self report as the primary indicator of pain. Pain assessments should be ongoing, and if interventions are not effective, the treatment plan should be revised accordingly." The facility policy of notification of changes included the following: "If the attending/ on call physician is unable to be reached by the nursing staff, the Medical Director/Assistant Medical Director may be called after a reasonable attempt has been made." On 8/20/14 at the end of the day exit, the Administrator, DON and the Corporate Nurse Consultant were notified of the above findings with a harm level deficiency.

Based on staff interview and facility documentation review, the facility staff failed to ensure medication administration was free from significant error for 1 resident (Resident #110) in a 13 resident survey sample. Specifically, the facility staff gave Resident #110 ten milliequivalents of potassium one time and day instead of the prescribed three times a day. The findings included: Resident #110 was admitted to the facility on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. Resident #110 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 09/18/2012 coded Resident #110 with severe cognitive impairment. In addition, the Minimum Data Set coded Resident #110 requiring extensive to total dependence, on staff for Activities of Daily Living care and incontinent of bowel and bladder. A review of Resident #110 ' s clinical record was conducted during the survey. The review showed a physician order [REDACTED]. However, a review of Resident #110 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview was conducted with the Director of Nursing on 10/11/2012 at approximately 10:00 a.m. The Director of Nursing stated that the order was transcribed wrong onto Resident #110 ' s the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility administration was informed of the findings during a briefing on 10/11/2012 at approximately 1:07 p.m. The facility did not present any further information about the findings.

Based on observation, resident interview, staff interviews, facility document review, clinical record review and in the course of a complaint investigation the facility staff failed to ensure two residents (Resident #2 and #5) were free from a significant medications error which resulted in one resident having an overdose and requiring hospitalization . 1. For Resident #2, the facility staff medication nurse did not ensure that the resident's old narcotic patches were removed prior to administering two new narcotic patches which resulted in the resident having a significant medication error which resulted in an overdose requiring hospitalization . 2. For Resident #5 the facility administered a double dose of [MEDICATION NAME] resulting in a significant medication error. The findings included: 1. Resident #2 was a [AGE] year old female with an Original admission date of [DATE] and the most recent Readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Significant Change MDS (minimum data set) with an ARD (assessment reference date) of 07/09/12. The resident's BIMS (brief interview for mental status) score was coded 10 which indicated the resident had moderately impaired cognition. The resident was coded as requiring limited to extensive assistance of one staff member with all of her ADLs (activities of daily living) except for eating, which she required set up. She was coded as using a cane for ambulating in her room and an electric wheelchair for locomotion throughout her unit and the rest of the facility. Further review noted that the resident was coded as being incontinent for both bladder and bowel. Further review of Resident #2's clinical record revealed a validated physician's orders [REDACTED]." A History and Physical from the hospital dated 06/24/12 noted: "The nursing staff here in the emergency room found a [MEDICATION NAME] 100 mcg (microgram) patch on the patient as well as another [MEDICATION NAME] 100 mcg patch and a 25 mcg [MEDICATION NAME]. So they found some current patches as well as some old patches. Patient will be admitted to the ICU (intensive care unit) for acute [MEDICAL CONDITION] due to respiratory depression from overdose of narcotic." Review of the resident's 06/2012 POS (physician order [REDACTED]. "Original 04/01/2012. [MEDICATION NAME] Dis 25 mcg/hr (micrograms per hour) for [MEDICATION NAME]-10 am-Remove-Apply-Site-Apply 1 patch topically to clean dry area of upper arm or back every 72 hours for pain in the morning-rotate site and record sites-use with (100 mcg) to equal (125 mcg)" "Original 04/30/12. [MEDICATION NAME] Dis 100 mcg/hr for [MEDICATION NAME]-10 am-Remove-Apply-Site-Apply 1 patch topically to clean dry area of upper arm or back every 72 hours for pain in the morning-rotate site and record sites-use with (25 mcg) to equal (125 mcg)." Review of Resident #2's June 2012 MAR noted the following for 06/23/12 at 10:00 am: LPN J's initials were noted on 06/23/12 10 am removal, application and site 13 indicated for the new administration of fresh [MEDICATION NAME] DIS 100 mcg/hr (micrograms per hour) [MEDICATION NAME], and also for [MEDICATION NAME] DIS 25 mcg/hr [MEDICATION NAME] to equal 125 mcg). An interview was conducted on 08/16/12 at approximately 1:00 pm, with Administration A (administrator) & B (DON-director of nursing). When asked what the facility had done about the medication error the DON stated, "I did not consider it as a medication error but a technique error. I did an inservice with all of the nurses after the incident on how to properly remove and administer [MEDICATION NAME] medications." The DON submitted copies of the sign up sheets, the agenda, and the material used in her 06/27-6/30/12 inservice. Administration informed of the findings on 08/17/12 at approximately 3:00 pm, at the pre-exit briefing. 2. For Resident #5 the facility administered a double dose of [MEDICATION NAME] resulting in a significant medication error. Resident #5, a [AGE] year old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #5's most recent minimum data set assessment was a quarterly assessment with an assessment reference date of 7/31/12. She was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. She required assistance with her activities of daily living. A review of Resident #5's physician orders [REDACTED]. Her physician orders [REDACTED]. 1. "[MEDICATION NAME] tab 40 mg CR, 1 tablet by mouth every morning for pain" 2. "[MEDICATION NAME] tab 80 mg CR, 1 tablet by mouth at bed time for pain" 3. "[MEDICATION NAME] tab 15 mg, 1 tablet by mouth as needed every 4 hours" On 8/15/12 at 10:43 a.m., LPN C, medication nurse, accessed the pill card and the narcotic sheet for Resident #5's [MEDICATION NAME] 40 mg from the locked medication cart. It was documented on the narcotic sheet that (2) 40 mg tabs of [MEDICATION NAME] were administered on 7/26/12. The order called for the administration of one pill. The error was reviewed with the Director of Nursing (DON) on 8/15/12 at 10:58 a.m. When asked how the facility responded to medication errors, the DON stated that a medication error report should be completed and the physician should be notified. The medication error report was requested at this time. On 8/15/12 at 11:04 p.m. the DON stated that there was no medication error report for Resident #5's [MEDICATION NAME]. A review of Resident #5's nursing notes for the end of July, to include 7/26/12, showed no documentation of a medication error or physician notification of a medication error. No adverse outcomes were documented for Resident #5 as a result of the extra [MEDICATION NAME] she was administered. The Administrator and Director of Nursing were notified of the significant medication error at the end of day meeting on 8/15/12. COMPLAINT DEFICIENCY

