Every finding on record at Lantern Park Specialty Care

Based on clinical record review, facility policy review, and staff interviews, the facility failed to educate a resident and/or a resident representative and obtain an informed consent prior to two changes in psychotropic medications for 1 of 3 residents (Resident #60) reviewed. The facility reported a census of 86 residents.Findings include:Review of the Minimum Data Set (MDS) assessment, dated 7/2/25 for Resident #60 revealed diagnoses list which included post-traumatic stress disorder (PTSD), depression, and adjustment disorder with mixed anxiety and depressed mood. A Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicated a severe cognitive impairment. Review of the Care Plan revealed Focus areas to address: a. I feel down or depressed at times. Date initiated: 12/9/24.b. I feel lonely or isolated at times. Date initiated: 3/11/25.c. I have a history of physical or emotional trauma. Date initiated: 3/15/25.d. I use antipsychotic medications related to depression. Date initiated: 4/16/25. A Focus area, dated initiated 3/7/25, addressed I use Duloxetine an antidepressant medication. Interventions included, in part Educate me, my family, and caregivers about risks, benefits and the side effects and/or toxic symptoms of antidepressant medication. Date Initiated 9/28/24. Review of a document titled Medical Record-Doctor's Orders, dated 6/20/25 revealed Week 1: decrease duloxetine to 30 mg (milligrams) daily and start sertraline 50 mg daily. Week 2: Stop duloxetine and increase sertraline to 100 mg daily (continue until follow-up). Continue prazosin 1 mg QHS (every bedtime). Continue quetiapine 100 mg QHS. Continue trazodone 25 mg BID (twice daily). Follow up in 6 weeks.Review of the electronic health record (EHR) revealed a Order-Administration Note entered at 9/24/25 at 9:11 AM revealed N.O. (new order) from VA (Veteran Affairs) - Week 1: Decrease Duloxetine to 30 mg daily and start Sertraline 50 mg daily; Week 2: Stop Duloxetine and increase Sertraline to 100 g daily (continue until follow-up). Continue Prazosin 1 mg q HS; Continue Quetiapine 100 mgq HS. Continue Trazodone 25 mg BID; Follow up in 6 weeks. Entered into [redacted brand name of EHR system]Review of a Communication-with Family note entered on 6/24/25 at 0:33 AM revealed Attempted to notify [name of Resident #60 wife redacted] of new orders. Left message for her to call facility for notification. Review of the EHR revealed a lack of follow up communication with the Resident #60's family representative regarding the change in psychotropic medications ordered on 6/20/25 and started on 6/24/25. Review of a SPN - Focused Evaluation noted entered on 6/25/25 at 10:04 AM revealed, in part:.Monitoring d/t (due to) decrease dose of Duloxetine and N.O. Sertraline. Initial dose of each this morning. No s/s (signs/symptoms) adverse rxn (reaction) @ this time. Will continue to monitor. During an interview on 7/31/25 at 9:49 AM, the Administrator stated when a medication change is made there would be a signed informed consent document to indicate the resident and/or family representative was informed and educations on the change. Review of the facility provided Informed Consent for Psychotropic Medication for Resident #60 psychotropic medications revealed an unsigned consent with an effective date for 6/24/25 for Antidepressant Zoloft (sertraline) 25-200 mg per day, once daily dosing. On 7/31/25 at 11:35 AM by email communication, the Administrator stated the facility does not have a policy related to Mental Health Monitoring. The Administrator provided a policy titled Change in Condition Policy, revised March 2018. The policy did not address the need for informed consent to be completed prior to a change in psychotropic medications.

Based on clinical record review, Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023 (RAI) review and staff interview the facility failed to complete a Minimum Data Set for a significant change after a hospice admission for 1 of 4 residents (Resident #2) reviewed for hospice. The facility reported a census of 86 residents. Findings include:Review of Physician Orders for Resident #2 revealed Order Details entered on 6/2/25 with the Description: Receiving Hospice services from [provider name redacted] for Alzheimer's dementia effective 4/14/25. Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023 (RAI) page 2-17 directed providers, in part .the MDS completion date is no later than the 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). Page 2-25 of the RAI directed, in part .an SCSA (Significant Change in Status Assessment) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home.During an interview on 7/31/25, the MDS Coordinator confirmed Resident #2 started to receive hospice services on 4/14/25. She stated a significant change MDS should have been completed.

Based on clinical record review, Resident Assessment Instrument (RAI) manual review, and staff interviews the facility failed to complete quarterly Minimum Data Set assessments in a timely manner for 3 of 3 residents (Resident #49, Resident #51, Resident #84) in the sample. The facility reported a census of 86 residents.Findings include: 1. Review of the electronic health record (EHR) revealed Resident #49 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment documented a completion date of 2/26/25. Review of the MDS history list indicated a MDS Quarterly assessment completed on 7/18/25. A space of 142 days after the admission assessment. 2. Review of the EHR revealed Resident #51 admitted to the facility on [DATE]. The admission MDS assessment documented a completion date of 1/3/24. Review of the MDS history list indicated MDS Quarterly Assessments completed on 3/7/25, and 7/18/25. A space of 133 days between the assessments. 3. Review of the EHR revealed a Quarterly MDS assessment for Resident #84 completed on 9/30/24, with the next assessment completed on 1/3/25. A space of 95 days between the assessments. During an interview on 7/31/25 at 8:33 AM with the facility's new MDS Coordinator and the Administrator, the Administrator stated the corporate support team had been doing the MDS assessments on and off while a new Coordinator was hired. The MDS Coordinator indicated the nursing portion would be completed by her, social services and activities and dietary would do their own sections, and she would submit the final assessment. She stated the quarterly assessments should be completed within 92 days. The Administrator stated the prior Coordinator should have completed the assessments. The MDS Coordinator stated her training for the last few weeks had been correcting the errors they found. When asked if the facility had filled out the Self Identification form at the beginning of the survey to indicate MDS corrections were something they were working on, the Administrator said no. She stated they just opened them and fixed them. They MDS Coordinator indicated she would use the corporate team and the RAI manual for support going forward.Review of the RAI User's Manual dated October 2024, Version 1.19.1, page 2-18, revealed a direction for an assessment to be completed every 3 months. The Manual directed the assessment reference date could be no later than the last assessment plus 92 calendar days.

Based on clinical record review, resident interview and staff interview the facility failed to provide at least 2 baths per week for 2 of 3 residents (Residents #13 and Resident #61) reviewed. The facility reported a census of 86 residents. Findings include:1. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #13 with Brief Interview for Mental Status (BIMS) score 14 out of 15 which indicated intact cognition. The MDS assessed Resident #13 required substantial/maximal assistance for showering. Review of the Care Plan, dated 9/27/23 revealed a Focus area to address Activities of Daily Living (ADL's). Interventions included, in part: Bathing: I require 1 assist. Date Initiated: 9/27/23. During an interview on 7/28/25 at 11:30 AM, Resident #13 stated she does not get showers very often. Review of Resident #13's Documentation Survey Report V2 for April, May, June and July 2025 revealed the resident was scheduled for a shower twice a week on Tuesday and Friday. Resident #13 documented showers occurred in April 2025 on April 4, April 23, and April 24; in May 2025 on May 4, May 9, May 20, May 23, May 30, and May 31; in June 2025 on June 2, June 10, June 13, and June 27; and in July 2025 on July 1, July 8, July 11, July 15, and July 16. 2. Review of the MDS, dated [DATE], revealed Resident # 61 with a BIMS score 15 out of 15 which indicated intact cognition. The MDS assessed Resident #61 required substantial/maximal assistance for showering. Review of the Care Plan, dated 10/17/23 revealed a Focus area to address Activities of Daily Living (ADL's). Interventions included, in part: Bathing: I require x1 assist. Date Initiated: 10/17/23. During an interview on 7/28/25 at 1:19 PM, Resident #61 explained staff are slow to give showers. He stated he hadn't had a shower for over a week. The resident appeared to have greasy hair, and a slight body odor. Review of Resident #61's Documentation Survey Report V2 for April, May, June and July 2025 revealed the resident was scheduled for a shower twice a week on Tuesday and Friday. Resident #61 documented showers occurred in April 2025 on April 1, April 8, April 23, April 24, and April 25; in May 2025 on May 2, May 6, May 9, and May 20; in June 2025 on June 3, June 10, June 13, June 21, June 25, and June 27; and in July 2025 on July 1, July 2, July 11, July 15, July 18, and July 29. During an interview on 7/31/25 at 11:17 AM, the Administrator explained everyone should be getting a shower twice a week.

Based on observation, clinical record review, staff and resident interviews, and policy review the facility failed to ensure respiratory care devices are on and operational for 2 of 3 residents reviewed (Residents #1 and #18) and failed to maintain oxygen tubing in a clean and sanitary manner for 1 of 3 residents reviewed (Resident #1) for respiratory care. The facility reported a census of 86.Findings include: 1. The Minimum Data Set (MDS) for Resident #18 documented diagnoses of pulmonary hypertension due to left heart disease, heart failure, and dependence on supplemental oxygen. The Care Plan (CP) for Resident #18 documented altered respiratory status related to congestive heart failure, the resident experienced frequent shortness of breath, and staff should monitor oxygen at 2-4 liters and ensure sats were at comfort levels (88%-95%). During an interview with Resident #18 on 7/28/25 at 11:01 AM she indicated she had troubles breathing on and off. She pointed at the concentrator in her room and said it wasn't on, then stared at the machine to see if she could tell what number it was on. She thought she was hooked up to the concentrator. The resident stated she was was short of breath the other night, ended up in the emergency room, and once in awhile things like this happened. She clarified she meant the concentrator wasn't on or the tank wasn't working. During the interview the surveyor observed the oxygen tubing in her nose did not have a date tag on it and was attached to the portable tank behind her on her wheelchair. The tank was not producing a flow according to the resident. At 11:09 AM on 7/28/25 the resident put her call light on for help. 4 minutes later Staff E, Certified Nurses Aide (CNA) came in to help her. When asked if the oxygen should have been running through the tank or her tubing hooked up to the concentrator, he said yeah probably. He unhooked the tubing from the portable tank and indicated it was not running. He plugged it into the concentrator and turned it on. On 7/31/25 at 2:03 PM Resident #18 was in her room with family. They reported that her breathing seemed good today but they had come in a couple of times to find the portable was out of oxygen and she was not hooked up to the concentrator. At this time the resident stated she felt short of breath and wanted the nurse. The nurse left the resident's room at 2:11 PM on 7/31/25 at told the Administrator the resident 'desated' a couple of days ago and it was causing her to feel anxious that it would happen again. 2. The MDS for Resident #1 documented diagnoses of pneumonia, acute and chronic respiratory failure, and chronic obstructive pulmonary disease (COPD). The CP for Resident #1 revealed the resident experienced altered respiratory status/difficulty breathing. Staff provided oxygen therapy for sleep apnea, assistance with BiPAP/CPAP equipment, and ensured oxygen was set at 2 liters per nasal cannula. Staff were directed to ensure oxygen equipment was running. During an observation on 07/28/2025 at 2:19 PM the resident was in the common area with his nasal cannula hooked up to a portable oxygen tank talking with the hospice nurse. Staff determined the tank was not running and brought out the concentrator from his room. During an observation on 7/30/25 at 9:45 AM Resident #1 was out of his room. The oxygen tubing, dated 7/28/25, was attached to the concentrator in his room and partially wrapped in a circle around the top of the machine. A portion of the tubing approximately two feet long was hanging off of the side of the machine with a section about 4 inches long touching the side of a garbage can. The garbage contained an open brief and a soiled wipe hanging over the side. The tubing touched the side of the brief and the plastic of the garbage can liner. On 7/31/25 after breakfast the resident was observed using oxygen tubing dated 7/28/25. On 7/31/25 at 8:51 AM Staff B, Certified Medication Aide (CMA) stated tanks were monitored every shift, and that management encouraged concentrators instead of tanks because the tanks go fast. They didn't want residents to desaturate. She stated all staff were responsible for monitoring tanks and thought residents on 2 liters of oxygen should be checked at least every 45 minutes. During an interview with Staff C, Nurse, on 7/31/25 at 9:11 AM she stated the nurses did pretty much everything related to oxygen care. They dated the tubing, made sure it was the appropriate length, made sure the water was bubbling, ensured tanks were full, and made sure there was oxygen coming through the tubing. She didn't think the Certified Nursing Aides (CNA) did much with oxygen. She stated it was her job to switch residents from portable tanks to concentrators if needed. She wasn't sure about the tubing being on the floor next to the garbage can. She had not been made aware resident tanks were running out. On 7/31/25 at 9:27 AM the Director of Nursing stated any nursing personnel can turn the tanks on and off and bring concentrators to common areas, they just can't change the flow. She did not expect them to be off of the portable tanks in their rooms but did expect them to be running on the right setting and working no matter which one they used. Ideally they would switch to the concentrator in their rooms.A policy titled Oxygen Administration revised October 2010 directed staff to check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Staff should ensure there was water in the humidifying jar and that the water level was high enough that the water bubbles as oxygen flowed through.

Based on observation, clinical record review, interviews, and policy review the facility failed to provide trauma informed care for 1 of 3 residents reviewed (Resident #60). Resident #60 experienced suicidal ideations that were not addressed in their care plan, staff did not adequately monitor mental health behavior for patterns and medication changes, and staff were not able to articulate resident behavior triggers. The facility reported a census of 86 residents. Findings include: The Minimum Data Set (MDS) for Resident #60 dated 7/2/25 documented diagnoses of post traumatic stress disorder (PTSD), depression, and adjustment disorder with mixed anxiety and depressed mood. His Brief Interview for Mental Status (BIMS) assessment resulted in a score of 6/15, which indicated severe cognitive impairment. The Care Plan (CP) for Resident #60, with an admission date of 3/7/25, documented focus areas as follows:12/9/24 the resident felt down or depressed at times3/7/25 the resident used duloxetine as an antidepressant3/11/25 the resident felt lonely and isolated at times3/15/25 the resident had a history of physical or emotional trauma4/16/25 the resident used an antipsychotic related to depressionA CP goal was to not have a trauma triggered event. It did not identify the type of trauma, trauma triggering events, or signs and symptoms that indicated the resident was experiencing a trauma response. Another goal indicated the resident would decrease episodes of verbally aggressive behavior towards his wife and family by 50%. It did not address verbally aggressive behavior towards others in the facility or triggering events to watch for.The CP did not include the resident's history of suicidal ideations, safety measures or a crisis plan, or suicidal behavior monitoring. It did not include the resident's history of nightmares, medication for nightmares, or monitoring protocol.A point of care document used daily by the Certified Nursing Assistants (CNAs) printed on 7/30/25 did not include behavior monitoring, triggers, or interventions.The resident's Supplemental Documentation printed by the facility on 7/31/25 at 10:42 AM for July indicated the resident should be monitored for behaviors related to the use of antidepressant medication sertraline, trazodone, and duloxetine every shift as follows: 0- no behaviors; 1- lack of motivation; 2- excessive crying; 3- suicidal thoughts; 4- loss of appetite; 5- social withdrawal; 6- self isolation; 7- other see progress notes.Intervention codes included: 0- None; 1- encourage to voice concerns; 2- 1:1 with social services; 3- call family/friend; 4- weighted blanket; 5- music; 6- take a walk; 7- diversional activity; 8- other.A checkmark on the MAR meant administered. From 7/7/25 through 7/30/25 one day had a 6 and one day was blank. The remaining days contained a checkmark only.An additional section directed staff to document behaviors related to PTSD, and if there were no behaviors staff should enter a progress note. Of the 90 entries for 7/1/25 through 7/30/25 2 were blank, one contained the number 6, and the rest contained a checkmark. Corresponding progress notes indicated 1 shift of behavior monitoring on 7/6/25 and 7/8/25. No behavior documentation occurred in the progress notes on 7/5/25, 7/9/25, 7/10/25, 7/13/25, or 7/20/25 through 7/22/25.The task tab of the EHR indicated staff should monitor behavior symptoms PRN (as needed). There were no entries for the past 30 days. The facility did not provide the most recent psychology appointment summary for review.During an observation on 7/28/25 at 11:07 AM the resident was wheeling himself down the hall in his wheelchair past another resident's room. He yelled that he was going to protect his country and nothing could stop him, swung his arms in the air and at the resident's door, talked to himself, and grimaced. He groaned, started mumbling under his breath, and then yelled shut up and no dammit. The other resident asked the surveyor to shut her door and indicated this was not new behavior.During an observation on 7/28/25 at 12:41 PM Resident #60 left the dining room table independently in his chair and spoke to staff at the nurses station. He was then observed in the hallway shouting that his wife never came to see him and was cheating on him. An interview with Staff B, Certified Medication Aide (CMA) on 7/31/25 at 8:51 AM revealed she hadn't done much hands on non-pharmacological interventions with the resident. She didn't know what triggered some of his behaviors and he needed to be reassured a lot. She stated the nurses got the paperwork from his psychology appointments and they (CNA/CMA) were not allowed to see that. She thought behavior monitoring and interventions might be on the MAR.During an interview with Staff C, Nurse on 7/31/25 at 9:11 AM she stated she wasn't really sure what the resident's triggers were. She knew he got upset when he saw or talked to his wife sometimes, though it was just when she came in and when she left. Staff C stated all staff could watch for behavior changes. She reported a lot of recent medication changes. Staff C tried to put behavior information in the progress notes and thought that was where it should be but said there might be a behavior tab. She did not know what happened at his last appointment with the psychologist.On 7/31/25 at 1:21 PM Staff D, Social Services Director, stated the resident did have triggers. She indicated sound was a big trigger, especially the alarms. The resident was triggered by hallucinations regarding his wife, and would call and leave her nasty messages. He would talk about her cheating and being dead. Dementia could be a trigger because he forgot what was real and what was not. She reported interventions were therapy, 1:1, and being directed to the social services office and stated the other social worker knew more coping mechanisms. She didn't know why they were not on the care plan.The Administrator, during an interview on 7/31/25 at 9:49 AM, stated she didn't know if the resident had triggers and interventions in his care plan. She stated the psychologist wasn't good about sending the after visit notes, thought the nurses called to ask for them, and that documentation of that communication should be in the progress notes. She expected behaviors to be documented in the MAR or progress notes, and acknowledged marking behaviors as administered was not accurate documentation. She stated the resident's suicidal ideation was a report that he didn't want to live and she would expect that history, signs to watch for, and interventions would be in the care plan.The facility provided a policy titled Acute Condition Changes - Clinical Protocol revised March 2018 when asked for a policy for mental health changes or behavior monitoring protocol. It documented the nurse would assess and document baseline information related to cognitive and emotional status; onset, duration, and severity of condition; and history of psychiatric disturbances, mental illness, depression, etc. The nursing staff would collect pertinent details to report to the physician, and would monitor and document the resident's progress and responses to treatment.