Based on observations, resident interview, staff interview, facility document review, clinical record review, the facility staff failed to ensure one resident (Resident #5) was free from unnecessary medication which resulted in a drug overdose. 1. For Resident #5 the facility administered a double dose of [MEDICATION NAME] and administered [MEDICATION NAME] without completing physician ordered lab work. The Findings included: For Resident #5 the facility administered a double dose of [MEDICATION NAME] and administered [MEDICATION NAME] without completing physician ordered labwork. A. Resident #5, a [AGE] year old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #5's most recent minimum data set assessment was a quarterly assessment with an assessment reference date of 7/31/12. She was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. She required assistance with her activities of daily living. A review of Resident #5's physician orders [REDACTED]. Her physician orders [REDACTED]. 1. "[MEDICATION NAME] tab 40 mg CR, 1 tablet by mouth every morning for pain" 2. "[MEDICATION NAME] tab 80 mg CR, 1 tablet by mouth at bed time for pain" 3. "[MEDICATION NAME] tab 15 mg, 1 tablet by mouth as needed every 4 hours" On 8/15/12 at 10:43 a.m., LPN C, medication nurse, accessed the pill card and the narcotic sheet for Resident #5's [MEDICATION NAME] 40 mg from the locked medication cart. It was documented on the narcotic sheet that (2) 40 mg tabs of [MEDICATION NAME] were administered on 7/26/12. The order called for the administration of one pill. The error was reviewed with the Director of Nursing (DON) on 8/15/12 at 10:58 a.m. When asked how the facility responded to medication errors, the DON stated that a medication error report should be completed and the physician should be notified. The medication error report was requested at this time. On 8/15/12 at 11:04 p.m. the DON stated that there was no medication error report for Resident #5's [MEDICATION NAME]. A review of Resident #5's nursing notes for the end of July, to include 7/26/12, showed no documentation of a medication error or physician notification of a medication error. No adverse outcomes were documented for Resident #5 as a result of the extra dose of [MEDICATION NAME] she was administered. B. Resident #5 had a physician order [REDACTED]. The website www.surgery.com defined PT/INR as follows: PT ([MEDICATION NAME] time)-"This test is done to evaluate the blood for its ability to clot." INR (International Normalized Ratio)- "The INR is used to make sure the results from a PT test is the same at one lab as it is at another lab. The 2006 Nursing Drug Handbook 22nd edition documented the following: "[MEDICATION NAME] is an anticoagulant or blood thinner that works in the body by inhibiting vitamin K activated clotting factors in the blood. Unmonitored [MEDICATION NAME] can cause life threatening side effects such as hemorrhage. The potential for hemorrhage or bleeding is increased when [MEDICATION NAME] is taken with other blood thinning medications, such as aspirin. PT and INR determinations are essential for proper control of [MEDICATION NAME] dosages to prevent side effects. PT and INR are laboratory test values obtained from measurements of the time it takes for a clot to form, and are usually measured when taking anticoagulants such as [MEDICATION NAME] to assure the clotting time stays within the desired range, and to prevent side effects." According to the Laboratory Test Handbook, 5 th edition, Lexi-Comp, Cleveland, 2001; 327-358, "During the initiation of [MEDICATION NAME], the PT/INR is checked at least weekly, until the dose and INR are therapeutic and stable." "The interval between tests can then be gradually decreased to as infrequently as every 4 weeks." The medication [MEDICATION NAME] is a brand name for the medication [MEDICATION NAME]. Resident #5 had two physician orders [REDACTED]." Resident #5 received eight doses of [MEDICATION NAME] after 8/8/12, the date in which her PT/INR lab was not drawn. No adverse outcomes were documented regarding the administration of the [MEDICATION NAME] without obtaining the PT/INR lab for monitoring. A physician progress notes [REDACTED]. It appears not to be in the chart. It is important that in someone taking an anticoagulant to be monitored closely." At the end of day meeting on 8/15/12 the Administrator and Director of Nursing were notified of the missing PT/INR lab and the [MEDICATION NAME] error for Resident #5.

Based on observations, resident interviews, staff interviews, facility documentation review, clinical record reviews and in the course of a complaint investigation the facility staff failed to follow the professional standards of nursing for medication administration and documentation for seven residents (Resident #2, #6, #12, #4, #7, #1 and #17) of 27 residents in the survey sample. 1. For Resident #2, the facility staff failed to ensure that all of the previous dosed [MEDICATION NAME] (narcotic) [MEDICATION NAME]es (100 mcg and 25 mcg) were removed prior to administering the new [MEDICATION NAME] 100 mcg (micrograms) patch and [MEDICATION NAME] 25 mcg patch which totaled the ordered dose of 125 mcg. 2. For Resident #6, the Facility staff failed to administer and document supplements and treatments. 3. For Resident #12, the Facility staff failed to administer and document medications. 4. For Resident #4, the facility staff failed to obtain weekly blood pressure/pulse per physician's orders [REDACTED]. 5. For Resident #7, the facility staff failed to document medications and treatments as having been administered. 6. Resident #1's antibiotics were not signed as given for two days. 7. Resident #17's physician order [REDACTED]. The findings included: 1. For Resident #2, the facility staff failed to ensure that all of the previous dosed [MEDICATION NAME] (narcotic) [MEDICATION NAME]es (100 mcg and 25 mcg) were removed prior to administering the new [MEDICATION NAME] 100 mcg (micrograms) patch and [MEDICATION NAME] 25 mcg patch which totaled the ordered dose of 125 mcg. 1. Resident #2 was a [AGE] year old female with an Original admission date of [DATE] and the most recent Readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Significant Change MDS (minimum data set) with an ARD (assessment reference date) of 07/09/12. The resident's BIMS (brief interview for mental status) score was coded 10 which indicated the resident had moderately impaired cognition. The resident was coded as requiring limited to extensive assistance of one staff member with all of her ADLs (activities of daily living) except for eating, which she required set up. She uses a cane for ambulating in her room and an electric wheelchair for locomotion throughout her unit and the rest of the facility. Further review noted that the resident was coded as being incontinent for both bladder and bowel. Review of Resident #2's clinical record revealed a validated physician's orders [REDACTED]." A History and Physical from the hospital, dated 06/24/12 noted: "The nursing staff here in the emergency room found a [MEDICATION NAME] 100 mcg (microgram) patch on the patient as well as another [MEDICATION NAME] 100 mcg patch and a 25 mcg [MEDICATION NAME]. So they found some current patches as well as some old patches. Patient will be admitted to the ICU (intensive care unit) for acute [MEDICAL CONDITION] due to respiratory depression from overdose of narcotic." Review of the resident's 06/2012 POS (physician order [REDACTED]. "Original 04/01/2012. [MEDICATION NAME] Dis 25 mcg/hr (micrograms per hour) for [MEDICATION NAME]-10 am-Remove-Apply-Site-Apply 1 patch topically to clean dry area of upper arm or back every 72 hours for pain in the morning-rotate site and record sites-use with (100 mcg) to equal (125 mcg)" "Original 04/30/12. [MEDICATION NAME] Dis 100 mcg/hr for [MEDICATION NAME]-10 am-Remove-Apply-Site-Apply 1 patch topically to clean dry area of upper arm or back every 72 hours for pain in the morning-rotate site and record sites-use with (25 mcg) to equal (125 mcg)." Review of Resident #2's June 2012 MAR noted the following for 06/23/12 at 10:00 am: LPN J's initials were noted on 06/23/12 10 am removal, application and site 13 indicated for the new administration of fresh [MEDICATION NAME] DIS 100 mcg/hr (micrograms per hour) [MEDICATION NAME], and also for [MEDICATION NAME] DIS 25 mcg/hr [MEDICATION NAME] to equal 125 mcg). An interview was conducted on 08/12/12 at 9:30 am, with LPN F-Unit Head Nurse. When asked about the events that caused Resident #2 to be sent to the ER (emergency room ) she stated, "During my morning rounds, that I do when I first get on the Unit, I noticed Resident #2 was mumbling and felt clammy." She further stated, "I called the MD about her drastic changes and we started to apply oxygen and to send her out 911 (immediately). LPN F was then asked if she knew the reason for Resident #2's sudden change she stated, "After the resident was seen at the ER the hospital notified us that she was admitted to the ICU (intensive care unit) because of a drug overdose due to an extra [MEDICATION NAME] not being removed." An interview was conducted on 08/12/12 at 10:00 am, with Administration B-DON (director of nursing) regarding Resident #2's overdose on 06/24/12 resulting in the resident's overdose. She stated, "After the call was made to the facility from the hospital about a [MEDICATION NAME] overdose, I checked the MAR (medication administration record) to see who had administered the most recent doses and found it to be LPN J." She further stated, "I then started an investigation and talked with LPN J about the documentation on the MAR for 06/23/12 where she had initialed that the previous patches had been removed. LPN J told me that she wasn't 100% sure but she thought she had removed both patches as she had signed for removal of both." When asked about the patch the hospital had found on the resident the DON did not have an explanation. The DON submitted proof of an inservice she performed dated 06/27-30/12 entitled : "Administration of [MEDICATION NAME] Patches". The inservice also had an attached copy of reference material on [MEDICATION NAME] taken from "Nursing 2012 Drug Handbook by Lippincott." Under Black Box Warning on page 579 it was noted, "[MEDICATION NAME] is an opioid agonist and schedule II controlled substance with potential for abuse. Be alert for signs of misuse, abuse or diversion. Alert: [MEDICATION NAME] drug levels peak between 24 and 72 hours after initial application and dose increases. Monitor patients for life-threatening hypoventilation, especially during these times. Monitor patients closely, and provide immediate care for evidence of overdose such as slow or shallow breathing, a slow heartbeat, severe sleepiness, cold and clammy skin, trouble walking and talking, and feeling faint, dizzy, or confused." Further guidance can be found in "Perry & Potter, Clinical Nursing Skills & Techniques, 7th edition." On page 543, Step C 'A variety of medications are available as [MEDICATION NAME] (skin) patches. Technique for applying a [MEDICATION NAME]: (1) Locate and remove old patch before applying a new one. Check beneath skin folds, if necessary. Cleanse the area. Rationale: Failure to remove the old patch can result in drug overdose if a new patch it applied and the old patch remains on. Many [MEDICATION NAME]es are small, clear, or flesh-colored and can be easily hidden beneath skin folds. Cleansing the area removes traces of the older dose and adhesive, which may irritate the skin/" Administration informed of findings on 08/17/12 at approximately 12:00 pm, at the pre-exit briefing. No additional information was submitted for consideration. 2. Resident #6 was an [AGE] year old admitted to the facility on [DATE]. Resident #6's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 5/29/12, coded Resident #6 as being able to understand and be understood by others. On 8/14/12 a review was conducted of Resident #6's clinical record, revealing a care plan dated 6/5/12 read, (1) "Resident is at risk for alteration in cardiac output related to hypertension. Resident will experience cardiac output sufficient to daily needs. Resident's quality of life will be maintained through prompt attention to signs and symptoms of cardiac output alteration. Administer medication per order. (2) Nutrition/Hydration risk. Offer and encourage resident to consume fluids throughout the day. Resident #6's clinical record contained a signed Physician order [REDACTED]." Resident #6's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #6's clinical record contained a signed physician order [REDACTED]." Resident #6's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 8/15/12 at 2:00 P.M. an interview was conducted with the LPN F at the Rappahannock nurse's station. When asked why the medication wasn't administered and documented, LPN F stated, "Our policy is to document everything that you do. Any adverse reactions. If you don't document then you did not do it. You can remember within 24 hours, but not a month ago because you don't know what happened a month ago." 3. Resident #12 was a [AGE] year old admitted to the facility on [DATE]. Resident #12's [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Depression, [MEDICAL CONDITION], Dysphasia, [MEDICAL CONDITION], and Contact [MEDICAL CONDITION]. The Minimum Data Set, which was an Admission Assessment, with an Assessment Reference Date of 6/7/12, coded Resident #12 as being able to understand and be understood by others. On 8/14/12 a review was conducted of Resident #12's clinical record, revealing a care plan, dated 6/5/12 read, (1) "Resident is at risk for side effects related to use of psychoactive medication - antidepressants. Resident will receive desired effect from ordered medications. Administer medications as ordered." Resident #12's clinical record contained a signed physician order [REDACTED]." Resident #12's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 8/15/12 a review was conducted of facility documentation, revealing a Medication Administration Guidelines Policy dated 2/6/12, which read, "Only the licensed or legally authorized personnel who prepares a medication may administer it. This individual records the administration on the resident's MAR/TAR (Medication Administration Record/Treatment Administration Record) to ascertain that all necessary doses were administered and all administered doses were documented." Guidance was provided for nursing, Fundamentals of Nursing, 7 th. Edition, P. 336, "The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary," 4. For Resident #4, the facility staff failed to obtain weekly blood pressure/pulse per physician's orders [REDACTED]. Resident #4, an [AGE] year old female, was admitted to the facility 8/6/10. Her [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) with an ARD (assessment reference date) of 6/11/12 was coded as a quarterly assessment. Resident #4 was coded as having short term memory deficits and required moderate assistance with making daily life decisions. Resident #4 was also coded as requiring assistance of one person for her activities of daily living. Review of Resident #4's clinical record revealed no evidence that the following medications and treatments were administered as ordered by the physician: House shake (a supplement) 1 by mouth daily: 5/20/12 Skin Prep to the top of right foot twice daily: 5/19, 5/20/12 Cleanse lower back with normal saline, apply med honey, cover with dry dressing and secure with tape daily: 5/19, 5/20/12, 7/11/12 [MEDICATION NAME] 30 mg (milligram) one by mouth at bedtime (for depression/[MEDICAL CONDITION]): 5/28/12 [MEDICATION NAME] one drop in both eyes twice a day (dry eyes): 5/22, 5/28/12 Artificial tears one drop in both eyes three times a day (dry eyes): 6/27/12 at 1 p.m., 7/5/12 at 1 p.m. Zinc sulfate 220 mg one daily x 14 days (wound healing): 7/26/12 Promod 30 ml (milliliter) by mouth twice daily: 7/9/12 at 5 p.m. Review of the facility's policy entitled "Medication Administration Guidelines" included: "*Medications are prepared, administered, and recorded only licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medication. *The resident's MAR/TAR (medication administration record/treatment administration record) is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR/TAR are verified with a full signature in the space provided. *Only the licensed or legally authorized personnel who prepares a medication may administer it. This individual records the administration on the resident's MAR/TAR to ascertain that all necessary doses were administered and all administered doses were documented." Guidance is given to nursing by "Fundamentals of Nursing 7th Edition, Potter-Perry, p. 713, "After administering a medication, record it immediately on the appropriate record form. Never chart a medication before administering it. Recording immediately after administration prevents errors. The recording of a medication includes the name of the medication, dose, route, and exact time of administration." Review of Resident #4's clinical record also revealed a signed physician's orders [REDACTED]." A thorough review of Resident #4's clinical record including the MAR/TAR revealed no weekly blood pressure and pulse was obtained during July/2012. No entry was noted on the MAR for the blood pressure and pulse to be obtained. An entry was noted on August, 2012 MAR indicated [REDACTED]. When interviewed, LPN A, the charge nurse, stated 8/15/12 at 12:38 p.m., a weekly blood pressure and pulse was not obtained during the month of July. LPN A said the order was not transcribed to the MAR. LPN A was unaware if a weekly blood pressure and pulse had been obtained on 8/7/12. Guidance for nursing practice for the administration of medications was included in, "Fundamentals of Nursing 7th Edition, p 336, The physician is responsible for directing medical treatment. Nurses follow physician's orders [REDACTED]." A signed physician's orders [REDACTED]." Documentation revealed Resident #4 was administered Vitamin C daily from 6/7/12 until 7/9/12 (two days after the order was finished). LPN A said, 8/15/12 at 12:38 p.m., the order was not transcribed to the MAR indicated [REDACTED]. Guidance for nursing standards for the administration of medication was provided by "Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation." Review of the MAR for June, 2012 revealed Resident #4 was not administered Promod as ordered by the physician from 5 p.m. on 6/17/12 through 9 a.m. on 6/19/12. Documentation on the back of the MAR indicated [REDACTED]." LPN A said 8/15/12 at 12:38 p.m., she was uncertain why Promod was unavailable 6/17-19/12. LPN A stated she would check with the staff member responsible for ordering supplies. Other D stated 8/16/12 at 7:30 a.m.. she was responsible for ordering supplies. Other D said she gets a report from the staff regarding what supplies are needed. Other D did not remember if the facility was out of Promod on 6/17-19/12. Review of the order vouchers revealed three cases of Promod were ordered on [DATE] with a notation that the Promod would be sent from the supplier on 6/18/12. No documentation was available to determine when Promod had been ordered prior to 6/18/12. The administrator, DON, and corporate consultant were advised of the failure of the staff to ensure medications were administered per physician's orders [REDACTED]. 