Based on observation, resident interview and staff interview the facility failed to answer call lights in 15 minutes or less for 3 of 3 observations for call light response. The facility reported a census of 86 residents.Findings include:During an interview on 7/28/25 at 3:20 PM, Resident # 18 explained it takes a long time for staff to answer call lights, over 15 minutes. During an interview on 7/28/25 at 4:06 PM, Resident # 3 explained it takes 35-40 minutes for staff to answer call lights. During an observation on 7/28/25, the call light was observed on for room [ROOM NUMBER] at 3:30 PM. Staff did not enter the resident's room until 4:05 PM. The light was observed on for 35 minutes. During an observation on 7/28/25, the call light was observed on for room [ROOM NUMBER] at 3:40 PM. Staff did not enter the resident's room until 4:10 PM. The light was observed on for 30 minutes. During an observation on 7/31/25, the call light was observed on for room [ROOM NUMBER] at 8:47 AM. Staff did not enter the resident's room until 9:04 AM. The light was observed on for 17 minutes. During an interview on 7/31/25 at 11:17 AM, the Administrator explained her expectation would be for call lights to be answered in less than 15 minutes.

Based on clinical record review, staff interview, and facility policy review the facility failed to ensure residents were free from significant medication errors for six of ten residents reviewed for medication administration (Resident #3, Resident #4, Resident #12, Resident #13, Resident #14, and Resident #15). The facility reported a census of 84 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 8/1/24 revealed the resident scored 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Review of the resident's October 2024 Medication Administration Record (MAR) revealed multiple morning medications marked with a code of 9, which indicated other/see progress note. The resident's morning medications not given included Metoprolol Succinate ER Tablet Extended Release 24 hour 25mg (milligrams), with instructions to give 0.5 tablet by mouth once a day for hypertension. Review of Progress Notes for Resident #3 revealed the following: a. 10/8/24 at 10:58 AM authored by Staff A, Registered Nurse (RN): Missed administration d/t (due to) not enough help. b. 10/9/2024 at 1:25 PM: Notified [Name Redacted] ARNP (Advanced Registered Nurse Practitioner) of medication error on 10/8/24, no new orders received. 2. Review of the clinical record revealed the MDS Assessment for Resident #15 remained in progress. Resident #15's Care Plan dated 10/4/24 revealed, I have altered cardiovascular status related to Paroxysmal Atrial Fibrillation, Cardiomyopathy, Unspecified, Essential (Primary) Hypertension, Acute on Chronic Diastolic (Congestive) Heart Failure). Review of the resident's October 2024 MAR revealed multiple morning medications marked with a code of 9. The resident's morning medications not given included Digoxin Oral Tablet 125 MG. Review of Progress Notes for Resident #15 revealed the following: a. 10/8/24 at 10:53 AM authored by Staff A: Missed administration d/t not enough help. Review of the Daily Staffing Sheet dated 10/8/24 revealed two nurses and one Certified Medication Aide (CMA) were scheduled to work first shift. Staff A was one of the two nurses scheduled to work. On 10/17/24 at 8:48 AM during an interview with the Regional Director of Operations (RDO), the RDO explained the following about what occurred on 10/8/24: Staff A had asked the RDO if she could connect prior to Staff A leaving. Per the RDO, as Staff A was walking out (of facility), the RDO said it looked like they did not connect. Per the RDO, Staff A explained she did not have a lot of time and needed to get out of (facility), said she (Staff A) didn't get everything done today, later further clarified per interview as supplemental documentation and a couple/some meds (medications). The RDO explained Staff A asked if she could come back the next day. The RDO explained she (RDO) connected with the team and it had not just been a couple of meds, was a lot of AM meds. The RDO explained Staff A had been at the facility until around 3:30 PM, and had been scheduled for 6:00 AM to 2:00 PM on the date of the incident. Review of the Facility Policy titled Administering Medications, revised 4/19, revealed the following: Medications are administered in accordance with prescriber orders, including any required time frame .the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 48888 3. Resident #4 example: Review of the MDS assessment for Resident #4 dated, 9/13/24, revealed the resident scored 11 out of 16 on a BIMS exam, which indicated moderately impaired cognition. Resident #4 had diagnosis of Diabetes Mellitus. The Care Plan, initiated 1/15/22, revealed Resident #4 required insulin related to diagnosis of Diabetes Mellitus with an intervention that instructed staff to administer insulin as ordered by physician. Review of the resident's October 2024 MAR indicated that the morning dose of Insulin Glargine 18 units had been given by Staff A on 10/08/24. Review of Progress Notes for Resident #4 revealed the following: On 10/08/24 at 9:55 AM, a note written by executive department informed that Resident #4 missed medication insulin glargine 18 units morning dose and weekly weight. On 10/9/2024 at 1:25 PM: Notified Provider of medication error on 10/8/24, no new orders received. 4. Resident #12 example: Review of the MDS for Resident #12, dated 7/12/24, revealed the resident scored 14 out of 15 on a BIMS exam, which indicated intact cognition. Diagnoses included: atrial fibrillation, Heart Failure, and Coronary Artery Disease (CAD). Review of the resident's October 2024 MAR revealed multiple morning medications marked with a code of 9, which indicated other/see progress note. The morning medications not given included Metoprolol Tartrate 50mg (milligrams), with instructions to give 1 tablet by mouth twice a day for hypertension, Furosemide (Lasix) 20mg, with instructions to give 2 tablets daily for blood pressure, and Eliquis 5mg, with instructions to give 1 tablet twice a day for blood clots. Review of Progress Notes for Resident #3 revealed the following: a. 10/8/24 at 10:58 AM, authored by Staff A, Registered Nurse (RN): Missed administration due to not enough help. b. 10/9/2024 at 1:25 PM: Notified Provider of medication error on 10/8/24, no new orders received. 5. Resident #13 example: Review of the MDS assessment for Resident #13, dated 9/23/24, revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. Diagnoses included Diabetes Mellitus, Coronary Artery Disease (CAD), and hypertension Review of the resident's October 2024 MAR revealed multiple morning medications marked with a code of 9, which indicated other/see progress note. The morning medications not given included Carvedilol 25mg, with instructions to give 1 tablet by mouth twice a day for hypertension and Furosemide (Lasix) 20mg, with instruction to give 1 tablet by mouth twice per day for hypertension. The MAR additionally revealed omission of morning and noon doses Insulin Aspart 5 units, with instructions to inject 5 units subcutaneously at meal times. Review of Progress Notes for Resident #14 revealed the following: a. 10/8/24 at 10:58 AM, authored by Staff A, Registered Nurse (RN): Missed administration due to not enough help. b. 10/9/2024 at 1:25 PM: Notified Provider of medication error on 10/8/24, no new orders received. 6. Resident #14 example: Review of the MDS assessment for Resident #14, dated 9/12/24, revealed the resident scored 12 out of 15 on a BIMS exam, which indicated moderately impaired cognition. Review of the resident's October 2024 MAR revealed multiple morning medications marked with a code of 9, which indicated other/see progress note. The morning medications not given included Furosemide (Lasix) 20mg, with instructions to give 1 tablet by mouth once a day for Congestive Heart Failure (CHF), Metoprolol Succinate ER Tablet Extended Release 24 hour 25mg (milligrams), with instructions to give 0.5 tablet by mouth once a day for hypertension, and Levetiracetam (Keppra) 500mg, with instructions to give 1 tablet by mouth twice per day for seizures. Review of Progress Notes for Resident #14 revealed the following: a. 10/8/24 at 10:58 AM, authored by Staff A, Registered Nurse (RN): Missed administration due to not enough help. b. 10/9/2024 at 1:25 PM: Notified Provider of medication error on 10/8/24, no new orders received.

Based on interview, clinical review review, and facility policy review, the facility failed to thoroughly investigate an allegation of physical abuse for 1 of 3 residents reviewed for dignity. The facility reported a census of 84 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], reviewed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. On 10/11/24, the facility collected a statement from Resident #2 in which the resident alleged that during the overnight hours of 10/03/24, she had been hit in the head with a back hand, which caused glasses to be knocked off face and fall across the floor near the bathroom. Resident #2 informed that the glasses did not break and upon waking, no one was there. Resident #2 claimed she did not see who allegedly hit her but heard a person call her an exploitive name. Resident #2 reported she had been unable to report the incident until 10/11/24 as she had gotten sick. On 10/11/24, the facility asked 7 current residents, with intact cognition, the following questions: Do you know who to report abuse to? Have you ever witnessed a staff member hit someone? Have you ever been mistreated? No additional resident concerns identified from the above questions asked. On 10/11/24, the facility obtained a statement from Staff D, Licensed Practical Nurse (LPN), which provided information on Resident #2's recent respiratory illness and hospitalization . Staff D's statement lacked information related to alleged abuse. On 10/11/24, the facility obtained a statement from Staff E, Certified Nursing Assistant (CNA), which provided information on Resident #2's recent respiratory illness and hospitalization . Staff E's statement lacked information related to alleged abuse. The facility provided nursing staff schedules for the dates of 10/03/24 and 10/04/24. According to the facility schedules, neither Staff D or Staff E worked with Resident #2 during the time frame in which the alleged incident occurred. On 10/16/24 at 11:30 AM, Staff C, LPN, confirmed they had worked the morning of 10/04/24 with Resident #2. Staff C denied any reports received that Resident #2 had been hit or had glasses knocked off her face. Staff C stated that Resident #2 had previously made paranoid comments at times but denied Resident #2 ever making false allegations. Staff C denied being asked by facility to write any recent statements regarding Resident #2. On 10/16/24 at 12:30 PM, Staff F, LPN, confirmed they had worked overnight shift on 10/03/24 with Resident #2. Staff F denied any reports received that Resident #2 had been hit or had glasses knocked off her face. Staff F stated she believed Resident #2 had a normal night on 10/03/24. Staff F denied being asked by facility to write any recent statements regarding Resident #2. On 10/17/24 at 1:30 PM, Interim Facility Administrator informed that they had been made aware of Resident #2's allegation of being hit on 10/11/24 from review of Hospital notes. Administrator stated in response to the allegation he notified regional clinical staff, police, and the Department of Inspections, Appeals, and Licensing (DIAL). Administrator informed that facility had documented that Resident #2 had yellow drainage from the right eye related to an eye infection, but no signs of injury noted. Administrator revealed he went to the Hospital on 10/11/24 to interview Resident #2 and delegated staff interviews to be conducted by the Interim Director of Nursing (DON). Administrator unsure if staff who worked the night of allegation or the following day had been interviewed. On 10/17/24 at 2:13 PM, Regional Director of Clinical Services, stated that the Interim Administrator would obtain additional staff interview at this time from staff who worked with Resident #2 during the alleged incident and was unaware this had not been completed previously. The facility provided an untitled document, dated 10/11/24, that summarized the facility's investigation of Resident #2's allegation of abuse that occurred 10/03/24. Document revealed that the facility reviewed the witness statements, and Resident #2's MDS, Care Plan, face sheet, and medication list as part of the investigation. Document concluded that from staff and resident interviews conducted, there were no concerns noted. The facility policy titled, Abuse and Neglect- Clinical Protocol, revised March 2018, revealed the expectation that the facility will investigate alleged abuse to clarify what happened and identify possible causes.

Based on resident and staff interview, clinical record review, and facility policy review, the facility failed to obtain physician orders when utilizing supplemental oxygen or transcribe verbal order for supplemental oxygen for 1 of 3 residents (Resident #2) reviewed for assessment/intervention. The facility additionally failed to administer medications as ordered when multiple morning and afternoon medication doses were omitted on 10/08/24 for 1 of 10 residents (Resident #6) reviewed for medication administration. The facility reported a census of 84 residents. Findings include: 1. Resident #2 example: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #2 diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and asthma. No shortness of breath or oxygen therapy indicated on MDS assessment. The Care Plan, dated 8/27/24, lacked respiratory focus area for diagnosis of COPD or asthma. The Care Plan lacked intervention related to use of oxygen. Review of Nursing Progress Note, dated 10/07/24 at 04:08 AM, revealed that Resident #2 had an oxygen saturation of 71% on room air (normal results being greater than 90%), nurse applied 3 liters (L) of oxygen in response, and oxygen saturation improved. -On 10/09/24 at 1:36 AM, a Nursing Note informed that Resident #2's oxygen saturation had been 76%, nurse applied 4L of supplemental oxygen in response, and notified the Provider on resident's condition with a verbal order received for oxygen 4L via nasal cannula for shortness of breath. Resident #2 refusing hospitalization . -On 10/09/24 at 4:54 PM, Resident #2's lips had been purple and oxygen saturation found to be between 49-51% on room air, supplemental oxygen applied at 4L with improved saturation. -On 10/10/24 at 11:33 AM, Resident #2 complained of shortness of breath and generalized pain all over, oxygen saturation found to be 88% while wearing 4L of oxygen, Resident #2 transferred to the hospital. The Medication and Treatment Administration Record (MAR/TAR), dated October 2024, lacked any orders for supplemental oxygen administration. On 10/16/24 at 11:30 AM, Staff C, Licensed Practical Nurse (LPN), informed that Resident #2 had not always required routine supplemental oxygen and revealed that an order would be required for use of oxygen to know how many liters of oxygen to use and how often. On 10/16/24 at 12:07 PM, Interim Director of Nursing (DON) confirmed that Resident #2 lacked oxygen order in the resident's MAR/TAR. On 10/16/24 at 1:00 PM, the Regional Director of Clinical Services, informed that on 10/07/24 oxygen was applied to Resident #2 per nursing judgment, and on 10/09/24 a verbal order received from the Provider to apply oxygen at 4L via nasal cannula. The Regional Director of Clinical Services revealed that other nurses would not know that Resident #2 required oxygen or how much to use without an order in place. The facility policy titled, Oxygen Administration, revised October 2010, revealed the expectation of staff to verify that there is a physician's order for oxygen administration and to review the physician's order for oxygen administration. 45338 2. Review of the MDS assessment for Resident #6 dated 7/18/24 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. Review of the resident's October 2024 MAR revealed the following medications were marked with a code of 9, which indicated other/see progress notes, for morning medications on 10/8/24: Cholecalciferol 1000mg (milligram) two tablets, Glycopyrrolate 1mg, Midodrine Hcl 5mg (medication to treat low blood pressure), Rivastigmine 3mg two capsules, Carpidopa-Levodopa 25-250mg (for Parkinson's Disease), and two doses of Refresh Celluvisc Opthalmic Gel 1% (scheduled for AM and mid per MAR). Review of Progress Notes for Resident #6 revealed the following: a. 10/8/24 at 10:51 AM, authored by Staff A, Registered Nurse (RN): Missed administration d/t (due to) not enough help. b. 10/8/24 at 2:02 PM: Missed administration d/t not enough help. c. 10/9/2024 at 1:23 PM [Name Redacted] ARNP (Advanced Registered Nurse Practitioner) of medication error on 10/8/24, no new orders received. Review of the Daily Staffing Sheet dated 10/8/24 revealed two nurses and one Certified Medication Aide (CMA) were scheduled to work first shift. Staff A was one of the two nurses scheduled to work. On 10/17/24 at 8:16 AM, the facility's Regional Director of Clinical Services (RDCS) explained both she and the Regional Director of Operations (RDO) were at the facility on 10/8/24. When queried if Staff A had come to the RDCS with any concerns, the RDCS acknowledged Staff A had not done so, had not asked for help, or let them know she needed anything. On 10/17/24 at 8:48 AM during an interview with the Regional Director of Operations (RDO), the RDO explained the following about what had occurred on 10/8/24: Staff A had asked the RDO if she could connect prior to Staff A leaving. Per the RDO, as Staff A was walking out (of facility), the RDO said it looked like they did not connect. Per the RDO, Staff A explained she did not have a lot of time and needed to get out of (facility), said she (Staff A) didn't get everything done today, later further clarified per interview as supplemental documentation and a couple/some meds (medications). The RDO explained Staff A asked if she could come back the next day. The RDO further explained she (RDO) connected with the team and it had not just been a couple of meds, was a lot of AM meds. The RDO explained Staff A had been at the facility until around 3:30 PM, and had been scheduled for 6:00 AM to 2:00 PM on the date of the incident. Review of the Charge Nurse-RN Job Description revised 4/18 revealed, in part, the following per the Essential Functions Section: Assume responsibility for unit/shift staff compliance with rules, regulations, standards of practice and facility policy and procedure; assure that residents receive needed nursing care and services on that shift, according to plans of care and physicians' instructions.

Based on record review and staff interview the facility failed to provide baths for 1 out of 3 residents reviewed (Resident #1) The facility identified a census of 85 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 indicated a Brief Interview for Mental Status (BIMS) score of 15 which indicates no cognitive impairment. It further indicated diagnoses including: chronic obstructive pulmonary disease (COPD), respiratory failure and anxiety. The MDS indicated Resident #1 required moderate assist from staff for transfers, bathing, dressing and personal hygiene. The care plan with a date initiated of 8/12/24 revealed Resident #1 needed assistance with activities of daily living. The care plan interventions directed staff to provide assistance of one with baths on Monday and Thursday. The facility provided documentation of Resident #1 baths for August 2024 and he only received one bath on 8/29/24. The facility failed to provide documentation of baths in September. During an interview on 9/26/24 at 10:42 AM Staff A, Registered Nurse (RN) stated residents should get baths 2 times a week. There is a designated bath aide and if there are not available certified nursing assistants will complete the bath. During an interview on 9/26/24 at 10:46 AM Staff B, RN stated the bath aides are responsible for giving baths. If the bath aides get pulled we have them do them on Sunday as a make up day. There is a master list of room numbers is how the aides know who should get a bath and the list is done by room numbers. There is a master sheet that has all the room numbers and this is how they know who needs a bath. The bath aide also have a sheet they should fill that the sign off when they are done and also note on there if they have any skin problems. On 9/26/24 at 11:03 AM Staff C, Certified Nurse Assistant (CNA) stated baths are assigned to resident by their room number then staff complete. I have a bath list on who to do the bath for and they all have assigned days. New admission are assigned by room number and they always keep those bath days for that room number. Residents should get baths 2 x a week if they request sometimes it is on the care plan for 3 times a week. On 9/26/24 at 11:10 AM the Regional Director of Clinical Services states typically resident get baths 2 times a week. We assign bath days, normally it would be done on admission they would sign on a task bar in the electronic health record and it would flow over to a careplan. She stated we do usually give baths 2 times a week. The facility provided a policy titled Supporting Activities of Daily Living dated March 2018 which directed staff to: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems).

Based on clinical record review, observation, staff interviews, and facility policy review the facility failed to provide appropriate supervision with ambulation that resulted in injury for one of four residents reviewed. (Resident #4). The facility reported a census of 85. Findings include: The MDS (Minimum Data Set) dated 8/15/2024 revealed Resident #4 had no cognitive impairment, transferred to the toilet with partial/moderate supervision and had bladder and bowel incontinence. The MDS indicated the resident had diagnoses including periprosthetic fracture around internal prosthesis left hip (a break in the bone around the joint replacement), pneumonia and anemia. On 2/29/2024 the resident's Care Plan identified the resident had pain related to his periprosthetic fracture of the left hip joint, and had a fall risk. It instructed staff to monitor for unsteady gait, encourage to use call light for assistance, provide a safe environment and wear proper footwear. The Care Plan directed staff to provide assistance for activities of daily living and indicated the resident transferred with moderate independence and a front wheeled walker on 2/28/2024. A revision on 9/9/2024 directed staff to transfer the resident with assistance of one staff and a wheeled walker and use a wheel chair to follow for long distances. The Care Plan with a revision on 9/17/2024 revealed the resident changed to non-ambulatory status. The Therapy to Nursing Communication note dated 9/6/2024 recommended staff provide the assistance of one staff and a front wheeled walker and wheel chair for mobility in the halls, and the assistance of one staff with front wheeled walker in his room. The Progress Notes included the following: 9/11/2024 - Hospice to evaluate and admit. 9/13/2024 - admit to hospice, care plan updated. 9/14/2024 at 4:07 P.M. - resident fell in the bathroom using a walker and no gait belt. At 4:31 P.M. - EMS (Emergency Medical Services) on way to transport. At 10:45 P.M. - resident returned to facility via EMS services, resident has a fracture right hip, greater trochanter and non-operable. An Emergency Department After Visit Summary dated 9/14/2024 revealed the resident had an x-ray that showed a fracture of the greater trochanter that did not require surgery, and should heal on its own. The summary indicated the resident could bear weight as tolerated, but would not be able to bear weight over the next several weeks. The hospital x-ray report included: History: unwitnessed fall, complained of right hip pain. Two views of the right hip. FINDINGS: Acute fracture of the greater trochanter of the right femur. IMPRESSION: 1. Acute mildly displaced periprosthetic fracture of the greater trochanter of the right femur. Observation on 9/17/2024 at 8:15 A.M. revealed the resident in bed with oxygen on via nasal cannula, head of bed elevated and pillows underneath his bilateral lower extremities. Observation revealed the resident's recliner sat approximately 6 feet from the bathroom doorway. Staff H, LPN (Licensed Practical Nurse) indicated the resident remained in bed due to the fall and his non-weight bearing status. The resident appeared alert and verbal, and when interviewed, he had no recall of the injury. He reported he had pain and must have fallen on his butt. Staff H offered the resident morphine, however, he refused. On 9/17/2024 at 9:20 A.M., Staff J, DON (Director of Nursing) revealed the facility terminated Staff A due to a final warning related to similar incidents. Staff A, C.N.A. assisted Resident #4 to the restroom, stood him from the recliner with a walker and failed to apply a gait belt. Staff A removed the resident's oxygen when he reached the bathroom doorway, turned away from him to place the tubing on the recliner, and the resident fell after she left go of him. Staff B, C.N.A. in training, entered the room, observed the resident take a couple of steps on his own and fell . When staff attempted to assist him in standing, he complained of pain and he transferred to the emergency department. An x-ray revealed he fractured his right greater trochanter and it was non-operable. Staff J provided education to all staff, instructed them to use a gait belt at all times and look to the Kardex (care card) if they needed to look up information on each resident. Staff receive a gait belt when they are hired and are expected to have it on them at all times. On 9/16/24 at 2:15 PM., Staff A, C.N.A. stated she worked the evening shift on 9/14/24, assigned to Resident #4. Staff A responded to the resident's call light and his request to use the restroom. Staff A observed the resident in the recliner with oxygen on per nasal cannula, with tubing attached to the oxygen concentrator. Staff A placed the resident's walker in front of him and assisted him to standing position by grabbing the back of his slacks and assisted in lifting him up. Staff A admitted she failed to place a gait belt on the resident, and ambulated with the resident to the bathroom door. Staff A stated she thought the oxygen tubing was too short for him to make it to the toilet so she removed the oxygen from the resident and she turned away from him. She took one step out of the bathroom so she could place the oxygen tubing on his recliner. She admitted she released her grip from the resident's jeans allowing him to stand in the bathroom alone. She reported she did not witness the resident fall as he was standing in the bathroom alone. Staff B did witness the resident's fall as entered the resident's room. Staff A heard a crash and found the resident sitting on the floor just inside his bathroom door way. The resident continued to indicate he had to use the toilet. Staff B left the room to get the nurse. The nurse entered the room and asked what happened. Staff A reported the resident fell and she failed to use a gait belt. Staff placed a gait belt on him, attempted to assist him up, but he complained of hip pain. The resident stated he thought he broke something. The nurse left the room to call 911. Staff A worked the remainder of her shift and left at 10:30 PM. When asked why she did not use a gait belt, Staff A stated she did not see one in his room and she had left her gait belt in her back pack in her locker. Since she had no gait belt, she held onto the resident's pants to assist him in going to the restroom. Staff A knew to check the resident's Kardex or ask another staff if she needed to know what assistance a resident required to safely transfer or ambulate. Staff A learned during her C.N.A. training to always use a gait belt when a resident required assistance with transfers. Staff A failed to recall if the facility instructed her to use a gait belt during her orientation. Staff A stated the facility terminated her employment due to this incident and a prior similar incident where she failed to use a gait belt when transferring a resident. Staff A admitted she should have used a gait belt on 9/14/24 when she assisted Resident #4 to the bathroom as he required staff assistance with transfers. On 9/17/2024 at 9:50 A.M., Staff B, C.N.A., in orientation, revealed she arrived to work on 9/14/24 at 3:30 P.M. She first observed Staff A, C.N.A. in Resident #4's room. Staff B walked into the resident's room and witnessed Resident #4 fall in his bathroom. She indicated Staff A stood several feet outside the resident's bathroom as the resident stood alone with his walker approximately 2 feet inside the bathroom. Resident #4 had no gait belt on him at that time. Staff B observed the resident take two small, rapid steps, lose his balance, twisted his body and fell . The resident landed on his bottom with his back against the wall, and his walker landed towards the bathroom sink. The resident initially did not yell out, but subsequently stated he broke his leg and hip. Staff B summoned the nurse and they called 911, and the resident transferred to the hospital. Staff A and Staff B discussed the fall with the nurse, and they were instructed to always use a gait belt, and if needed, let the oxygen tubing fall on the floor as it can be replaced. Staff B stated she had no way to quickly reference how a resident transferred. She would have to leave the resident's room and check the computer or ask another staff. Staff B stated she did not know what assistance Resident #4 required to transfer. Staff A's Corrective Action Form dated 9/17/2024 revealed the facility terminated her due to assisting a resident to the bathroom without a gait belt, turned her back to the resident and the resident fell . The facility Nursing Assistant Orientation Checklist included: #19. Resident Transfer - Assist ambulation - gait belt. The facility Safe Lifting and Movement of Residents revised July, 2027 included: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: Resident's preferences for assistance; Resident's mobility (degree of dependency); Resident's size; Weight-bearing ability; Cognitive status; Whether the resident is usually cooperative with staff; and the resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.

Based on clinical record review, staff and resident interviews and observations the facility failed to update residents care plans to reflect their current level of functioning for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 85. Findings include: According to the quarterly Minimum Data Set (MDS) dated [DATE] the resident had diagnoses which included metabolic encephalopathy, legal blindness, lack of coordination and muscle weakness. The resident required substantial assistance of staff for transfers from the bed to chair, ambulation and had total dependence on staff for toileting needs. The resident utilized a wheelchair to move about the facility. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated he gave reliable information. Review of the Care Plan dated 1/4/2024, last revised on 3/25/24, indicated the resident will continue to participate in his activities of daily living as his condition allows. The care plan informed the staff the resident uses a wheelchair, requires 1 person to assist him with toileting, and transfers using a front wheeled walker with 2 staff assist. The care plan revealed the resident is at risk of falls. Observation on 9/16/24 at 11:23 am Staff C- C.N.A. entered the resident's room to assist him to the bathroom. The C.N.A. brought in the sit to stand mechanical lift (EZ stand) to assist the resident to the bathroom. Staff C transferred the resident to the bathroom, allowed him to void and assisted him to his wheelchair. Review of the Nursing/Therapy Communication sheet dated 1/17/2024 directed the staff to transfer Resident #1 with a front wheeled walker with 2 assist. During an interview with Staff I-Physical Therapy Assistant on 9/16/24 at 2:30 pm revealed in January 2024 the resident required assist of 2 staff with walker for pivots and did not use a sit to stand lift at that time. Staff I indicated nursing will request therapy to see the resident and complete an evaluation if the staff notice a change in their transfer abilities. The therapy department did not receive a request from nursing staff for another evaluation and didn't know the resident utilized an EZ Stand for all transfers. During an interview with Staff C-C.N.A. on 9/16/24 at 1:45 pm revealed she has been using the EZ Stand to transfer the resident from bed/chair to another surface for the past 4 months. During an interview with Staff H-LPN on 9/16/24 at 1:45 pm, Staff H indicated she has been coming to the facility since January 2024 and the staff have always utilized an EZ Stand to transfer the resident. During an interview with Staff D-C.N.A. on 9/16/24 at 1:45 pm, Staff D stated she has been employed at the facility since May 2024 and they have always used an EZ Stand to transfer the resident. During an interview with Staff J-Director of Nurses on 9/17/24 at 10:45 am revealed physical therapy will determine if the staff can use an EZ Stand when transferring a resident. The therapy department will send recommendations to the nursing department, the staff then are expected to check the Kardex to see how the residents are transferred. During an interview with Staff K-LPN and Staff L RN-CO-MDS Coordinators on 9/17/24 at 10:55 am, both nurses stated a resident will be re-evaluated if they sustain a fall or if staff request an evaluation. Both nurses reviewed the care plan and acknowledged the care plan directs the staff to use a front wheeled walker with 2 staff for transfers and didn't know the staff were using an EZ Stand with the resident for transfers. They revealed the process is the therapy department will assess and send recommendations to the nursing department. The recommendation is then placed in the resident's Kardex and this is how the staff would know how to transfer their residents.

Based on clinical record review, observation, staff interview and facility policy, the facility failed to transfer a resident who required a mechanical lift in a safe manner for one of three residents reviewed. (Resident #2). The facility reported a census of 85 residents. Findings include: The MDS (Minimum Data Set) dated 8/15/2024 indicated Resident #2 had no cognitive impairment, had diagnoses including Cerebrovascular Accident (stroke), hypertension and hemiplegia (paralysis of one side of the body). The non-ambulatory resident required total assistance of staff to use the toilet and transfer from one surface to another. The Care Plan revealed the resident had hemiplegia following a cerebral infarct affecting the left, non-dominant side dated 7/31/2024. The resident did not ambulate and required the assistance of one staff to transfer and use the toilet with the use of a sit to stand (E-Z stand) mechanical lift. Communication from therapy to nursing dated 7/30/2024 recommended staff use the E-Z Stand for all transfers, wheel chair for mobility and assistance of one staff for activities of daily living. Observation on 9/16/2024 at 9:42 A.M. revealed Staff C, C.N.A. responded to the resident's request to use the restroom. Staff C brought the E-Z Stand lift to the resident's room, positioned it in front of the resident's wheel chair, attached the torso harness and assisted the resident with placing her feet on the foot platform. Staff C failed to buckle the shin strap and indicated it failed to have a buckle in order to secure it. Staff C assisted the resident to hold onto the lift with both hands, and raised her up, transferred her to the bathroom and lowered her onto the toilet. Staff C unbuckled the harness, handed the resident the call light and left the room. At 9:54 A.M. the resident pulled the bathroom call light and Staff D, C.N.A. responded and assisted the resident. Staff D reapplied the harness, raised the resident from the toilet and pulled the lift away from the toilet. Staff D provided cares and transferred the resident with the E-Z Stand lift from the bathroom to the wheel chair positioned in the resident's room, approximately ten feet away. During the transfer the resident's left leg remained straight and tilted back, away from the shin pad. Staff E, PTA (Physical Therapy Aide) entered the room and reported the resident often leaned back out of fear. Staff E indicated he did not like the resident's leg position during the transfer. On 9/16/2024 at 1:20 P.M., Staff D revealed she had not been trained to buckle the leg harness. Staff D knew to always buckle the back harness. On 9/16/2024 at 1:30 P.M., Staff C revealed she knew to buckle the leg strap, however the strap had no buckle. Staff C recently completed the Relias (online) education regarding the use of the E-Z Stand lift and knew to buckle the torso and leg harnesses. On 9/16/2024 at approximately 10:00 A.M. with Staff F, Corporate Nurse revealed the facility had three E-Z Stand lifts. One of three lifts had a broken shin strap. Staff F instructed Staff G, Maintenance to repair the lift. Staff G indicated the facility had the needed buckle to make the repair. On 9/17/2024 at 9:20 A.M., Staff J, DON (Director of Nursing) revealed staff need to apply the leg strap at all times when they transfer a resident using the E-Z Stand lift. The E-Z Way Smart Stand mechanical lift manual revised 7/30/2018 included: Position shin pad and foot plate: Use of Shin Pad Strap: If a caregiver deems it necessary to keep a patient's shins or feet on the foot plate, secure the shin strap around the patient's legs. 2) Position the unit in front of the patient. 3) Have patient place feet (help patient if needed) on foot plate and position their shins into the shin pad. The shin pad should be positioned below the knees.