5. For Resident #7. the facility staff failed to document medications and treatments as having been administered. Resident #7, an [AGE] year old male, was admitted to the facility 1/11/08 and readmitted after a hospitalization , 8/1/12. His [DIAGNOSES REDACTED]. Resident #7's most recent MDS (minimum data set) with an ARD (assessment reference date) of 6/5/12 was coded as a quarterly assessment. He was coded as having no memory deficits and was able to make his own daily life decisions. Resident #7 was coded as requiring total assistance with all of his activities of daily living. Review of Resident #7's clinical record revealed no documentation that the following medications and treatments were administered per physician's orders [REDACTED]. [MEDICATION NAME] 15 ml by mouth four times a day for cough: 7/19/12 at 8 p.m., Juven 1 packet by mouth daily (for wound healing): 7/7/12 [MEDICATION NAME] one drop in both eyes three times a day (dry eyes): 6/29/12 at 1 p.m. Promod 30 ml by mouth daily (wound healing): 6/2, 6/3, 6/8-10, 6/18, 6/19/12 Check topical drug patch placement every shift: 7/24/12 on 3-11 shift When interviewed 8/15/12 at 11:42 a.m., LPN F, the unit manager stated she was uncertain if the medications or treatments were administered. As of the end of the survey, no further information was provided regarding whether the medications and treatments were administered per physician's orders [REDACTED]. The administrator, DON, and corporate consultant were advised of the failure of the staff to document medications and treatments as having been administered, 8/16/12 at the end of day conference. 6. Resident #1's antibiotics were not signed as given for two days. Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date of 6/26/12 was a quarterly assessment. Resident #1 was coded with 15 out of possible 15 points on a " Brief Interview of Mental Status " (BIMS) meaning no cognitive deficits. In addition, the Minimum Data Set coded Resident #1 as requiring extensive assistance for Activities of Daily Living care and incontinent of bowel and bladder. Resident #1 was also coded with one stage 2, one stage 3, one stage 4, and 2 unable to stage pressure ulcers. Review of July, 2012, MAR's (medication administration record) was reviewed. On 7/10/12 [MEDICATION NAME] (antibiotic) was ordered for a urinary tract infection. The sixth and seventh dose were not signed as given. On 8/14/12 at 12:40 PM, an interview was conducted with LPN (licensed practical nurse) A. She stated, "it means it was not given." Further review revealed that the medications had been given, but not signed off as given. 7. Resident #17's physician order [REDACTED]. Resident # 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date of 6/19/12 was a quarterly assessment. Resident #17 was coded with 15 out of possible 15 points on a " Brief Interview of Mental Status " (BIMS) meaning no cognitive deficits. In addition, the Minimum Data Set coded Resident #17 as requiring supervision to limited assistance for Activities of Daily Living care and incontinent of bowel and bladder. During the medication pass pour observation, Resident #17 was administered Tylenol 1000 mg (milligrams) for mild pain at 9:00 AM. Reconciliation of the medications revealed for the POS dated (signed by physician) 8/6/12 revealed no order for the Tylenol. Further review revealed a telephone order dated 7/4/12 for the Tylenol. Review of the facility's policy for documentation of a medication order revealed the following: * Transcribe newly prescribed medications on the MAR * After completion, document each medication order noted on the physician's orders [REDACTED]. On 8/17/12 at 2:00 PM, the Administrator and DON (director of nursing) were notified of above findings. COMPLAINT DEFICIENCY

Based on observations, resident interview, staff interview, facility documentation review, clinical record review and in the course of a complaint investigation, the facility staff neglected to remove a previously applied [MEDICATION NAME] (narcotic) [MEDICATION NAME] (absorbed through the skin) patch prior to the administration of new patches resulting in a medication overdose for one resident (Resident #2) in a survey sample of 27 residents. For Resident #2 the facility staff neglected to remove a previously applied [MEDICATION NAME] 100 mcg (micro-grams)/hour narcotic [MEDICATION NAME] prior to the administration of a new [MEDICATION NAME] 100 mcg/hr and a new [MEDICATION NAME] 25 mcg/hr to total 125 mcg/hr of the ordered narcotic. The findings included: Resident #2 was a [AGE] year old female with an Original admission date of [DATE] and the most recent Readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Significant Change MDS (minimum data set) with an ARD (assessment reference date) of 07/09/12. The resident's BIMS (brief interview for mental status) score was coded 10 which indicated the resident had moderately impaired cognition. The resident was coded as requiring limited to extensive assistance of one staff member with all of her ADLs (activities of daily living) except for eating which she required set up. She used a cane for ambulating in her room and an electric wheelchair for locomotion throughout her unit and the rest of the facility. Further review noted that the resident was coded as being incontinent for both bladder and bowel. Review of Resident #2's clinical record revealed a validated physician's orders [REDACTED]." A History and Physical from the hospital dated 06/24/12 noted: "The nursing staff here in the emergency room found a [MEDICATION NAME] 100 mcg (microgram) patch on the patient as well as another [MEDICATION NAME] 100 mcg patch and a 25 mcg [MEDICATION NAME]. So they found some current patches as well as some old patches. Patient will be admitted to the ICU (intensive care unit) for acute [MEDICAL CONDITION] due to respiratory depression from overdose of narcotic." An interview was conducted on 08/16/12 at approximately 1:00 pm, with Administration A (administrator) & B (DON-director of nursing). When asked if the facility had notified the SA (State Agency) about the resident's overdose and subsequent hospitalization the DON stated, "No, but I counseled the nurse responsible for the overdose." and the Administrator stated, "I wasn't sure so I asked the hospital and they told me since it wasn't a deliberate mistake that they didn't think it needed to be reported. The DON did do an investigation and came to the conclusion that there was no abuse." Review of the facility's Resident Neglect Policy and Procedure dated 05/25/05 noted: "Procedure: All alleged violations involving neglect must be reported immediately to the Administrator of the facility and then reported immediately by fax to Virginia Department of Health/Center for Quality Health Services and Consumer Protection. The facility must complete a thorough investigation and must prevent further potential neglect while the investigation is in progress. The facility must also take corrective action of alleged violations and report the results to VDH/CQHSCP, in writing, within five working days. Details of further reporting may be found in the Abuse Policy. Investigation: 1. Possible Signs of Neglect: Failure to provide necessary treatment or services that cause a negative outcome in a resident's wellbeing. This may include failing to provide or follow regular nursing protocols, standards of care or failure to respond or intervene when necessary to residents change in condition. 2. Types of neglect: Unintentional neglect is the non-deliberate but consistent failure by staff to provide needed care or service to a resident resulting in a serious negative outcome. 