Based on observations, clinical record review, resident and staff interviews, and facility policy review the facility staff failed to treat residents with respect and dignity for 4 out of 4 residents reviewed (Residents #4, #13, #78, and #86). The facility reported a census of 84 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment for Resident #78 dated 5/2/24, included diagnoses of cancer, hepatitis, and malnutrition. The Brief Interview for Mental Status (BIMS) reflected a score of 15 (intact cognition). On 07/29/24 at 11:49 AM, Resident #78 reported as he walked around in his room. One nurse just got fired for her mistreatment of him. Resident #78 stated when he went to Staff A and asked for his pain medication, Staff A, Licensed Practical Nurse (LPN) told him he had cancer that metastasized and he's going to die and there's nothing to do about that. Resident #78 revealed that made him upset and angry. On 7/29/24 at 5:50 PM Staff E, LPN reported Resident #78 walked up to the nurses station and told the Staff A he needed a pain pill. Staff E said Staff A told him he had cancer that metastasized and he was going to die. Staff E reported she had to tell management after she talked about it with a few other staff. Staff E said Staff F, Certified Nurses Aid (CNA) was in the area when Staff A talked to the resident like that. On 7/31/24 at 11:55 AM, Staff F confirmed Resident #78 and Staff A held a heated conversation at the nurses station. Staff F reported he failed to hear all the conversation. Staff F said Resident #78 wanted pain medication. On 7/31/24 at 5:22 PM, Staff A confirmed a conversation with Resident #78 at the nurses station. Staff A reported another nurse recorded her conversation with Resident #78. Staff A denied she told Resident #78 his cancer metastasized and was going to die. Staff A confirmed her termination from the facility. On 7/31/24 at 5:49 PM Staff E, LPN sent the audio recording of the conversation between Staff A and Resident #78. The audio recording dated 7/13/24, revealed Staff A said what are you going to do when there are no nurses to take care of you? Resident #78 said what if nobody got in my way and I was getting well. Staff A responded you are not going to get well you have cancer that metastasized. Resident #78 told the staff not to tell him he isn't going to get well, that's where he differs with her. Resident #78 told Staff A people like her were getting in his way stopping him from getting well. Staff A told Resident #78 he has every right to go home any time he wants, he can go home. Staff A reported to the resident the need to follow the Physician's order. Resident #78 stated the Physician's wrong that's why so many die from cancer is because they are in so much pain and your system worked against you. Staff A told Resident #78 he's not in pain. Resident #78 told her she was wrong. On 8/01/24 at 9:00 AM, the Administrator reported the facility terminated Staff A, LPN because of her comments to Resident #78. Review of the Suspension Pending Investigation Form dated 7/19/24, revealed Staff A, suspended pending further investigation started 7/19/24 and ended on 7/25/24 with Termination of employment. 48452 2. The MDS for Resident #13 revealed diagnoses of Parkinson's disease, psychotic disorder, PTSD, and delirium due to known physiological condition. The resident scored 10/15 on the Brief Interview for Mental Status (BIMS) which indicated moderately impaired cognition. It indicated the resident was dependent on staff for assistance with toileting hygiene, and required substantial to maximal assistance with toilet transfers. The resident's Care Plan, with an admitted [DATE], documented focus areas for high fall risk, impaired cognitive function due to Parkinson's disease, and risk for urinary tract infection with a prophylactic antibiotic. During an interview at 1:38 PM on 7/30/24 with Resident #13 she stated staff left her on the toilet for 20 minutes the night before (7/29/24). She stated an aide (Certified Nursing Aide, CNA) helped her to get to the bathroom and told her they would be right back, but were not. She added this was not the first time and it made her feel scared to go in there sometimes because she was not sure when they would come back. In an interview with Staff C, CNA at 10:01 AM on 8/1/24 about the resident she revealed that most of the time there was enough staff to answer call lights within 15 minutes and within 7 was preferred. She stated sometimes, if staff called in or if it was a busy time of day such as after meal times, it was a little impossible to get to them all because of the workload. She stated staying in a resident's room for supervision during toileting happened for some residents and not others, depending on their needs, and staff should not leave if a resident was a fall risk. During an interview with Staff B, Licensed Practical Nurse (LPN) on 8/1/24 at 10:16 AM she confirmed they try to answer call lights in 7 minutes, 15 at the most. She stated they did the best they could and most of the call light complaints she heard from residents were around meal times. 3. The MDS for Resident #86 documented a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated intact cognition. Diagnoses included Urinary Tract Infection (UTI), hip and other fractures, anxiety, and depression. Section GG indicated the resident was dependent for toileting hygiene. Resident #86's Care Plan documented the resident had focus areas for fragile skin due to a skin graft, was at risk for falls, experienced pain related to fractures, and required the assistance of staff for toileting ADL (activities of daily living). On 07/29/24 at 01:03 PM during an interview in her room, the resident stated the staff were poor at answering call lights. She reported evenings and weekends it took up to 2 hours, and she knew because she had a clock on her wall above her TV. She stated call lights over 15 minutes happened on all shifts, and she had to have help because of the fractures she had. She stated this happened more often when there were not enough staff to provide care, usually because of call-ins. She knew this because aides would complain about it. The resident stated there was not consistency with anything and she was incontinent waiting for the bathroom more than once. This made her feel like the chair or the door. Not important. An interview with the Administrator on 8/1/24 at 10:25 AM confirmed staff were expected to answer call lights in 15 minutes. She stated she could not run a call light log report to check on resident concerns because the information could be altered so it might be inaccurate. She stated staff were trained on call lights as part of their orientation and it was discussed in meetings. A policy titled Answering the Call Light, revised March 2021, documented the purpose of the procedure was to ensure timely responses to resident's requests and needs. Steps included staff were to respond to the light and tell the resident the approximate time it will take to respond, if the resident's request required another staff member to notify the individual, and if aides were uncertain as to whether or not a request could be fulfilled to ask the nurse supervisor for assistance. The policy lacked documentation regarding time frames for response. 48374 4. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed medical diagnoses of acute osteomyelitis right foot and ankle, acquired absence of other right toes, and acute hematogenous osteomyelitis. On 07/30/24 at 08:57 AM The facility Administrator was queried on any reported concerns regarding two CNA's being rude or inappropriate with residents. The Administer advised she had one complaint on Staff G, CNA and Staff H, CNA and disciplinary action was completed with both of them. She advised both CNA's had a write-up for talking abrasive to a resident. The resident identified was Resident #4. As a result, all staff were trained on customer service and completed a review on abuse. Both Staff G and Staff H attended the training. The Administrator advised it is her expectation that all staff assist all residents regardless of who's responsibility it is. On 7/30/2024 at approximately 1:45 PM the Administrator provided the following documentation titled Internal Investigation Witness Statement: Witness Name: Staff G, CNA Interviewed by: Facility Administrator on 6/21/24. Phone interview Resident involved Resident #4 Staff G stated that her and staff H went into the resident's room to answer the call light he asked for help. I told him you are independent, can you try? Witness Name: Staff H, CNA Interviewed by: Facility Administrator on 6/21/24. Phone interview Resident involved Resident #4 Staff H reported I went in after Staff G to check and see if she needed help. I heard the resident say can you wipe me. Staff G replied can you try to wipe yourself and he responded never mind so we left the room. Witness Name: Resident #4 Interviewed by: Facility Administrator on 6/21/24. In person interview Resident involved Resident #4 The resident was interviewed pertaining to the grievance. Resident reported that he put his call light on for assistance. 2 CNA's entered the room. He asked for help with the bathroom. The resident stated that they told him you are independent, they asked me to try myself. On 7/30/2024 at approximately 1:45 PM the Administrator provided the following document titled Grievance/Concern Investigation Form Explanation: Resident #4 had his call light on in the bathroom to get help wiping himself and two CNA's came in and told him he was independent and left the room. Action and Follow-up: Staff education at stand-down. Staff had coaching in person On 7/31/24 at 4:50 PM During an interview with Resident #4 it was disclosed that two Certified Nursing Assistants (CNA), Staff G and Staff H had been rude to him. The resident advised the two CNA's walk around together and do everything together all of the time including assisting residents. The resident reported he was in the bathroom and he turned on his all light for assistance. The CNA's came in the room and he advised them he needed cleaned up and reportedly one of them, the resident was not sure which one, responded, what you can't wipe yourself anymore and turned around and walked out without assisting him. Resident #4 advised he went to management about the situation and feels it was resolved. He shared he believed one of the workers was dismissed. Resident advised he often says where is the CDR and when asked responded, the courtesy, dignity, and respect is lacking here. On 08/01/24 at 02:13 PM the Social Services Coordinator advised she was aware of the incident as the resident went to her with his concerns. She advised she filled out the grievance paperwork on behalf of the resident and submitted it to the Administrator. The Social Services Coordinator advised the resident told her that two CNA's answered his call light and reportedly told him you are independent and can probably do that yourself. The Social Services Coordinator shared she is aware that staff members were reeducated on resident care after this incident. She advised she has never seen any staff member being rude to any of the residents.

Based on resident interview, record review, staff interview, and policy review the facility failed to ensure residents were informed of new medications and participated in their own treatment plan for 1 of 3 residents reviewed (Resident #41). The facility reported a census of 84 residents. Findings include: The Minimum Data Set (MDS) for Resident #41 revealed diagnoses of cancer, anxiety, and heart failure. The resident scored 15/15 on the Brief Interview for Mental Status (BIMS) which indicated intact cognition. The resident's Care Plan documented a focus area dated 6/18/24 for poor impulse control related to getting medications or cares at an exact time frame. Interventions included analyze key times, places, circumstances, triggers, that help de-escalate behavior; administer medications as ordered; and document and give as many choices as possible about cares and activities. On 7/30/24 at 9:50 AM during an interview with Resident #41 she stated nurses were messing with her medications and did not tell her what they were for or why they were doing it. She stated it was tough, especially when they (the medications) made her feel different and she did not know why. She reported staff did not explain changes or what medication she was taking, just brought it to her and told her to take it. A document titled Care Plan Conference Signature page dated 1/30/24 did not include documentation of resident or power of attorney (POA) attendance. A Care Plan conference Progress Note dated 4/30/24 at 13:38 PM lacked documentation that the resident was invited to the conference, where medications were discussed. A Provider Encounter Note signed 5/29/24 at 4:49 PM documented the resident's brother was her power of attorney and the resident was currently 'decisional' which indicated the power of attorney had not been enacted. A social services note dated 7/5/24 documented the resident was cognitively intact with decision making skills. Progress Notes indicated the following medication and order changes with documented notifications to the power of attorney that lacked notification of the resident: 5/29/2024 15:16 Order Note, Note Text: New order pharmacy GDR D/C Mucinex. POA notified 6/25/2024 08:00 Order Note, Note Text: New order to change Senna to PRN and D/C scheduled POA notified 7/5/2024 17:13 Nurses Note, Note Text: Resident has been seen by NP today. New order: UA with culture and sensitivity if indicated. Change furosemide to 60 mg PO daily. POA notified. 7/10/2024 19:13 Order Note, Note Text: Received new order to increase Coreg to 12.5 mg BID. Daily BP x 5 days. POA notified. 7/20/2024 20:14 Order Note, Note Text: NP wrote order for CBC, Mag level, and BMP on next lab day; POA notified. An interview with Staff B, Licensed Practical Nurse (LPN) on 8/1/24 at 10:16 AM revealed that in most cases residents with high BIMS would have medication changes explained to them and a POA or family contact if the resident chose. She stated staff should discuss it with the resident. She stated residents say they don't know what they are taking 'all the time.' She indicated level of understanding was based on cognition and in some cases she had printed medication administration records or brought medication cards to explain. On 8/1/24 at 10:25 AM the Administrator stated she was aware this resident had a BIMS of 15 and reported her brother was involved in care conferences by resident choice, not because the POA was enacted. The Administrator confirmed she expected nursing staff to review care changes with residents with high BIMS. Dated 5/2023, the facility admission agreement section IV. Rights and Responsibilities of the Resident noted the resident had the right to be fully informed in a language that resident can understand of the resident's total health status including but not limited to medical condition. The facility's dignity policy, revised February 2021, documented each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feels of self-worth and self-esteem. Facility culture supported dignity and respect by honoring resident goals, choices, preferences, values, and beliefs.

Based on Payroll Based Journal (PBJ) Data, schedule review, staff interview, and policy review the facility failed to submit payroll data for agency staff during the second quarter of the current fiscal year. The facility reported a census of 84 residents. Findings include: A document titled PBJ Staffing Data Report for Fiscal Year 2024 Quarter 2 (January 1 - March 31) documented the facility triggered for one star staff rating and excessively low weekend staffing. On 7/30/24 at 1:00 PM the Administrator provided staff schedules for the month of March. These documented hours worked by nurses, certified medication aides, and certified nursing aides for three shifts each day and included the name of the on-call staff. The documentation also included both facility and agency staff. During an interview with the Administrator on 7/31/24 at 3:22 PM she stated the PBJ data submitted by the facility did not include agency staff. She acknowledged this impacted the data the Centers for Medicare and Medicaid Services had for the facility and stated the facility would have to look into it. A policy titled Reporting Direct-Care Staffing Information (PBJ) revised October 2017 documented direct-care staffing information included staff hired directly by the facility, those hired through an agency, and contract employees.

Based on Minimum Data Set (MDS) review, Pre-Admission Screening and Resident Review (PASRR), staff interview, and policy review the facility failed to complete an updated PASRR evaluation for a resident with a new diagnosis for 1 of 1 residents reviewed (Resident #13). The facility reported a census of 84 residents. Findings include: The MDS for Resident #13 revealed diagnoses of Parkinson's disease, psychotic disorder, PTSD, and delirium due to known physiological condition. The resident scored 10/15 on the Brief Interview for Mental Status (BIMS) which indicated moderately impaired cognition. The resident's Care Plan, with an admitted [DATE], documented focus areas and interventions for PASRR, post traumatic stress disorder, behaviors and paranoia, cognitive function and decision making, hallucinations, and depression. The PASRR focus area indicated, on 7/9/21, the assessment was completed prior to admission to the facility. The PASRR Outcome, dated 7/7/21 indicated no Level II was required based on diagnoses of major depression, anxiety disorder, and panic disorder. It indicated there were no Neurocognitive disorders at that time, and there were no recent or current mental health symptoms. A section titled Ascend Outcome documented there was no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occurred or new information refuted these findings, a new screen must be submitted. Resident #13's electronic health record Medical Diagnoses tab documented diagnoses of Parkinson's disease with dyskinesia with fluctuations dated 10/1/23, delusional disorders dated 11/3/23, and delirium due to known physiological condition dated 3/15/24. An email dated 8/1/24 at 12:24 PM from the Administrator indicated the facility did not have a policy for PASRR completion, they just followed the regulation. An interview with the Administrator on 8/1/24 at 1:43 PM determined she reviewed the PASRR website and the only documentation of a completed assessment for this resident was in 2021.

Based on clinical record review, policy review and staff interview the facility failed to provide appropriate supervision to ensure the safety for 1 of 3 residents (Resident #4) reviewed. The facility reported a census of 83 residents. Findings include The Minimum Data Set (MDS) dated [DATE] documented the resident admitted to the facility on [DATE]. The MDS list diagnoses including hypertension, non-Alzheimer's dementia and orthostatic hypotension. The Care Plan included a focus area of being at risk for falls dated 1/31/24. Interventions included encouraging proper footwear and monitor for unsteady gait. The Care Plan also included interventions for Activities of Daily Living (ADL) bathing, personal hygiene, toileting, transfers, upper and lower body dressing all requiring assistance of 1 person. The Progress Note written on 4/21/24 documented the resident fell in the shower room, was complaining of pain 8/10 in her right hip and pelvis. Range of Motion (ROM) was completed to all extremities. The right hip was not able to be flexed to bring her knee to her chest. A mechanical lift was used to assist the resident off the floor and into a wheelchair and she was taken to her room. The University of Iowa Health Care computed tomography (CT) scan completed on 4/21/24 at 7:55 PM documented a nondisplaced fracture of the proximal right femoral neck. Facility policy titled Safe Lifting and Movement of Residents last revised July 2017 directed staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts) lifting devices. During an interview on 5/9/24 at 11:10 AM the Director of Nursing (DON) explained when a resident is assist of one a gait belt would be used. He stated That is standard practice. He further explained that he would expect staff to have hands on the gait belt at all times and it would not be appropriate to remove hands from the gait belt. During an interview on 5/9/24 at 12:42 PM Staff B, Certified Nursing Assistant (CNA) explained she was giving the resident a bath and she was almost finished. Staff B explained she was getting her dressed and had the resident stand up. As Staff B reached down to pull up the resident's pants, the resident slipped and fell . Staff B stated she did not have shoes on the resident and she did not have a gait belt on the resident.

Based on clinical record review, policy review and staff interview the facility failed to complete an accurate assessment and provide intervention based on that assessment after a fall for 1 of 4 residents (Resident #4) reviewed. The facility reported a census of 83 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented the resident admitted to the facility on [DATE]. The MDS list diagnoses including hypertension, non-Alzheimer's dementia and orthostatic hypotension. The Care Plan included a focus area of being at risk for falls dated 1/31/24. Interventions included encouraging proper footwear and monitor for unsteady gait. The Care Plan also included interventions for Activities of Daily Living (ADL) bathing, personal hygiene, toileting, transfers, upper and lower body dressing all requiring assistance of 1 person. The Progress Note written on 4/21/24 documented the resident fell in the shower room, was complaining of pain 8/10 in her right hip and pelvis. Range of Motion (ROM) was completed to all extremities. The right hip was not able to be flexed to bring her knee to her chest. A mechanical lift was used to assist the resident off the floor and into a wheelchair and she was taken to her room. The University of Iowa Health Care computed tomography (CT) scan completed on 4/21/24 at 7:55 PM documented a nondisplaced fracture of the proximal right femoral neck. Facility policy titled Assessing Falls and Their Causes last reviewed March 2018 directs staff to provide first aid and/or obtain medical treatment immediately if there is evidence of an injury after a fall. During an interview on 5/9/24 at 11:10 AM the Administrator explained Staff A, agency nurse, showed poor judgement when using a mechanical lift and putting the resident in a wheelchair when the resident was complaining of right hip and pelvis pain and unable to flex hip. During an interview on 5/9/24 at 11:38, Staff A explained she was called to the shower room where Resident #4 had fallen and was laying on her right side. She explained she assisted to roll the resident on to her back and assessed the resident including Range of Motion (ROM) to all extremities. She explained the resident was not able to flex her right hip in a knee to chest motion and complained of pain when she tried to do so. She further explained the resident was lifted off the floor with a mechanical lift and placed in her wheelchair.