3. Reporting: Unintentional neglect scenarios should be reported if it results in a serious negative outcome and/or a pattern has been established whereas the establishment of a pattern may deem the situation to be more intentional in nature. In situations of unintentional neglect, a staff members ability to do the job and carry out the functions of their job need to be evaluated. A skills competency test should be administered and a probationary period should be established where the staff member is being monitored for effectiveness." At the end of the interview the Administrator and DON both agreed that the incident with Resident #2 was unintentional neglect by LPN J. Administration did not submit any additional information.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, facility staff failed for two residents (Resident # 108 and Resident #107) of 15 residents in the survey sample to provide adequate supervision and/or assistance to prevent accidents. 1. Resident #108's chair alarm was not working, the resident got up and walked unassisted from the dining room down the hall (approximately 80 ft.) and tripped over a Hoyer Lift on 9/12/11. She was to be assisted when ambulating. 2. The facility staff failed to provide supervision to prevent a fall for a resident during toileting for Resident #107. The Findings Included: 1. Resident #108 was admitted to the facility on [DATE]. Resident #108's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Annual Assessment with an Assessment Reference Date of 7/26/11, coded Resident #108 as usually being able to understand and be understood by others. Resident #108 was coded as having impaired vision. For locomotion from the dining room, and other distant locations, Resident #108 was coded as requiring a one person physical assist. A review of Resident #108's clinical record was conducted on 9/20/11, revealing a nurse's note written by LPN B dated 9/12/11 at 7:00 P.M., which stated, "This nurse was summoned to resident by (CNA) D (Certified Nursing Assistant) found resident sitting on the floor. When asked resident what happened resident stated 'I was walking to my room and tripped and fell .' Resident's chair alarm pad did not alarm. Assessed resident- no bruising, skin tears, pain or distress noted." On 9/12/11, CNA D made the following statement to the nurse, "While walking the hall it was noticed that the resident had gotten up out of her chair, While walking she tried to step around the total lift, she stepped too wide and fell backwards, sliding down the wall. She stated she was going to her room." CNA D was not directly supervising the resident, she happened to notice her while walking the hall. During the survey, on 9/21/11, CNA D submitted the following written statement, which conflicted with her original statement, "While supervising (Resident #108) ambulating, while she had a clear path to walk, this resident began messing with the lift that was position against the wall, she lost her footing and fell on to the floor. Nurse help immediately." On 9/21/11, LPN B also submitted the following written statement that conflicted with her original note, "Reported to me by the CNA that resident was walking from dining room down the hallway CNA supervising resident to walk with supervision, resident began touching lift and CNA went to assist resident but the resident fell before she could get to her. The lift was positioned against the wall and was not in the resident's path during ambulation on 9/12/11. Resident #108 was supposed to have a one person assist when walking from the dining room to her room, according to her MDS (minimum date set assessment). A review of Resident #108's clinical record, revealing a Plan of Care dated 8/28/11 which read, "Resident has impaired vision, risk and history of falls, keep corridors and areas of resident use uncluttered. Resident requires the use of a Gait Belt, and assistance with locomotion in wheelchair and walking." Resident #108's clinical record contained the following physician order [REDACTED]. Check placement and function in the morning and evening as needed." According to their documentation, Resident #108's chair alarm was not working when she fell after getting up from her chair unassisted, and the resident walked from the dining room down the hall, approximately 80 Ft. away and tripped over a Hoyer Lift on 9/12/11. During the survey, the Hoyer Lift was observed to be stationed in the corridor near Resident #108's room on 9/20/11 at 2:45 P.M., and 9/21/11 at 1:45 P.M. The lift was observed to be plugged in to the red electrical outlet. The location of the lift was approximately 80 Ft. down the corridor from the dining room. An interview was conducted with CNA B at 1:45 P.M. on 9/21/11, who was observed placing a Sit-to-Stand Lift in the corridor and plugging it in to a socket next to the socket used for the Hoyer Lift. The lifts were blocking access to the handrails. When asked why the lifts were stored in the hallway, CNA B stated, "They are always kept here. We have to have them plugged in." On 9/21/11, at 2:00 P.M., CNA E was asked to check Resident #108's chair alarm. She tested it twice. The alarm did not work properly. CNA E stated, " That's unusual. It usually goes off immediately." On 9/21/11, Administration B (Director of Nursing) stated that the alarm was discarded and that Resident #108 had a new chair alarm. 2. The facility staff failed to provide supervision to prevent a fall for Resident #107 during toileting for Resident #107. Resident #107 was a [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #107's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 9/15/2011 coded Resident #107 as being cognitively intact regarding her mental status. The facility staff coded Resident #107 as needing limited assistance with one person physical assist for toilet use. A review was conducted on 9/21/2011 of Resident #107's facility documentation and clinical record. Resident #107 ' s clinical record revealed on 9/12/2011 at 1:20 p.m. that the resident was found on the floor in her bathroom. The facility " Incident Interview Summary Form " dated 9/12/2011, was completed by the facility Physical Therapist (PT) who found Resident #107. The PT stated, " At 1:30 p.m. I began walking another patient when I heard a clatter in the bathroom. I found Resident (#107) on her hands and knees on the floor. She denied injury but stated she felt faint. I helped her stand and sit on the commode. Her underpants were still down around her knees. Patient stated she thinks she may have passed out " . In addition, Resident #107's nursing notes had documented after the fall, " Resident aware of precautions and usage of call bell express understanding by repeating ' I will call for help when I need to go to the bathroom ' . Further review of Resident #107 MDS documentation indicated the facility staff coded resident as needing limited assistance which included staff providing guided maneuvering of limbs or other non-weight bearing assistance and the need for one person physical assist regarding toilet use (how resident uses the toilet room and transfers on/off toilet). Moreover, the facility coded the resident under Section G " Balance During Transitions and Walking " as being not steady, only able to stabilize with human assistance performing the following tasks: -Moving from seating to standing position -Walking -Turning around and facing the opposite direction while walking -Moving on and off the toilet -Surface-to-surface transfer " The surveyor reviewed Resident #107's MDS with an ARD date 9/1/2011 which was prepared by the facility prior to the fall and the facility coding of Resident #107 was exactly the same regarding both Sections above. Resident #107's facility care plan documented that the resident required assistance with transfers, walking and toilet use. The Resident was at risk for falls and has a history of falls related to unsteady gait and required staff assistance for transfers. An interview was conducted on 9/21/2011 at 10:00 a.m. with Resident #107 regarding her fall. Resident stated that prior to entering the facility, she lived at home and had a fall over a " watermelon " which resulted in a fractured hip. Resident stated the day of the fall she was sitting on her toilet alone in her room and " blacked out " . An interview was conducted on 9/22/2011 at 8:00 a.m. with the Director of Nursing (DON) regarding the stated findings. The DON stated the resident stayed at home alone prior to admission and the facility wanted her to maintain her independence at the facility. The Administrator and management team were made aware of the findings on 9/21/2011 during the end-of-day briefing.

Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation the facility failed, for one resident, (Resident #20) of thirty-four residents in the survey sample, 1. To ensure that Resident #20 was safely propelled (pushed) in her wheel chair down the hall to prevent accidents. During the wheel chair transport the resident sustained [REDACTED]. And 2. The staff failed to ensure a safe transfer from bed to wheel chair for one resident (Resident # 9) of thirty-four residents in the survey sample. Resident #9 was transferred by one staff, fell and sustained a bilateral fracture of the distal femur (both thigh bones). The Findings included: 1. Facility staff failed to safely propel Resident # 20 in her wheel chair down the hall. During the wheel chair transport the resident sustained [REDACTED]. The findings included: 1. Resident #20 was a [AGE] year old originally admitted to the facility on [DATE]. Resident #20's [DIAGNOSES REDACTED]. The Minimum Data Set, which was an Annual Assessment with an assessment reference date of 7/29/10, coded Resident #20 as follows: "Cognitive/Decisionmaking - Moderately impaired Hearing - Hears in special situations only, speaker has to adjust tonal quality and speak distinctly. Indicators of Delirium - Periodic disordered thinking/awareness. Mental function varies over the course of the day. Long and Short-term memory - Impaired Vision - Moderately impaired Physical Functioning and Structural Problems - Total dependence in locomotion. Requires one person physical assist. Transfer from wheelchair requires two person assist. Mode of locomotion - Wheelchair - wheeled by other person Functional Limitation in Range of Motion - Partial loss of voluntary movement in right and left legs. Partial loss of voluntary movement in right and left feet." On 8/10/11 and 8/11/11 a review was conducted of facility documentation, revealing an investigation report dated 9/7/10 regarding Resident #20. The report read as follows: "Resident was noted by staff on 9/7/10 with swelling to her left leg. Dr. (name of Medical Doctor) notified and resident was assessed by a nurse practitioner who gave orders to send her to the hospital for evaluation of her leg. At the hospital x-rays were performed and the resident was diagnosed to have acute non-displaced fractures to her right tibia and fibula. Dr. (name of MD) stated that based on the x-rays that the fractures occurred 7-10 days prior to the date of her hospital admission which was 9/7/10." The investigation revealed that while being transported to activities on 9/1/10 in her wheelchair that the residents legs touched the floor while it was in motion causing her wheelchair to come to an abrupt stop. The resident was assessed at the time and medicated for pain per her standing orders. "During transports in her wheelchair, resident (Resident #20) had consistently demonstrated the ability to hold her legs up when needed during transports. Due to her dementia, wheelchair legs were not always used because if Resident attempted to stand then she would be at risk for falls due to the placement of the wheelchair legs." An interview was conducted with Administration B (Director of Nursing) on 8/10/11. According to Administration B, Resident #20 was always transported in her wheelchair without the use of leg supports or foot pedals. Administration B stated, " Evaluations for wheelchair use, and whether or not to use foot pedals, etc., are done by nursing staff, not by a physical therapist. Resident had a [DIAGNOSES REDACTED]. The resident was evaluated and the decision was made that the use of wheelchair legs created a greater potential for falling and serious injury." Administration B further stated, "Wheelchair legs and foot pedals are an accessory, not standard equipment." On 8/11/11, a facility documentation review was conducted, revealing a (name of company) wheelchair manual, which was submitted to the surveyor by Administrator B. Administrator B stated that Resident #20 used one of the standard wheelchairs from one of the three companies used by the facility. Regarding 'accessories', (pg. 21) the company only identified the following available accessories (none of which were leg rests or footrests, which was standard equipment): Anti-fold/anti-theft device Anti-tipper Brake Handle Extension I.V. Telescoping Pole I.V./ Oxygen Tank Holder Safety Belt The manual contained the following safety precautions: "The footrest assembly must be adjusted to your leg-length to prevent pressure on your thighs and to assure that your feet rest comfortably. Warning alert - Never use the wheelchair without proper training (p. 4). Attendants must follow all safety precautions. Understand the mechanisms of the chair prior to using it. Ensure footrests are locked in place maintaining proper floor clearance (p. 11)." On 8/10/11, a review of Resident #20's clinical record was conducted, revealing an examination report from (name of hospital) dated 9/7/10. The report read, "Findings compatible with fractures in the distal right tibia and fibula." On 9/10/10, Resident #20's physician ordered an X-ray and Doppler, which revealed a fracture of her left femur. Resident #20's clinical record did not contain any nursing notes from the date of the accident 9/1/10 thru 9/6/10. The clinical record did not contain any assessment of Resident #20's condition from 9/1/10 thru 9/6/10. The clinical record did not contain any skin assessments, physical evaluations, x-rays, or notification of the accident to her physician. On 8/11/11, an interview was conducted with Administrator B at 1:00 P.M. in the conference room. When asked about the lack of nurses notes or assessments in Resident #20's clinical record regarding the accident, Administration B stated, "We only chart by exception. Resident (#20) had no unusual symptoms on 9/1/10. After the incident, the resident was not screaming in pain. I know that the nurse should have written an assessment in the nurses notes. If she had pain, we would have addressed it. When asked if staff are trained to use wheelchairs, she stated "no they are not." Resident #20's plan of care dated 8/5/10 was reviewed. Prior to the accident on 9/1/10 the care plan made no reference to restless leg syndrome, or osteoporosis. The use of her wheelchair, and the decision to not use foot pedals or leg rests were not addressed in the care plan. Resident #20's Minimum Data Set, an annual assessment with an assessment reference date of 7/29/10, coded Resident #20 as having Quadriplegia, which was not addressed in her plan of care, regarding the use of a wheelchair or other adaptive equipment. Complaint Deficiency 2. Facility staff failed to transfer Resident #9 safely, resulting in bilateral distal