Based on clinical record review, observations, staff interview, and policy review, the facility failed to conduct accurate Skin assessments, report the development of a pressure ulcer, and notify the Physician of pressure ulcer development for one of three sampled residents with pressure ulcers (Resident #171). This failure to conduct accurate Skin Assessments, report the development of a pressure ulcer, and notify the physician of pressure ulcers resulted in an Immediate Jeopardy (IJ) at F686-J; Pressure Ulcers due to the increased likelihood of serious, severe, systemic infection and serious pain. On 05/16/23 at 8:57 PM, the Administrator and Director of Nursing (DON) were notified of the IJ at F686 Pressure Ulcers. The Immediate Jeopardy began on 05/12/23 when an Agency Certified Nurse Aide (CNA 4) reported observing the untreated pressure ulcer and explained reported the finding to a facility CNA (CNA 1), a Licensed Practical Nurse (LPN 2), and a Nurse Practitioner (NP 1). The facility provided an acceptable Removal Plan on 05/17/23. The removal plan included: a. Conducting skin assessments for all residents in the facility. b. Reviewing Braden Scores for all residents to identify other residents at high risk for skin breakdown. c. Retraining all nursing staff on pressure ulcer prevention, reporting, and treatment. d. Updating the agency orientation checklist to include pressure ulcer prevention, reporting, and treatment. e. Completed risk management evaluations. Through interviews with facility staff, skin observations, and review of staff in-services, the Survey Team verified all elements of the facility's IJ Removal Plan and therefore removed the IJ, effective 05/17/23 at 5:35 PM. The scope lowered from a J to D at the time of the Survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 82 residents. Findings Include: Review of Resident #171's Clinical Census, located in the Electronic Medical Record (EMR) under the Census tab, revealed Resident #171 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, lung cancer, and dysphagia. Review of Resident #171's Admission Skin Assessment, dated 04/27/23 and located under the Evaluations tab of the EMR, indicated Resident #171 had no skin breakdown. Review of Resident #171's Braden Scale for Predicting Pressure Sore Risk, dated 04/27/23 and located under the Evaluations tab of the EMR, indicated Resident #171 scored a 14, indicating the resident at moderate risk for skin breakdown. Review of Resident #171's Care Plan, dated 04/30/23 and located under the Care Plan tab of the EMR, indicated Resident #171 was at risk for skin impairment. Interventions included to report abnormalities. Review of Resident #171's 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/03/23 and located under the MDS tab of the EMR, revealed Resident #171 had a Brief Mental Status (BIMS) score of 14 out of 15, indicating cognitively intact, required extensive assistance with most activities of daily living, was frequently incontinent of bladder and bowel, and had no pressure ulcers. Review of Resident #171's Skin Observation Tool, dated 05/15/23, completed by the Director of Nursing (DON), and located under the Evaluations tab of the EMR, indicated Resident #171 had no new skin issues. Review of Resident #171's Physician Orders, dated 04/27/23 through 05/16/23, indicated no treatment orders for any skin breakdown. On 05/16/23 at 11:30 AM, Certified Nurse Aide (CNA) 1 was observed retrieving Licensed Practical Nurse (LPN) 1 to look at Resident #171. CNA 1 and LPN 1 entered Resident #171's room and observed the resident lying in her bed. CNA 1 asked LPN 1 a question that was inaudible and LPN 1 replied with a confirmation that she was aware. CNA 1 and LPN 1 left Resident #171's room. On 05/16/23 at 1:41 PM, the Surveyor observed Resident #171 with LPN 1 and CNA 1. Resident #171 was observed to have a tear drop shaped pressure ulcer to her coccyx. The perimeter of the wound was red. The upper wound bed, from approximately 10:00 o'clock to 2:00 o'clock and extending approximately 0.5 centimeters (cm) onto the wound bed was black eschar. An area of white slough was noted around the bottom perimeter of the wound, from approximately 4:00 o'clock to 7:00 o'clock and onto the wound bed by approximately 0.25 cm. The rest of the wound bed was brown eschar. LPN 1 confirmed CNA 1 had asked her about the wound at 11:30 AM and that she had told CNA 1 she would notify the Physician and get a treatment in place. LPN 1 confirmed that she had not contacted the Physician yet. On 05/16/23 at 1:51 PM, CNA 1 confirmed CNA 4, an Agency CNA, had told her about the pressure ulcer on 05/12/23. On 05/16/23 at 2:01 PM, the DON stated Resident #171 did not have any skin breakdown. The DON reviewed the electronic data on the tablet, an instrument used by the facility to photograph and measure pressure ulcers, and stated Resident #171 did not have any open areas. On 05/16/23 at 2:07 PM, Resident #171's skin breakdown was observed with the DON, LPN 1, and the Surveyor. The DON described the pressure ulcer's wound bed as soft eschar, with hardness to the center of the wound; dry, peeling, flaking edges; slough at the bottom perimeter; and hard redness all around the perimeter of the wound. The DON took a picture of the pressure ulcer and confirmed the measurements to be 13.0 cm x 6.3 cm. The wound depth was not measurable due to the eschar. On 05/16/23 at 2:10 PM, the DON and LPN 1 confirmed the facility's policy was to notify the Physician or Nurse Practitioner (NP) if a pressure ulcer was noted, get treatment orders, do skin and wound assessments, notify the Dietician and family, do a Risk Management Evaluation, and ensure interventions were in place. The DON confirmed the expectation was for these steps to be taken immediately. LPN 1 confirmed she had not looked to see if there were treatment orders in place. During an interview on 05/16/23 at 3:00 PM, the Medical Director confirmed he had observed Resident #171's pressure ulcer and stated it was his opinion that the ulcer was a [NAME] Terminal Ulcer. The Medical Director stated that his expectation was to be notified, pain management and treatments, as appropriate, be put into place. The Medical Director confirmed he had not been notified. During an interview on 05/16/23 at 5:18 PM, LPN 2, who had worked on Resident #171's hall on 05/12/23 through 05/14/23, denied knowledge of the pressure ulcer. During an interview on 05/16/23 at 5:23 PM, CNA 2 confirmed he worked with Resident #171 on 05/14/23. CNA 2 confirmed Resident #171 had an area that looked like a yellowish-brown scab on her coccyx on 05/14/23. CNA 2 confirmed he put a barrier cream on it and did not tell the nurse because he assumed the nurses already knew about it because it looked like it had been there awhile. During an interview on 05/16/23 at 5:51 PM, CNA 3 confirmed she had worked with Resident #171 on 05/15/23 and noted the breakdown to Resident #171's coccyx. CNA 3 confirmed she did not tell anyone because they already knew. During an interview on 05/16/23 at 5:57 PM, CNA 4 confirmed she had worked with Resident #171 on 05/12/23 and had told CNA 1 about the pressure ulcer. CNA 4 confirmed she also told LPN 2 and Nurse Practitioner (NP) 1 about the pressure ulcer and they were supposed to look at the wound and see if any treatments were in place. During an interview on 05/16/23 at 6:27 PM, NP 1 stated another Nurse Practitioner was seeing Resident #171 and denied being told of the pressure ulcer on 05/12/23. During an interview on 05/16/23 at 6:30 PM, the Administrator confirmed NP 1 was the only Nurse Practitioner in the facility on 05/12/23. During an interview on 05/16/23 at 7:10 PM, the DON confirmed she had completed the Skin Assessment for Resident #171 on 05/15/23 while the resident was sitting at the dining room table. The DON confirmed she did not look at the resident's buttocks or coccyx. Review of the facility's policy titled, Acute Condition Changes, dated 09/2017, recorded, .physicians shall help identify and manage causes of acute changes of condition .The nursing staff will contact the physician based on the urgency of the situation . Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 04/2018, recorded, . the nurse shall describe and document/report . full assessment of pressure sore . pain assessment . mobility status . current treatments . all active diagnoses . the physician will, as needed, assist the staff to identify the type . of ulcer . as needed, the physician will order pertinent wound treatments .

Based on clinical record review, observations, staff interviews, and review of the facility assessment, the facility failed to ensure one of five Certified Nursing Assistants (CNA's) (CNA 2) was competently trained to report changes in one resident's skin immediately (Resident #171) to the Charge Nurse. In addition, the facility failed to ensure the Director of Nursing (DON) completed a Skin Assessment using basic competencies, including observing all areas of the resident's skin. These failures resulted in the resident experiencing actual harm (delay in treatment to a newly acquired wound.). (Cross Reference F686). The facility reported a census of 82 residents. Findings Include: 1. Review of Resident #171's Clinical Census, located in the Electronic Medical Record (EMR) under the Census tab, revealed Resident #171 was admitted to the facility on [DATE] with diagnoses that included lung cancer. Review of Resident #171's Skin Observation Tool, dated 05/15/23, completed by the Director of Nursing (DON), and located under the Evaluations tab of the EMR, indicated Resident #171 had no new skin issues. On 05/16/23 at 1:41 PM, the surveyor observed Resident #171 with Licensed Practical Nurse (LPN) 1 and CNA 1. Resident #171 observed to have a tear drop shaped pressure ulcer to her coccyx. On 05/16/23 at 2:01 PM, the DON stated Resident #171 did not have any skin breakdown. The DON reviewed the electronic data on the tablet, an instrument used by the facility to photograph and measure pressure ulcers, and stated Resident #171 did not have any open areas. On 05/16/23 at 2:07 PM, Resident #171's skin breakdown was observed with the DON, LPN 1, and the surveyor. The DON described the pressure ulcer's wound bed as soft eschar, with hardness to the center of the wound; dry, peeling, flaking edges; slough at the bottom perimeter; and hard redness all around the perimeter of the wound. The DON took a picture of the pressure ulcer and confirmed the measurements to be 13.0 centimeter (cm) by (x) 6.3 cm. The wound depth was not measurable due to the eschar. On 05/16/23 at 2:10 PM, the DON and LPN 1 confirmed the facility's policy was to notify the Physician or Nurse Practitioner (NP) if a pressure ulcer was noted, get treatment orders, do skin and Wound Assessments, notify the Dietician and family, do a Risk Management Evaluation, and ensure immediately. LPN 1 confirmed she had not looked to see if there were Treatment Orders in place. The DON confirmed nursing competency dictated for skin breakdown to be reported and for the Physician to be notified. During an interview on 05/16/23 at 5:23 PM, CNA 2 confirmed he worked with Resident #171 on 05/14/23. CNA 2 confirmed Resident #171 had an area that looked like a yellowish-brown scab on her coccyx on 05/14/23. CNA 2 confirmed he put a barrier cream on it and did not tell the nurse because he assumed the nurses already knew about it because it looked like it had been there awhile. Review of a document provided by the facility titled, Competency Assessment, for CNA 2 dated 02/28/23, indicated, Reporting.Reporting other information in accordance with facility policy and professional standards of practice. During an interview on 05/18/23 at 9:04 AM, the Interim Director of Nursing (IDON) stated CNA 2 should have reported the change in skin related to Resident #171. 2. Review of a document provided by the facility titled, Care Initiatives Job Description, indicated, . Under general supervision of the Administrator, the Director of Nursing manages Nursing Department human and material resources, with responsibility and accountability for provision of quality nursing care and service to facility residents/families, compliance with applicable laws and regulations. professional guidance and quality monitoring is provided by the Director of Nursing with added assistance from the assigned Nurse Consultant. Medical Director, Administrator. Interview on 05/16/23 at 7:10 PM, the DON confirmed she completed Resident #171's Skin Assessment on 05/15/23 while the resident was sitting at the dining room table and stated she did not look at the resident's bottom. During an interview on 05/18/23 at 1:36 PM, the Administrator confirmed she was to review the DON's competencies and did not. Review of a document provided by the facility titled, Facility Assessment, dated 03/27/23, indicated, . Documentation of competency of personnel, including managers, staff and volunteers in relationship to facility specific population: Quarterly Audits completed, documentation kept in employee file.

Based on clinical record review, observation, resident and staff interviews, and facility policy review, the facility failed to follow Physician Orders when the failed to administer lacosamide, a controlled substance anti-seizure medication, and/or Toradol, a pain medication, as ordered by the Physician for 2 of 35 sampled residents (Resident #170 and #15). Resident #170 had a recent seizure history requiring the use of Keppra (an anti-seizure medication) and lacosamide to control the seizures, and the facility failed to administer four doses of the lacosamide. Resident #15 had been prescribed Toradol to help with an uncontrolled migraine headache, and the facility failed to administer the medication for two days. The facility reported a census of 82 residents. Findings Include: 1. Review of Resident #170's Clinical Census, located under the Census tab of the Electronic Medical Record (EMR) revealed Resident #170 was admitted to the facility on [DATE] with a history of new onset seizure like activity. Review of Resident #170's Family Medicine Discharge Summary (Hospital Discharge Summary), dated 05/07/23 and located under the Documents tab of the EMR, revealed, . presented to the Emergency Department (ED) with chief concern of left sided weakness, neglect, and confusion. He was transferred from stroke service to family medicine inpatient service . patient continued to have waxing and waning mental status with episodes of left arm jerking and confusion that lead to a code stroke on 05/08/23 with a negative Computerized Tomography Angiography (CTA) brain. Patient was unable to tolerate Magnetic Resonance Imaging (MRI) as he had another episode in MRI at that time, so Electroencephalography (EEG) leads were placed and were positive for seizure like activity during an episode of confusion .Keppra (an anti-seizure medication) and Vimpat (lacosamide, a controlled substance, anti-seizure medication) were started on 05/09/23. He tolerated the medications well and his mental status improved . Review of Resident #170's Expected Medication List at Discharge (this document was sent with the Hospital Discharge Summary that was sent with the resident when admitted to the facility), dated 05/15/23, included lacosamide, 100 milligrams (mg) by mouth two times daily and levetiracetam (Keppra), 500 mg twice daily. Review of Resident #170's Medication Administration Record (MAR), dated 05/15/23 revealed Resident #170 received his evening medications on 05/15/23 except for lacosamide. The lacosamide medication was coded with a 9, which meant it was not available for administration. On 05/16/23 at 11:00 AM, Licensed Practical Nurse (LPN) 2 was observed providing Resident #170 his morning medications. LPN 2 stated she did not have Resident #170's lacosamide medication, which according to the MAR, should be administered between 9:00 AM and 12:00 PM. LPN 2 reviewed the MAR and confirmed Resident #170 did not receive the evening dose of lacosamide on 05/15/23. LPN 2 confirmed the 9 code on the MAR for the 05/15/23 evening dosage meant the medication was not available. LPN 2 confirmed there was no information documented that the Physician was notified that Resident #170 had not received the medication on 05/15/23. LPN 2 stated the facility had not received Resident #170's lacosamide medication because the medication was not in the medication cart. LPN 2 stated it was not reported to her by the Night Shift Nurse that the resident did not have the lacosamide. LPN 2 stated the process should be to notify the Physician and Pharmacy and pass it on in report. During the Medication Administration Observation on 05/16/23 at 11:00 AM, Resident #170 stated he had a bad headache and had visual hallucinations overnight of handwriting and flowers on the ceiling. Resident #170 stated he would rate his headache as a 12 overnight. Resident #170 rated his headache at a 6 to 7 at this time. During an interview on 05/16/23 at 12:00 PM, the Director of Nursing (DON) stated the process for ordering medications for a new admission included entering the orders into the EMR and sending the orders to the Pharmacy and to the Physician for signature. The DON stated that sometimes the Pharmacy would send a notification slip if a medication needed a hard prescription or if a medication was unavailable. The DON stated once the medications arrived at the facility, the nurse would administer the medications as ordered. The DON stated the facility had received notification that the Pharmacy did not have any lacosamide, needed a hard copy of the prescription, and that the Pharmacy had already contacted the Nurse Practitioner (NP) for the prescription. The DON confirmed staff should have contacted the NP on 05/15/23 when the medication did not arrive at the facility but stated she could not find documentation that they did. Review of MARS, dated 05/16/23 and 05/17/23, located under the Orders tab of the EMR, revealed Resident #170 did not receive his evening dosage of lacosamide. The lacosamide was coded with an H, meaning the medication was on hold. During an interview on 05/17/23 at 2:06 PM, LPN 3 reviewed the MARS for Resident #170 and confirmed she did not administer Resident #170's morning dose of lacosamide on 05/17/23 and that he did not receive the evening dose on 05/16/23. LPN 3 confirmed the medication was coded with an H, which meant it was on hold. LPN 3 stated she did not look for the medication. LPN 3 stated when she saw the medication was coded as held, she did not look for the medication. LPN 3 confirmed the medication had been in the narcotic lock box on the medication cart. During an interview on 05/17/23 at 2:35 PM, the Consultant Pharmacist stated the Pharmacy had lacosamide available in liquid form and in 50, 100, 150, and 200 mg dosages. The Consultant Pharmacist confirmed the facility had notified the Pharmacy on 05/16/23 at approximately 11:00 AM that Resident #170 needed lacosamide. The Consultant Pharmacist stated their Data Technician obtained the order from the EMR, sent it to the Nurse Practitioner for signature, and delivered the medication to the facility on the evening delivery on 05/16/23. The Consultant Pharmacist stated the facility was supposed to fax them orders for controlled substances because the Pharmacy could not automatically see those orders in the EMR. The Consultant Pharmacist stated she had no record of a faxed order from the facility on 05/15/23 when Resident #170 was admitted to the facility. The Consultant Pharmacist denied knowledge of the facility's process of putting medications on hold if they were not available for administration. During an interview on 05/17/23 at 2:52 PM, the Assistant Director of Nursing (ADON) stated if an ordered medication did not arrive from the Pharmacy, an order was written to hold the medication and the Physician or Nurse Practitioner (NP) were notified. During an interview on 05/17/23 at 4:04 PM, the Interim Director of Nursing (IDON) stated the NP had been notified on 05/15/23 that Resident #170 did not have his lacosamide and that she would obtain the documentation. During an interview on 05/17/23 at 4:45 PM, the Consultant Pharmacist stated the signed prescription for Resident #170's lacosamide was received from the NP on 05/16/23 at 1:55 PM and the medication had been delivered to the facility on [DATE], some time after 6:30 PM. She stated the evening deliveries left the Pharmacy between 6:00 and 6:30 PM, and the facility was the third stop on the route. During an interview on 05/17/23 at 5:25 PM the IDON reported Registered Nurse (RN) 1 had stated she had notified the NP on 05/15/23 that Resident #170 did not have the lacosamide via text, but RN 1 had deleted the text. During an interview on 05/17/23 at 5:43 PM, the Administrator reported the NP had stated she could not find the text message from RN 1, RN 1 could not produce the text, and the Pharmacy stated they sent the NP a request on the 15th, but they had no way to pull the record. The Administrator stated the Pharmacy reported they sent the request to the NP's phone, but the NP could not confirm or deny the request. During an interview on 05/17/23 at 5:16 PM, the IDON reported that on 05/15/23 at 9:30 PM, the facility had been notified a hard prescription was required for Resident #170's lacosamide. The IDON reported the facility called the Pharmacy on 05/16/23 for the medication, wrote a hold order for the medication on 05/16/23 at 5:25 PM, and received the medication on the evening of 05/16/23. The IDON confirmed the 05/16/23 evening dose and 05/17/23 morning dose were not administered because the hold order had not been removed when the medication arrived at the facility. 2. Review of Resident #15's EMR Admission Record, under the Profile tab, revealed Resident #15 was admitted to the facility on [DATE] with diagnoses of low back pain, sciatica, polyneuropathy, and polyosteoarthritis. Review of Resident #15's EMR Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/01/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated that Resident #15 was cognitively intact. During an interview with Resident #15 on 05/15/23 at 10:49 AM, Resident #15 stated that she gets headaches often and stated that a few months ago that she had a headache that turned into a migraine every day for about two weeks straight. Resident #15 stated normally she takes Excedrin when it goes into a migraine, but this time it lasted two weeks and she needed something stronger, something like Toradol. She stated that she only sees him [the Physician] every sixteen weeks and that they told her it was a tension headache. She has had MRIs and CAT scans, but they haven't shown anything. During a follow up interview with Resident #15 on 05/17/23 at 8:50 AM, she stated that she didn't do much during the period of time she had the two-week migraine because her head hurt so bad. She stated she laid down and didn't do much, the first few days made her sick, and then her stomach settled and she did not get sick any more. She didn't go to exercise class, she just stayed in her chair or laid down and kept the television on low volume. She said they finally gave her a shot of Toradol and it didn't work (sometimes they give a second shot and it works.) She had to wait until Monday until the Pharmacy got it in, she says she had to put up with it [the migraine] until that Monday and it was painful. She stated that even when she got it [the Toradol] on Monday it didn't help, she said it was probably past helping. She stated she thought they gave her a second one [shot of Toradol] but she's not sure. She said sometimes the NP orders stuff and they don't receive it. She stated she wasn't supposed to take the Celebrex because she had a gastric bypass, but she took one dose because they said it would be okay. She ate [during the migraine] but she ate small amounts, she said she had nausea at times during this period. Review of Resident #15's EMR Progress Notes under the Documents tab revealed an NP note dated 03/24/23 Chief Complaint: Acute visit follow up (f/u) headaches; [AGE] year-old female seen today for f/u of chronic migraines. She was seen earlier this week and was started on short course of Imitrex for ongoing migraine. Today she still endorses severe migraine with associated photophobia, nausea and diarrhea. Has received Toradol injections in the past with successful resolving of migraine, will try again today. Assessment and Plan: Migraine: Toradol 30 mg Intramuscularly (IM) x 2 doses, continue Tylenol 1000 mg, continue PRN Zofran Review of Resident #15's EMR Progress Notes under the Documents tab revealed an NP note, dated 03/27/23, Chief Complaint: Persistent HA now with associated visual changes; seen today for f/u on HA. She was seen on Friday by different provider and was subsequently ordered IM Toradol which pharmacy was unable to provide over the weekend. She has since been taking Excedrin, propranolol 40 mg TID and PRN Celebrex without improvement of symptoms. Today she reports that HA has moved to left temple area (from previous forehead) and behind her left eye. She reports L [left] eye vision changes that she describes as blurriness worse than before. Assessment and plan: Migraine, worsening .Will see if patient can be seen by ophthalmology within next few days. If unable to, will consider starting steroids preemptively while awaiting appointment. Okay to give Toradol 30 mg IM today. Review of the EMR Medication Administration Record (MAR) for March 2023 revealed an order for Ketorolac Tromethamine, Tablet 10 MG, Inject 30 mg, intradermally one time only for headache until 03/24/2023 11:59 PM -Start Date- 03/24/2023 03:15 PM -D/C Date-03/24/2023 03:20 PM which was never given, another order for Ketorolac Tromethamine Tablet 10 MG, Inject 30 mg intramuscularly one time only for headache until 03/24/2023 11:59 PM -Start Date-03/24/2023 03:30 PM which on March 24 was coded 9, bad at 2138, another order for Ketorolac Tromethamine, Tablet 10 MG, Inject 30 mg, intramuscularly one time only for headache until 03/25/2023 11:59 PM-Start Date-03/25/2023 03:30 PM which on March 25 was coded 9 DEV at 1805. During an interview on with Licensed Practical Nurse (LPN) 4 on 05/17/23 at 9:40 AM she stated regarding medications, if they did not have a medication in house, she would first look in the Emergency (E) Kit because it has medications, it's kept in the medication room. If they didn't have it in the E kit, she would order it from the Pharmacy and ask if they could execute it sooner than later. If she didn't receive it, then she would contact the Pharmacy, as they are pretty good at getting the medication here. During an interview with the Nurse Practitioner (NP) on 05/17/23 at 9:50 AM it was revealed that We had been treating it [Resident #15's headache] for a while, they had gone through neuropharmacology, she was negative for Giant Cell Arteritis (GCA), recently she was started on amitriptyline (Amitriptyline is a medication to treat major depressive disorder (MDD) in adults. The non-FDA-approved indications are chronic pain (diabetic neuropathy, fibromyalgia) and migraine prophylaxis. Resident #15 had a CT for sinuses and it was negative from the Ear Nose and Throat Doctor, they had it sent twice on two different referrals. Resident #15 is taking the Excedrin and that helps, every now and then we give her the PRN Toradol, she wants that all the time. The Celebrex did not work. Before now, we had shortage issues on all medicines. The NP revealed she isn't sure if it is the new Pharmacy that had the issues fulfilling the order for Toradol. It is always a new medicine that they have problems filling, once they know a resident is on a medicine, they don't have issues filling it. The NP probably wasn't notified of the medicine not being available, that's why she didn't put in an order for something else. She stated that If pain is uncontrolled, the patient can always go to the emergency room (ER), and Resident #15 has gone to the ER before for migraine. The Pharmacy write a notification form and tell the NP, on a piece of paper that a medication is not available, i.e. it is not on hand. The NP wasn't sure what happened on that day [that the Toradol was ordered but not fulfilled by the pharmacy]. She stated It would be nice if the pharmacy could tell us when it is not available. She revealed she couldn't say if it [order fulfillment] has gotten better, but the Pharmacist at Pharmacy utilized by the facility has her phone number and she can exchange information with them, they are still working through the kinks and finding the best pathway. She'd prefer it if they would just call her. She stated that the Pharmacy will tell the facility not the actual provider when the medication is not available. During an interview on 05/17/23 at 12:44 PM with the Assistant Director of Nursing (ADON) and the Regional Director of Operations (RDCO) it was revealed when a medication is not available from the Pharmacy, they have to get a hold order on it until they receive it from the Pharmacy. They ask the doctor to hold the medication, this means that they let the doctor know that is not available so they can order something else. When they are notified by the Pharmacy it means that they [the Pharmacy] did try to find it from another location, it could be something that could not have been in the E-kit. The nurses will check and see if there's any documentation that the Physician/NP was notified that the medication [Toradol] was not available. During a follow up interview with the RDCO on 05/17/23 at 5:54 PM, she stated the reason she could not bring up any communication from the Physician was because she couldn't find the hold order, in other words there was no hold order for the Toradol. During an interview with the Pharmacist on 05/18/23 at 10:33 AM, he stated that if there are things that aren't clinically needed, i.e. active right now, like the Toradol, that is certainly not a part of the inventory. He stated that if they need to have something that day, they send the driver to pick it up. So, during the period of time in question, being a new Pharmacy, they had more out of stocks than they have today. Once they have had one or two orders they are able to get an order from a distributor. He stated they can order every day for the next day. If it [an order] was on a Friday now, they [the Pharmacy] would send an out of stock to the facility. He has no record of this type of thing. His records showed that the facility dispensed an order on March 24, they [the Pharmacy] didn't have it and then dispensed it on the 27th, they sent the medication at noon, He stated that in general the pharmacy just sends an out-of-stock notification via the delivery, but they are working towards the fax notification. He concluded that if a medication is not available it's just not available. Review of facility's policy titled Medication Holds dated 2001, revised April 2007 revealed, Temporary medication holds may be ordered by the resident's Attending Physician .Policy interpretation and Implementation: 1. A hold order for a medication must be accompanied by a restart date or time it will be considered discontinued .3. The Nursing Staff must document in the resident's medication administration record (MAR) that such medication(s) is being held. 4. The Attending Physician must provide an explicit order as to when to restart a medication that has been held, either at the time the order is given to hold the medication or subsequently. If the medication was discontinued, a new order must be given. Review of the facility's policy titled, Ordering and Receiving Medication, dated 02/2023, recorded, . When there is a delay in the dispensing of medication such as . Physician/Prescriber signature on controlled medications . the pharmacy will notify the Nursing Staff . The Nursing Staff will document reason for the delay and notify the Physician/Prescriber. If there are further directions from the Physician/Prescriber those directions will be communicated to the Pharmacy .