fractures of the femur (thigh bone) in both legs. The resident was transferred with one staff person and not with two as coded per MDS assessment. Resident #9 was a [AGE] year-old admitted to the facility on [DATE] [DIAGNOSES REDACTED]. Resident #9's most recent MDS (Minimum Data Set Assessment) was a significant change with an ARD (Assessment Reference Date) of 7/5/2011 coded Resident #9 ' s BIMS (Brief Interview for Mental Status) summary score of 15 which determined the resident was cognitively intact. The facility staff coded Resident #9 as being totally dependent and needing 2 or more staff for transferring between bed and chair, wheelchair, and standing position. A review was conducted on 8/11/2011 of Resident #9 ' s facility documentation and clinical record. Resident #9 ' s clinical record dated 5/14/2011 at 10:30 a.m. documented the following: " Res. fell to floor during transfer from bed to wheelchair. ROM (range of motion) not tolerated. Complained of excruciating pain. (R) and (L) knee tender to touch with mild swelling noted ". Review of Resident #9 ' s clinical record revealed the resident was transferred to an emergency medical facility for additional evaluation. Resident #9 's hospital clinical record documented the resident was diagnosed with [REDACTED]. Subsequently, Resident #9 ' s hospital clinical records dated 5/15/11 at 3:57 p.m. documented " Pt stated she doesn ' t remember what happened, but she fell while she was walking from bedside to the wheelchair at her nursing home " . An interview was conducted on 8/10/2011 at 1:30 p.m. with Resident #9 and the resident was observed lying in bed watching television. The surveyor asked Resident #9 about her accident. Resident stated she was happy with the facility did not want to cause any trouble, but she had severe Arthritis and Osteoporosis in her lower extremities for years. The resident stated that both of her knees have been surgically replaced in the past and she can longer stand for a long time or walk prior to the fall. Resident #9 stated she remembered getting out of bed attempting to transfer into her wheelchair with the assistance of one Certified Nursing Assistant (CNA). Resident #9 stated she remembered before the fall standing in one position for a " long time " . The surveyor asked the resident if there was anything different about this transfer. Resident #9 answered my wheelchair was not in my room it was located at the entrance of my room doorway and usually the staff bring it next to my bed. The surveyor reviewed Resident #9 ' s MDS and care plan prepared by facility staff prior to the resident accident. Resident #9 ' s MDS with an ARD dated of 4/19/2011 coded resident ' s transfer ability from bed to chair/wheelchair as needing extensive assistance and needing 2 or more staff for physical assist. Moreover, the facility staff coded Resident #9's " Functional Limitation in Range of Motion " regarding her upper and lower extremities as being impaired on both sides. Resident #9 's " Balance during transitions and Walking " pertaining to surface-to-surface transfer (transfer between bed and chair or wheelchair) was coded as not steady, only able to stabilize with human assistance. Resident #9 ' s care plan also prepared prior to the fall indicated the facility staff care planned her for at risk for falls related to unsteady gait and requiring staff assistance for transfers. An interview was conducted on 8/10/2011 at 3:40 p.m. with the facility Certified Occupational Therapist Assistant (COTA) the staff who completed Resident #9 ' s Rehabilitation Screening. The COTA stated she completed Resident #9 last Rehab screening on 1/31/2011 and was going to re-evaluate the resident because of several concerns made by the nursing staff involving resident having difficulties with ambulating. COTA explained the resident had a difficult time during the screening and therapy session because she needed a lot of motivation and assistance from staff. The surveyor was provided a copy of Resident #9 Rehabilitation Screening Form. The COTA explained Resident #9 was screened as a MOD (A) for transferring 50/50 which means 50% assistance was needed from the resident and 50% from staff was needed to obtain this goal. Moreover, resident was screened as a MAX (A) for Gait (walking) which 25/75 which means 25% assistance was needed from the resident and 75% from staff to achieve this goal. The surveyor asked the COTA in order to transfer Resident #9 from bed to wheelchair how many staff would you expect was needed. The COTA answered at least 2 staff. The surveyor asked the COTA to explain the resident rehabilitation screening process and how that information is conveyed and interpreted to the nursing staff. COTA stated the resident 's rehabilitation screening was conducted by the rehabilitation department and that information was written in the resident 's chart. COTA stated the nursing staff interprets the screening meaning if a nurse feels comfortable getting a resident out bed alone it 's their decision. An interview was conducted on 8/11/2011 at 10:25 a.m. with CNA (J), nursing staff responsible for transferring Resident #9 during the fall. CNA (J) stated she had worked for the facility for 5 years and she had transferred Resident #9 to her wheelchair several times in the past. CNA (J) stated normally one staff was needed for Resident #9 with the assistance of a gait belt. She stated prior to the fall, the resident was standing hold onto the bed in the process of turning (pivoting) into the wheelchair which was positioned near the bed. CNA (J) stated " it was just one of those days " Resident #9 lost her balance and fell to the floor and we are trained to guide them to the floor. The surveyor asked how many staff was needed to transfer Resident #9. CNA (J) answered on a good day one staff with a gait belt and a bad you may need 2 staff present. Further review of Resident #9 ' s clinical record showed no additional documentation that the facility was continually monitoring the resident 's ability to transfer from bed to wheelchair. Resident #9's last rehabilitation screening was completed by the facility staff on 1/31/2011 and no additional evaluation of assessment was completed by the facility staff. In addition, the facility staff care plan and MDS regarding Resident #9 prior to the fall identified the resident as a fall risk, but the surveyor could not find any additional documentation that the facility staff was utilizing the clinical information documented regarding her transfers. The facility administrator and Director of Nursing were made aware of the stated findings at the end-of-day brief on 8/11/2011 and no additional information was provided to the surveyor.

Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation the facility failed, for one resident, (Resident #20) of 34 residents in the survey sample, to ensure that the resident was assessed and treated after an injury in a timely manner. Facility staff failed to assess and treat Resident #20 for six days after a wheelchair transport accident which caused two broken bones in her right leg, and one broken bone in her left leg. The findings included: Resident #20 was a [AGE] year old originally admitted to the facility on [DATE]. Resident #20's [DIAGNOSES REDACTED]. The Minimum Data Set, which was an Annual Assessment with an assessment reference date of 7/29/10, coded Resident #20 as follows: "Cognitive/Decisionmaking - Moderately impaired Hearing - Hears in special situations only, speaker has to adjust tonal quality and speak distinctly. Indicators of [MEDICAL CONDITION] - Periodic disordered thinking/awareness. Mental function varies over the course of the day. Long and Short-term memory - Impaired Vision - Moderately impaired Physical Functioning and Structural Problems - Total dependence in locomotion. Requires one person physical assist. Transfer from wheelchair requires two person assist. Mode of locomotion - Wheelchair - wheeled by other person Functional Limitation in Range of Motion - Partial loss of voluntary movement in right and left legs. Partial loss of voluntary movement in right and left feet." On 8/10/11 and 8/11/11 a review was conducted of facility documentation, revealing an investigation report dated 9/7/10 regarding Resident #20. The report read as follows: "Resident was noted by staff on 9/7/10 with swelling to her left leg. Dr. (name of MD) notified and resident was assessed by a nurse practitioner who gave orders to send her to the hospital for evaluation of her leg. At the hospital x-rays were performed and the resident was diagnosed to have acute non-displaced fractures to her right tibia and fibula. Dr. (name of MD) stated that based on the x-rays that the fractures occurred 7-10 days prior to the date of her hospital admission which was 9/7/10." The investigation revealed that while being transported to activities on 9/1/10 in her wheelchair that the resident ' s legs touched the floor while it was in motion causing her wheelchair to come to an abrupt stop. The resident was assessed at the time and medicated for pain per her standing orders. "During transports in her wheelchair, Resident (Resident #20) had consistently demonstrated the ability to hold her legs up when needed during transports. Due to her dementia, wheelchair legs were not always used because if Resident (Resident #20) attempted to stand then she would be at risk for falls due to the placement of the wheelchair legs." The investigation included a statement from the staff member who was transporting the resident at the time of the accident. It read, " I (name) was pushing (resident) down the hall to activities, and she had her feet up and then she dropped her feet and her left leg must of went under the wheelchair a little bit. She yell out ouch, and I asked her is she ' s okay, and she said yes, I ' m okay, and I finished bringing her down the hall. " The staff member took Resident #20 to the activity, without having a nurse do an assessment. The staff member was no longer employed at the facility during the time of the survey. The facility Administrator stated on 8/10/11 that no disciplinary action was taken against the staff member. On 8/10/11, a review of Resident #20's clinical record was conducted, revealing no documentation that Resident #20 was able to consistently hold her legs up during transport. The resident ' s care plan did not address her ability to hold her legs up during transport. Resident #20 ' s Minimum Data Set documented that Resident #20 could not always control the movement of her legs, " Functional Limitation in Range of Motion - Partial loss of voluntary movement in right and left legs. Partial loss of voluntary movement in right and left feet. " Due to her dementia, short term memory loss, and partial loss of voluntary movement in her legs, Resident #20 could not be expected to consistently hold her legs up on command during a trip from one location in the facility to another. An interview was conducted with Administration B (Director of Nursing) on 8/10/11. According to Administration B, Resident #20 was always transported in her wheelchair without the use of leg supports or foot pedals. Administration B stated, " Evaluations for wheelchair use, and whether or not to use foot pedals, etc., are done by nursing staff, not by a physical therapist. Resident (Resident #20) had a [DIAGNOSES REDACTED]. The resident was evaluated and the decision was made that the use of wheelchair legs created a greater potential for falling and serious injury." Administration B further stated, "Wheelchair legs and foot pedals are an accessory, not standard equipment." On 8/10/11, a review of Resident #20's clinical record was conducted, revealing an examination report from (Name of Hospital) dated 9/7/10. The report read, "Findings compatible with fractures in the distal right tibia and fibula." On 9/10/10, Resident #20's physician ordered an X-ray and Doppler, which revealed a fracture of her left femur. Resident #20's clinical record did not contain any nursing notes from the date of the accident 9/1/10 thru 9/6/10. The clinical record did not contain any assessment of Resident #20's condition from 9/1/10 thru 9/6/10. The clinical record did not contain any skin assessments, physical evaluations, x-rays, or notification of the accident to her physician. On 8/11/11, an interview was conducted with Administrator B at 1:00 P.M. in the conference room. When asked about the lack of nurse ' s notes or assessments in Resident #20's clinical record regarding the accident, Administration B stated, "We only chart by exception. Resident (Resident #20) had no unusual symptoms on 9/1/10. After the incident, the resident was not screaming in pain. I know that the nurse should have written an assessment in the nurse ' s notes. If she had pain, we would have addressed it." A review of Resident #20 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #20 was not evaluated or medicated for pain according to her clinical record. No evaluation for pain was done on 9/2/10, 9/3/10, 9/4/10, 9/5/10, or 9/6/10. The first evaluation was done on 9/7/10. An interview was conducted with the Director of Nursing on 8/10/11. When asked about the timeline regarding the facility ' s response to the accident, she stated that no assessment or treatment was done for the resident from 9/1/11 through 9/6/11. In response to the surveyor ' s request for a written timeline of the events, the DON submitted the following written timeline: " 9/7/10: New order to send to the Emergency Department for possible bilateral [MEDICAL CONDITION]/PE 9/8/10: Returned from ER [DIAGNOSES REDACTED]. 9/9/10: MD in to visit ...significant [MEDICAL CONDITION] with advanced [MEDICAL CONDITION] as well as fracture of left femur. New order for ortho follow up 9/10/10-9/15/10: Resident with pain issue that were being managed with her pain medication as per order 9/15/10: Up and out to follow up appointment with ortho 9/16/10-9/20/11: (typo In document- should state 9/20/10) Continuing to address pain management issues as per order. " Resident#20's plan of care dated 8/5/10 was reviewed. Prior to the accident on 9/1/10 the care plan made no reference to restless leg syndrome, or [MEDICAL CONDITION]. The use of her wheelchair and the decision to not use foot pedals or leg rests was not addressed in the care plan. In addition, the care plan addressed falls. It read, " Problem: resident is at risk for falls related to short term memory loss, requires reminders to call for assistance, requires staff assistance for transfers, and impaired sensation (paralysis). Approach: falling star program, keep bed in lowest position, refer to Physical therapy or Occupational therapy for screening or evaluation. " " Problem: Updates/Revisions to plan of care for falls secondary to resident experiencing a fall(s) or change in risk factors. Approach: Educate resident and/or responsible party on risks associated with potential for fall; invite and encourage resident to participate in prevention plan. " The intervention did not address the use of a wheelchair without using foot pedals. The resident was not referred to physical therapy or occupational therapy for an evaluation. Resident #20 ' s care plan addressed pain management. It read, " Problem: Resident is at risk of pain/discomfort related to [MEDICAL CONDITION], GERD. Approach: Encourage and assist resident to identify intensity, quality and location of pain. Encourage resident to tell nurse when pain interventions are not being effective. " Resident #20's Minimum Data Set, an annual assessment with an assessment reference date of 7/29/10, coded Resident #20 as having [MEDICAL CONDITION], which was not addressed in her plan of care, regarding the use of a wheelchair or other adaptive equipment. Complaint deficiency.