Based on observation, record review, resident, family and staff interviews, the facility failed to document a complete assessment of a resident that fell and sustained a laceration to the head (Resident #10), failed to arrange for transportation for weekly blood draws for several weeks and to document an assessment on Resident #12 who had to be hospitalized with hemoglobin level of 4.8. The facility also failed to assess and to document an assessment of Resident #13 who had a UTI, failed to document the nurse practitioner or physician had been notified of UA results prior to the resident being sent to the hospital and passing away. These circumstances constituted an Immediate Jeopardy to resident health and safety. The facility reported a census of 84 residents. The Immediate Jeopardy began on 12/26/22. State Agency informed the facility of the Immediate Jeopardy (IJ) situation on 2/15/23 at 10:00 AM. The IJ was removed on 2/16/23 at 4:37 PM when the facility took the following actions: a. Resident #12's cancer clinic appointments have been coordinated as recommended by the Cancer Clinic. These appointments have been entered into the resident appointment book and also entered into PCC (Point Click Care) as an order b. Resident #13 no longer resides at the facility c. Facility staff and agency staff have been/will be educated to ensure the resident's physician progress note is received after outside appointments, noted by that nurse, and validated by a 2nd nurse. If there are no follow-up notes received after the appointment, staff will place a follow-up call to obtain the notes so appropriate follow-up has been made by the facility (orders/return appointment). Lab orders will be entered into PCC (the Electronic Medical Record, or EHR) in the orders section. Staff education also included appropriate assessment, intervention, and documentation of changes in condition and also timely physician notification of any abnormal lab results. d. The facility revised the agency orientation checklist to include assessment, intervention, and documentation protocols and also the protocol for physician appointments, lab monitoring, and follow-up. After the facility implemented education and their policy and procedures to remove the IJ, the scope was lowered from a K to a G. Findings include: 1. The Minimum Data Set assessment tool (MDS) dated [DATE] identified Resident #10 as cognitively impaired with a BIMS (brief interview for mental status) of 8 of 15 possible points. The MDS revealed the resident had diagnoses that included cancer, coronary artery disease and peripheral vascular disease. The MDS documented Resident #10 required extensive staff assistance with transfers, locomotion on and off the unit, toilet use, personal hygiene, and bathing. A review of the incident reports dated from 10/11/22 through 12/30/22 revealed the resident had a total of 11 falls: 7 occurred on night shift (10:00 PM to 6:00 AM), and 4 occurred on day shift (6:00 AM to 2:00 PM). On 11/7/22 at 10:45 AM, staff found Resident #10 on her knees near the bathroom yelling out and holding the handles of the wheelchair. The resident said she had to have a bowel movement and had called for help, but no one came. On 12/25/22 at 10:15 AM, a housekeeper told the nurse she found Resident #10 laying on the floor. The resident reported she attempted to transfer herself to bed. The resident sustained a bleeding laceration to the right side of her head; sent to the hospital ED (emergency department) for evaluation. On 10/12/22, the care plan identified the resident with the problem of being at high risk for falls and directed staff: 10/10/22 I have a sign in my room to remind me to call for help before getting up. 10/18/22 keep wheelchair near my bed for any attempts of self transfer 11/14/2022 Toilet resident approximately every two hours and prn 12/25/22 Educate to alert staff for assist. Frequent checks when in bed A review of the nurse's notes revealed the following: On 12/25/2022 at 10:15 AM, the housekeeper told the nurse Resident #10 was on the floor. When the nurse entered the room, she noted the resident lay on her right side with her head underneath her roommate's bed. The resident had hit her head and sustained a bleeding laceration to the right side of head. The nurse notified the family, called the physician, and obtained an order to send the resident to the ER for evaluation. On 12/25/22 at 11:00 AM The housekeeper told the nurse she found the resident on the floor. When the nurse entered the room, the resident lay on her right side with her head underneath her roommate's bed. The nurse called 911 as the resident had hit her head and sustained a bleeding laceration to the right side of her head. The resident reported she had tried to transfer herself to the bed. The nurse took the resident's vital signs, initiated neuro checks, and not move the resident until paramedics arrived to take the resident to the hospital for evaluation and treatment. The nurse also notified the resident's daughter, the hospice nurse, and the nurse practitioner. On 12/25/22 at 9:43 PM, staff documented Resident #10 had a fall today that caused a laceration to the back of her head. She ended up with 4 staples - bloodwork and UA both negative for abnormalities. The resident reported pain related to the injury on her head. Call light in reach and able to make needs known. Will continue to monitor. The assessment did not include documentation of the appearance of the stapled wound, any signs of bleeding, assessment of the resident's pain level, and if she required analgesics. A review of the neurological flow sheet revealed only one entry documented on 12/25/22 at 10:15 AM prior to Resident #10's hospital transfer at 11:00 AM. Observations of the resident revealed: On 1/30/23 at 9:53 AM, Resident #10 lay in bed with her call light in reach, properly positioned and she appeared to be comfortable. The resident reported she could not really remember what happened when she sustained her head injury, she remembered lost her balance when nobody was with her and she had to go to the hospital to get sutures. On 2/3/23 8:04 AM, Resident #10 sat up in wheelchair in the main dining room. Resident #10 was able to feed herself breakfast and appeared comfortable. In an interview on 2/7/23 at 1:36 PM, Staff H, LPN gave the following answers when asked the following questions: Q. When a resident is sent to the hospital and returns from the hospital after a fall to have a laceration stapled, what should the nurse document in the nurse's notes? A. She would document any orders that the resident came back with, what they did to the laceration - I remember doing that because I spoke to the nurse at the hospital. I would describe the way the skin looked, any bruising, any bleeding, mental status, and how she returned to the facility. Q. Can you remember what happened when Resident #10 had been sent to the ED on 12/25/22? A. She tried to self-transfer to the bathroom. She was not independent, Staff H could not remember how she was care planned, and she required at least the assistance of one staff. The housekeeper told her the resident fell . The resident lay by her roommate's bed with her head underneath the roommate's bed. She had a moderate amount of bleeding and no clots. Staff H reported she called 911 right away Q. How was she transported back from the hospital back to Lantern Park? A. She did not return during Staff H's shift. Q. Do you remember what happened on the day she fell in the bathroom on 11/7/22? A. She could not remember what happened exactly that day Q. Do you feel you have the help you need to meet the residents' needs? A. No, generally there is one nurse for each team, sometimes 2 nurses and a med aide and there's usually one aide per hallway. Each team would be responsible for 30 residents. There have been many residents who have complained that their call lights are not being answered timely. In an interview on 2/13/23 at 8:59 AM, Staff I, CNA gave the following answers when asked the following questions: Q. a. Can you remember what happened when Resident #10 had been sent to the ED on 12/25/22? A. She could not remember if worked that hallway, but remembered when she returned by ambulance, but could not be 100% sure. Q. Do you feel you have the help you need to meet the residents' needs? A. Typically there are 3 nurses for the whole building and there should be one CNA per hallway and one bath aide. We have been so short staff at least 3 times a week, we are short staffed when agency staff are scheduled but they will not always show up. In an interview on 2/14/23 at 1:39 PM, Staff X, housekeeper gave the following answers when asked the following questions: Q. Do you remember what happened when you found Resident #10 on the floor? A. She heard her yelling as she stood out in the hallway and she stood in the doorway and told her not to move until nursing staff to come help her. She saw her laying on the floor by the privacy curtain but 2 to 3 feet away from her bed. She could not see much as she lay behind the curtain. Q. What did you see? How much blood would you say was on the floor by her head? A. I couldn't see how much blood was coming from her head. Q. After you found her, what did you do? A. She went to get help from the nurses. They came right away, but she could not remember which nurse came to check on her. In an interview on 2/14/23 at 7:40 AM, the DON described the corrective actions the facility took: a. changed her bed to keep it in the lowest position b. started the toileting program where staff would go in there every 2 hours and at least offer to take her to the bathroom and as needed c. got her a new mattress d. assessed her bowel regimen medications e. talked to the staff in her hall to keep a closer eye on her as she continues to do things impulsively In a subsequent interview on 2/15/23 at 7:20 AM, the DON (Director of Nursing) reported: Q. Who was the nurse who assessed her after the fall? A. Staff H took care of her that day Q. With an unwitnessed fall and head injury - what is the protocol? How often are vitals and neuros checked, and where should that be documented? A. We do neuro checklist under evaluations tab in PCC every 15 min for an hour, then every 30 min for the next hour then hourly for the next four hours Q. Do you remember what time the ambulance took her to the hospital? Had it been more than an hour after her fall? A. The DON checked the electronic medical record to see the discharge form which showed the incident occurred at 10:15 AM. However, she verified she could not find documentation as to the time she left the facility. Q. What would you expect the nurse to chart for an assessment afterward? A. Document how she found her, if anyone else had in the room, what the head to toe assessment was of the resident, vitals, neuros, what was the resident trying to do, what did they do? Clean her up, call 911, and notify the NP, physician and family. This should also include the size of the laceration, the appearance, actively bleeding, presence of any clots, presence of any tissue coming out, amount of blood they saw? They need to paint the picture of what happened with the resident. 2. The MDS dated [DATE] identified Resident #12 as cognitively intact with a BIMS (brief interview for mental status) of 15 points. The MDS documented the resident had the following diagnoses: anemia, deep vein thrombosis (DVT) and limb girdle muscular dystrophy. The MDS also documented Resident #12 required extensive staff assistance with bed mobility, transfers, and toilet use, and totally dependent on staff for locomotion on and off the unit and bathing. On 4/27/21, Resident #12's care plan identified the resident required blood transfusions as needed related to anemia. The care plan did not include documentation of the frequency of the hematology appointments or mention that he had a port-a-cath for blood draws. During an observation and interview with the resident on 2/13/23 at 8:17 AM, the resident sat up at the edge of his bed, feeding himself breakfast. The resident's call light was in reach and he wore a clean t-shirt. The infusaport site on his right chest contained an intact, clean, and dry band aid and his skin appeared pink. A review of the After Visit Summary from the Cancer Center revealed the following documentation: a. Next appointment scheduled for 12/30/22 at 8:00 AM b. Next appointment at Cancer Center Infusion Site 12/30/22 at 9:00 AM c. CCC follow up scheduled for 1/6/23 - weekly lab and infusion services on Fridays d. Infusion appointments scheduled for: 1/20/23, 1/27/23 A physician order dated 6/25/21 directed when you receive Resident #12's labs (CBC) and if his Hgb is less than 7, you are to call the comprehensive cancer center. They will arrange for him to come in for his transfusion. He goes by CARE ambulance van or Yellow Cab wheelchair van. A review of the nurse's notes revealed the following: - On 1/23/23 at 7:33 AM Resident refused to have labs drawn this morning - will only allow labs to be drawn at the Cancer Center via his port. - On 1/27/23 at 2:00 PM Received a call from the Cancer Center and resident is being admitted to the hospital from his appointment. - On 2/4/23 at 5:59 AM no documentation of assessment of his infusaport site, signs of infection, etc. A hospital physician history and physical dated 1/27/23 revealed Resident #12 is a [AGE] year-old with a past medical history significant for pre red aplasia. The resident appeared disheveled and weak. He had also missed weekly appointments for desferal and blood transfusions for the past month. His hemoglobin was 4.8 and he was scheduled to receive two units of packed red blood cells, but did not receive those prior to arriving to the floor. On interview, the resident complained he felt cold, which is how he feels before he receives his transfusions on Fridays. He did note that he has missed prior appointments. In an interview on 1/31/23 at 10:12 AM, Staff E, LPN reported the following: a. She did not know how often he is supposed to have appointments at the Cancer Center. b. It is the responsibility of the nurse to enter appointments into the appointment book and making arrangements to and from the appointments. She admitted some days are really busy and sometimes she forgets to document. c. When a resident leaves the facility to go to an appointment, there usually is no documentation of an assessment. If the resident is being sent out to the hospital, should take their vital signs and neuros, not really sure. In an interview on 1/31/23 at 10:48 AM, Staff F, CNA reported the morning the resident went to the hospital, she helped clean him up before his appointment, however, she could not recall what his skin looked like. She could only recall that he had been able to feed himself. In an interview on 1/31/23 at 11:00 AM, Staff G, RN reported the ADON (Assistant Director of Nursing) usually schedules the appointments in the appointment book and makes arrangements for transportation for the residents. Some of the nurses will help her as she has new duties of being the ADON. In an interview on 1/31/23 at 11:23 AM, the nurse consultant reviewed the appointment book and could not find any documentation of appointments scheduled for Resident #12 for the month of January. Usually the DON or ADON is responsible for scheduling appointments in this book and making arrangements for transportation. In an interview on 1/31/23 at 11:29 AM, the nurse consultant reviewed the December appointment book and it showed documentation Resident #12 had an appointment on 12/2/22 and 12/30/22 and went to both appointments. In an interview on 1/31/23 at 12:04 PM, the ADON reported the following: a. When she had been the nurse manager, she recalled Resident #12 had weekly appointments, then it got switched to every 2 weeks, then it changed to monthly. b. When he comes back from the clinic, he usually will hand her paperwork from the clinic which would tell us when his next appointment is due. It's supposed to get scanned to PCC. c. When she had been the nurse manager, everyone brought her their papers and she would be the one to schedule appointments/transportation. But since she became the ADON in December 2022, the nurses took over that task and sometimes the DON or ADON will still make appointments. d. The nurse is responsible for writing the appointments in the schedule book and all the orders will be double checked by 2 nurses. After it's checked, a note should be entered into the nurse's notes by the nurse who processes the order. When the order is double checked, the two nurses will initial as being processed. e. When a resident leaves the facility to go to an appointment, there usually is no documentation of an assessment prior to them leaving. f. He may have missed appointments because the appointment itself did not get written in the schedule book, or we could not get him a ride, as he usually goes early in the morning and if that happened, we would try to reschedule. She had not been aware that he was supposed to have appointments once a week. g. We have a lot of agency nurses and I don't know that they would know to look for the paperwork from the clinic when he returns from there. In an interview on 1/31/23 at 1:56 PM interview, the DON reported the following: a. When Resident #12 went to his appointment 1/27/23, she recalled that he appeared a little pale in color, was able to eat breakfast in the main dining room and come to the front door for his appointment. b. For a while his appointments at the Cancer Center had been every 2 weeks, then every 3 weeks, however, now she did not know what his schedule should be. c. Beginning of December 2022, the process changed from the DON and ADON making the arrangements and scheduling it in the schedule book to the nurse who has the resident. There are days they do not have a nurse manager. d. The Cancer Center makes the appointments and they will send the information back with the resident who is supposed to give it to the nurse when he gets back so he or she can make arrangements for transportation and put the next appointment in the books. e. When a resident leaves the facility to go to an appointment, she would expect the nurse to put in some type of note in there and something did not look quite right. She would also expect them to make some type of note when they return from the appointment also. f. When he came back from his appointment 12/30/22, the packet he came back with said his next appointment at the Cancer Center was scheduled for 3/3/23. g. 50 to 75% of our staff are from agency. h. The nurses who take care of him should be responsible for following up on the labs that should be drawn at the Cancer Center every 2 weeks. i. The scheduling book did not have anything scheduled for him for the month of January. j. When he returns back from the Cancer Center, the process the staff should follow: The nurse that has him would need to ask him for the paperwork that came from the center Assess him, if he's ok, toilet him or take him to the next meal Double check his paperwork and see what the center did with him Put the scheduled appointments on the books If there had been medication changes, enter in the computer and fax to pharmacy The paperwork would get scanned by the medical records person or the business office assistant into PCC. This would be double checked by 2 different nurses. Shift report is done verbally but there is also communication in PCC. 3. The MDS dated [DATE] identified Resident #13 as cognitively intact with a BIMS (brief interview for mental status) of 14 points. The MDS contained the following diagnoses: heart failure, renal insufficiency (poor kidney function) and diabetes mellitus. The MDS revealed the resident required extensive staff assistance with transfers, locomotion on and off the unit and toilet use. The MDS identified the resident as occasionally incontinent of bladder and bowel. On 9/21/22 the care plan documented Resident #13 required assistance with all ADL's (activities of daily living) and directed staff to: 9/29/22 assist with routine toileting and repositioning 9/29/22 assist of one staff for all ADLs 10/18/22 one assist using EZ stand for transfers On 9/16/22, the care plan identified the resident was on diuretic therapy related to hypertension and directed staff to: a. Monitor for side effects (low sodium levels, headaches, dizziness, thirst, muscle cramps and low potassium) and effectiveness b. Monitor, document and report as needed any adverse reactions to diuretic therapy: dizziness, postural hypotension, fatigue and an increased risk for falls. A nurse's note dated 1/20/23 at 2:59 PM New order for UA (urinalysis) received, resident and family informed. The entry did not include documentation of an assessment related to the rationale for UA, vital signs, etc. The UA lab report dated 1/21/23 revealed a leukocyte esterase (suggests there are white blood cells indicating a urinary tract infection) of 3+ (normal negative) and a WBC (white blood cells indicating a urinary tract infection) of 1758 (normal range 0-3) The nurse's note dated 1/24/23 at 3:56 PM, staff called to invite the resident's daughter to care plan conference scheduled for Thursday. The entry did not include documentation that her physician, nurse practitioner or daughter had been notified of UA results after 1/21/23. The notes did not include assessments from 1/21/23 until 1/26/23. A review of the Hospitalist's history and physical dated 1/27/23 revealed documentation that indicated the resident had UTI with sepsis and a serum WBC (white blood count) of 24.6 (normal range 4.5 to 11). A review of the hospital discharge summary dated 1/27/23 revealed documentation to show the UA showed pyuria bacteriuria with leukocytosis of 24 and pronounced clinically dead at 4:45 PM. The summary contained principal Diagnosis listed as Encephalopathy, Acute Hypoxemic Respiratory Failure. Conditions Directly Contributing to Death: Acute Hypoxemic Respiratory Failure, encephalopathy, A. fib with RVR, NSTEMI type II or I, UTI, sepsis. A review of the ADL documentation by the CNAs for transfers showed documentation this had been completed on: With supervision on January 18 at 10:36 AM, 20 on 7:19 AM, 23 at 8:32 AM, 25 at 10:55 AM With limited assistance required on January 16 at 9:36 AM, 18 at 3:24 PM, 23 at 8:23 PM Required extensive assistance January 16 at 9:59 PM, 18 at 3:24 PM, 24 at 9:43 AM and 8:42 PM A review of the ADL documentation by the CNAs for toileting showed documentation this had been completed on: Review of record for toileting showed documentation was completed on: With supervision on January 18 at 10:36 AM, 20 at 7:19 AM, 23 at 8:32 AM, 25 at 10:54 AM Required limited assistance on January 16 at 9:36 AM, 22 at 9:56 AM, 23 at 8:23 PM Required extensive assistance on January 16 at 9:59 PM, 18 at 3:24 PM, 20 at 2:54 AM, 21 at 2:16 AM, 24 at 9:42 AM and 8:42 PM Totally dependent on January 16 at 4:11 AM, 17 at 3:58 AM, 18 at 3:40 AM, 19 at 5:17 AM, 22 at 2:15 AM, 23 at 5:19 AM, 24 at 3:31 AM, 25 at 5:05 AM and 7:56 PM, 26 at 2:42 AM In an interview on 2/6/23 at 11:44 A, Staff Q, LPN reported the resident sleeps in her recliner and she remembered when the ambulance came to get her, she had a BM and she did not know how long it had been there. She asked the aides if any of them cleaned her up during the night, they said she had been peaceful when they tried to move her and they left her that way .they probably did not clean her up at night. Her daughter asked if they check and changed her and that's when the aides said they really didn't do anything with her. Staff should check and change residents every 2 hours. In an interview on 2/6/23 at 12:34 PM, the ADON (assistant director of nursing) reported she had actually worked as her aide that day. She saw her last at 7:30 AM and could not get her to wake up, felt warm, like she had a fever. When she checked her temperature it had read 97.7. She asked the nurse practitioner to see her and decided to send her to the hospital. The ADON reported she did not check her brief as she sat in the recliner. When she received report from night shift, they did not report that they had checked and changed her. In an interview on 2/7/23 at 4:30 PM, the resident's POA (power of attorney) reported the following: - On 1/22/23, she went to visit her mother and noted she did not feel well: she had to use the bathroom more often and now required assistance to get up with the use of a mechanical lift. She asked a nurse if they could test her for a UTI because she's going to the bathroom more. Her roommate reported that sometimes she would find blood on the toilet seat after Resident #13 had used the bathroom. No one had said anything to the resident's POA about this bleeding. - On 1/24/23, when she went to visit the resident, she appeared to be agitated and uncomfortable, and the POA thought someone would have followed up with her having a possible UTI. - On 1/25/23, she received a call from the administration staff saying they wanted to have a meeting on 1/26/23. There was no mention of any concerns about her, just that it had been for a quarterly meeting (care conference). - 1/26/23 when the ambulance came to take her to the hospital, the ambulance staff informed the POA that Resident #13 had been allowed to sit in her own urine for hours. - On 1/27/23, the emergency room nurses said she's soaked in urine in her robe and underwear and they had to clean her up and stabilize her. Later the same day, Resident #12's temperature went up to 105.8 F. At 5:00 PM, the staff woke me up to tell me she had passed probably around 4:00 PM. In an interview on 2/10/23 at 11:29 AM, Staff G, RN reported when a nurse sends a resident to the hospital ED (Emergency Department), she should chart a physical assessment which should include the appearance of the resident's skin color, respirations, etc. The nurse should also document what happened, why the resident had been sent out, and when they notified the doctor, called the ambulance, and notified the family. She also reported with the UA report Resident #13 had, she would have called the doctor and document in the progress notes. She would also take vital signs at least every shift; especially the temperature, urine color, odor, urgency, presence of pain, and usually if an antibiotic is ordered, monitor for signs of a possible allergic reaction. In an interview on 2/13/23 10:53 AM, Staff S, LPN reported a UA had been sent out, days before the resident had been sent to the hospital. She also reported when a nurse sends a resident to the hospital ED, she should document an assessment, vital signs, that orders had been obtained from the doctor and notify the family. In an interview on 2/13/23 at 11:09 AM, Staff Q, LPN could not recall when the resident began to show signs and symptoms of a UTI which would include: confusion, dark urine, odor to urine, dizziness, sudden incontinence, fever. When a resident shows these symptoms, the nurse should call the doctor, ask if he wants a UA, obtain the UA, and then chart this in the nurse's notes. They should be placed in hot charting. After the UA shows that they have an organism that needs to be treated with an antibiotic, staff should chart at least once a shift. She recalled when the medics wheeled passed her to take Resident #12 to the hospital, she noticed the resident had a strong odor of urine. She also reported when a resident is sent to the hospital, the nurse should obtain a set of vitals, find out what's going on, get a full body assessment, and notify the nurse practitioner. The assessment and vitals all should be charted in the nurses' notes. In an interview on 2/13/23 at 9:48 AM, Resident #14 (Resident #13's roommate) reported the night before Resident #13 went to the hospital, the aides only came in 2 or 3 times. They just looked at her. They didn't change her or touch her all night until her daughter came in the morning. When her daughter came in, she couldn't get a rise out of her or get her to move. When the ambulance came to get Resident #13, they took her temperature and it was over 102 F. In an interview on 2/14/23 at 10:11 AM, the medical director reported, he would have expected staff to document vital signs and assessments under hot charting at least daily. In an interview on 2/14/23 at 11:21 AM, Staff Z, Nurse Practitioner, reported she would have expected nurses, upon identification of a possible UTI, to document assessment and vitals which would also include a temperature. Staff Z reported the resident had a temperature of 102 F before she left the building. A review of the facility policy titled: Change in a Resident's Condition or Status last revised February 2021, directed the nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times); g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting); b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan; and d. ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. there is a significant change in the resident's physical, mental, or psychosocial status; c. there is a need to change the resident's room assignment; d. a decision has been made to discharge the resident from the facility; and/or e. it is necessary to transfer the resident to a hospital/treatment center.

Based on observation, record review, resident and staff interviews, the facility failed to provide adequate nursing supervision and assistance devices to prevent accidents for 2 of 3 residents reviewed (Residents #10 and #11). The facility reported a census of 84 residents. Findings include: 1. The Minimum Data Set assessment tool (MDS) dated [DATE] identified Resident #10 as cognitively impaired with a BIMS (brief interview for mental status) of 8 of 15 possible points. The MDS revealed the resident had diagnoses that included cancer, coronary artery disease and peripheral vascular disease. The MDS documented Resident #10 required extensive staff assistance with transfers, locomotion on and off the unit, toilet use, personal hygiene, and bathing. A review of the incident reports dated from 10/11/22 through 12/30/22 revealed the resident had a total of 11 falls: 7 occurred on night shift (10:00 PM to 6:00 AM), and 4 occurred on day shift (6:00 AM to 2:00 PM). On 11/7/22 at 10:45 AM, staff found Resident #10 on her knees near the bathroom yelling out while holding the handles of the wheelchair. The resident said she had to have a bowel movement and had called for help, but no one came. On 12/25/22 at 10:15 AM, a housekeeper told the nurse she found Resident #10 laying on the floor. The resident reported she attempted to transfer herself to bed. The resident sustained a bleeding laceration to the right side of her head; sent to the hospital ED (emergency department) for evaluation. On 10/12/22, the care plan identified the resident as at high risk for falls and directed staff: 10/10/22 I have a sign in my room to remind me to call for help before getting up. 10/18/22 keep wheelchair near my bed for any attempts of self transfer 11/14/2022 Toilet resident approximately every two hours and prn 12/25/22 Educate to alert staff for assist. Frequent checks when in bed A review of the nurse's notes revealed the following: On 12/25/2022 at 10:15 AM, the housekeeper told the nurse Resident #10 was on the floor. When the nurse entered the room, she noted the resident lay on her right side with her head underneath her roommate's bed. The resident had hit her head and sustained a bleeding laceration to the right side of head. The nurse notified the family, called the physician, and obtained an order to send the resident to the ER for evaluation. On 12/25/22 at 11:00 AM The housekeeper told the nurse she found the resident on the floor. When the nurse entered the room, the resident lay on her right side with her head underneath her roommate's bed. The nurse called 911 as the resident had hit her head and sustained a bleeding laceration to the right side of her head. The resident reported she had tried to transfer herself to the bed. The nurse took the resident's vitals signs, initiated neuro checks, and not move the resident until paramedics arrived to take the resident to the hospital for evaluation and treatment. The nurse also notified the resident's daughter, the hospice nurse, and the nurse practitioner. On 12/25/22 at 9:43 PM, staff documented Resident #10 had a fall today that caused a laceration to the back of her head. She ended up with 4 staples - bloodwork and UA both negative for abnormalities. The resident reported pain related to the injury on her head. Call light in reach and able to make needs known. Will continue to monitor. Observations of the resident revealed: On 1/30/23 at 9:53 AM, Resident #10 lay in bed with her call light in reach, properly positioned and she appeared to be comfortable. The resident reported she could not really remember what happened when she sustained her head injury, she remembered lost her balance when nobody was with her and she had to go to the hospital to get sutures. On 2/3/23 8:04 AM, Resident #10 sat up in wheelchair in the main dining room. Resident #10 was able to feed herself breakfast and appeared comfortable. In an interview on 2/7/23 at 1:36 PM, Staff H, LPN gave the following answers when asked the following questions: Q. Can you remember what happened when Resident #10 had been sent to the ED on 12/25/22? A. She tried to transfer herself to the bathroom. She was not independent, Staff H could not remember how she was care planned, she required at least the assistance of one staff. The housekeeper told her the resident fell . The resident lay by her roommate's bed with her head underneath the roommate's bed. She had a moderate amount of bleeding and no clots. Staff H reported she called 911 right away Q. How was she transported back from the hospital back to the facility? A. She did not return during Staff H's shift. Q. Do you remember what happened on the day she fell in the bathroom on 11/7/22? A. She could not remember what happened exactly that day Q. How often are the staff supposed to be checking on her toileting needs? A. The aides should be checking her at least every 2 hours Q. What were most of the falls caused by? A. She could not recall. Most of the time when she found her, she had tried to go to the bathroom, she had episodes of confusion, she'll tell me she had the light on, but the light would not be on. Maybe the call light was hard for her to press the button. Q. Do you feel you have the help you need to meet the residents' needs? A. No, generally there is one nurse for each team, sometimes 2 nurses and a med aide and there's usually one aide per hallway. Each team would be responsible for 30 residents. There have been many residents who have complained that their call lights are not being answered timely. In an interview on 2/13/23 at 8:59 AM, Staff I, CNA gave the following answers when asked the following questions: Q. Can you remember what happened when Resident #10 had been sent to the ED on 12/25/22? A. She could not remember if worked that hallway, but remembered when she returned by ambulance, but could not be 100% sure. Q. How often are the staff supposed to be checking on her toileting needs? A. Every 2 hours Q. What were most of the falls caused by .trying to go to the bathroom? A. A lot of it, she gets confused, she wants to lay down then wants to get up because she needs to go to the bathroom and will forget to use the call light Q. Do you feel you have the help you need to meet the residents' needs? A. Typically there are 3 nurses for the whole building and there should be one CNA per hallway and one bath aide. We have been so short staff at least 3 times a week, we are short staffed when agency staff are scheduled but they will not always show up. In an interview on 2/14/23 at 1:39 PM, Staff X, housekeeper gave the following answers when asked the following questions: Q. Do you remember what happened when you found Resident #10 on the floor? A. She heard her yelling as she stood out in the hallway and she stood in the doorway and told her not to move until nursing staff to come help her. She saw her laying on the floor by the privacy curtain but 2 to 3 feet away from her bed. She could not see much as she lay behind the curtain. Q. What did you see? How much blood would you say was on the floor by her head? A. I couldn't see how much blood was coming from her head. Q. Did she tell you what she was trying to do when you found her? A. No Q. After you found her, what did you do? A. She went to get help from the nurses. They came right away, but she could not remember which nurse came to check on her. In an interview on 2/14/23 at 7:40 AM, the DON described the corrective actions the facility took: a. changed her bed to keep it in the lowest position b. started the toileting program where staff would go in there every 2 hours and at least offer to take her to the bathroom and as needed c. got her a new mattress d. assessed her bowel regimen medications e. talked to the staff in her hall to keep a closer eye on her as she continues to do things impulsively In a subsequent interview on 2/15/23 at 7:20 AM, the DON (Director of Nursing) reported: Q. Resident #10 had quite a few falls in a short span of time, is there any documentation to show a root cause analysis had been completed and how did you determine what was causing the falls? A. We talked that out with our team and hospice to see if there was anything that might be causing this, med reviews, toileting schedules, changing of medications, went to different appointments for cancer She thought might have documentation of a root cause analysis and will check. Q. Did Resident #10 have problems with incontinence? A. Sometimes. Q. How often was staff supposed to be helping her to the bathroom? A. Every 2 hours and as needed Q. Who was the nurse who assessed her after the fall? A. Staff H took care of her that day Q. With an unwitnessed fall and head injury - what is the protocol? How often are vitals and neuros checked and where should that be documented? A. We do neuro checklist under evaluations tab in PCC every 15 min for an hour, then every 30 min for the next hour then hourly for the next four hours Q. Do you remember what time the ambulance took her to the hospital? Had it been more than an hour after her fall? A. The DON checked the electronic medical record to see the discharge form which showed the incident occurred at 10:15 AM. however, she verified she could not find documentation as to the time she left the facility. 2. The MDS dated [DATE] identified Resident #11 as slightly cognitively impaired with a BIMS (brief interview for mental status) of 11. The MDS documented the resident had diagnoses that included coronary artery disease, diabetes mellitus and cerebrovascular accident (stroke). The MDS also documented Resident #11 required extensive staff assistance with bed mobility, locomotion on and off the unit, dressing and toilet use, and was totally dependent on staff for showers/baths. On 10/19/20, the care plan identified the resident could not transfer independently and directed the staff to provide the following interventions on the following dates: 02/11/2021- I need assist of two using Hoyer (should have been removed when he began transferring via EZ stand) 10/26/2022 - Ensure my feet are properly placed on a platform prior to standing me up (with the EZ stand). A review of the incident report dated 10/25/22 at 11:13 AM revealed the incident happened during a transfer with EZ stand. The resident stated his feet had not been placed in the stand properly. He fell to his knees on the EZ stand. Staff returned him to the chair using a Hoyer lift and dressed his foot using compression due to severe bleeding. Staff notified the physician who gave orders to send to ER for possible stitches. An observation on 2/13/23 at 8:29 AM, revealed the resident sat up in bed and appeared comfortable. He could correctly identify the current date, name of the facility, and his date of birth correctly. During an interview, the resident reported what occurred regarding an incident with an EZ stand transfer which resulted in an injury. He stated he kept telling the aides something was not right. They had the strap around his chest, but then he fell to his knees. They didn't have his feet positioned correctly on the stand and it began to really hurt. The staff tried to lift him but they couldn't and had to lay him on the floor on his side. His toes kept bleeding through his sock and when they removed his sock, it kept bleeding and bleeding, so they took him to the hospital. He reported he had to get sutures to all of the toes on his right foot. Continued observation at the time of the interview revealed he had a scabbed area approximately 1.27 centimeters (cm) in diameter to 4th toe and a 0.5 cm diameter scabbed area to the 3rd toe without signs of infection. A review of the nurse's notes revealed the following: - On 10/25/22 at 1:31 PM, the resident in an EZ stand, he stated feet had not been placed properly and fell to his knees in the stand, arms supported by the EZ stand when the CNA left to get therapy to help lower the EZ stand to the floor, laid him on his back and transferred him from the floor by Hoyer lift to the chair. Laceration noted to right toes and compression placed to right foot. Physician notified and ordered to send the resident to the ED (emergency department) for evaluation. Family notified. - On 10/25/22 at 6:54 PM, Resident #11 returned from the ED. He had a new skin tear to the right heel from a transfer out of the car when he returned that drained a moderate amount of serosanguinous discharge noted. Staff applied pressure to the area. Also noted scant amount of sanguineous drainage to toes on his right foot - sutures intact. The notes failed to contain any documentation to indicate staff measured the skin tear to the heel or the lacerations to the toes on his right foot. In an interview on 2/16/23 at 4:15 PM, the DON reported there is incomplete documentation due to the severity/emergency of the situation as he had been sent to the ER (emergency room ). A review of the facility policy titled: Falls Clinical Protocol dated as last revised March 2018 had documentation of the following: Assessment and Recognition 1. The physician will help identify individuals with a history of falls and risk factors for falling. a. Staff will ask the resident and the caregiver or family about a history of falling. b. The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days). c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in cognition or level of consciousness; e. Neurological status; f. Pain; g. Frequency and number of falls since last physician visit; h. Precipitating factors, details on how fall occurred; i. All current medications, especially those associated with dizziness or lethargy; and j. All active diagnoses. 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. a. Examples of risk factors for falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension, and medical conditions affecting the central nervous system. 4. The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications that cause dizziness or hypotension) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant). a. Falls often have medical causes; they are not just a nursing issue. 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. 6. Falls should also be identified as witnessed or unwitnessed events. a. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. a. Examples of such interventions may include calcium and vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing, or changing problematic medications (for example, those that could make the resident dizzy or cause blood pressure to drop significantly on standing). 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). Monitoring and Follow-Up 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resi- dent is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented.

Based on clinical record review, observations, resident and staff interviews, facility policy review and physician interview, the facility failed to assure that staff provided appropriate tracheostomy care to include the assessment of the humidification system and failed to provide appropriate training to Nursing Staff on procedures during an accidental extubation (tracheostomy tube fall out) and having the obturator (used to insert a tracheostomy tube) readily available at bedside for 1 of 1 resident reviewed (Resident #1). This failure resulted in several visits to an emergency room for treatment for the resident, therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of November 19, 2022 on December 28, 2023 at 10:45 a.m. The facility staff removed the Immediate Jeopardy on December 29, 2022 by implementing the following actions: a. Placement of emergency supplies in Resident #1's room to provide general trach care and emergency management as needed. b. Staff education on trach care by a local respiratory company with a competency review. c. Specific resident will be sent to hospital for tracheostomy tube changes until training and competency met and resident/staff comfortable for tracheostomy tube changes at facility. d. A Local Ear Nose Throat (ENT) Clinic has agreed to provide the tracheostomy tube changes in accordance with Physician Orders every 2 weeks. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 84 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 reveals diagnoses of heart failure, respiratory failure, tracheostomy, dependence of supplemental oxygen, obesity and obstructive sleep apnea requiring extensive assist with bed mobility, dressing and toilet use from 2 persons. Resident #1 had difficulty with breathing with activity, at rest and when lying flat. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. The Care Plan dated 10/18/22 for Resident #1 directed staff to monitor vital signs, perform oral care, keep extra trach tube and obturator at bedside, if unable to reinsert obtain medical help immediately. The Physician Orders for Resident #1 revealed to change oxygen tubing weekly and as needed, administer oxygen 3-5 liters continuously with heated humidity using a trach mask, give tracheostomy care and change the split gauze 2 times a day, offer to suction after administration of duoneb & normal saline nebulizer treatments 2 times per day and change the Bivona 7 XL trach with no inner cannula every 2 weeks. Interview on 12/27/22 at 9:51 AM, Resident #1 stated she had been in the hospital 3 times and the last time she was so dry that her lungs were bleeding. Resident #1 stated she had to wait 2 hours to be suctioned. Resident #1 stated, It makes me feel like they don't care if I can breathe or not. Resident #1 stated Staff H, Licensed Practical Nurse (LPN) was the only nurse who knew how to change her trach, I'm afraid the others will not be able to help if I need it. Resident #1 stated on 12/20/22 she could not breathe and requested to go to the hospital emergency room (ER) as she was squealing out of the trach. Resident #1 stated the Hospital (ER) Doctor got the blockage out but was unhappy since this was the third time she was there with a dried-out trach. Resident #1 stated, They were constantly running out of suctioning tubing, and had to reuse the suction catheters. Resident #1 stated sometimes the split gauze did not get changed and there was not an extra tracheostomy tube at her bedside at the facility. Observation on 12/27/22 at 9:51 AM, noted Resident #1 in room sitting in a wheelchair with blue tubing connected to Resident #1's neck, over the trach, draped down to a bag containing clear fluid then up to a half full of fluid humidifier machine, [NAME] Paykel, and O2 tubing connected to that down to Oxygen concentrator set on 4 liters, the tubing is not dated. The Suction machine on table next to Resident #1's bed, has 200 cc of yellow secretions in the bottle and the tubing is not dated. No extra trach at bedside, no obturator at head of bed, 3 suction tubings in bedside table drawer, no suction catheters, and suction equipment at bedside. A large black room humidifier on a stand next to #1's bed is not on. Observation on 12/28/22 at 8:20 AM, Resident #1 in room in the wheelchair, nebulizer tubing to tracheostomy, medication completed. Resident #1 stated she would need to be suctioned, crackling sounds heard when Resident #1 breathed. Staff F, LPN, entered room with suction catheters in hand. After hand hygiene, gloved, and removed nebulizer, Staff put on non-sterile gloves and suctioned the tracheostomy 2 times and used saline to clear tubing between the passes. The suction machine did not work right, new canister had nothing in it, nurse checked connections and adjusted the canister and a mucous plug with the saline came out of the tube and into the canister. Staff F checked Resident #1's O2 Saturation and noted at 94% and did not listen to lung sounds with a stethoscope, did not clean around the stoma, did not apply split gauze. Staff F turned on the portable O2 and a Certified Nurse Assistant (CNA) came in room and took Resident #1 to the dining room for lunch. The Medication Administration Record (MAR) dated December 2022 for Resident #1 revealed no documentation for the 12/6/22 tracheostomy tube change and not changed 12/20/22 either. Resident #1 had the tracheostomy tube change documented in her phone by Staff H, LPN on 12/11/22 and 12/25/22. Treatment Administration Record (TAR) dated December 2022 for Resident #1 revealed an order for trach care as follows: place split gauze around trach, change 2 times a day and as needed. On 12/28/22 the TAR revealed oxygen ordered continuously at 3-5 liters, verify obturator is visible at head of bed in case of emergent extubation, and heated humidity via trach mask, fill tank with distilled water every 4 hours. Document titled Hospital (Name Redacted) Report dated 11/19/22 revealed Resident #1 presented to the emergency room (ER) at 8:19 PM with shortness of breath and blockage of tracheostomy, lack of humidification to tracheostomy as a contributing factor to the condition with a recommendation to increase humidity and possible nebulizer with saline. Document titled Hospital (Name Redacted) Report dated 12/1/22 revealed Resident #1 presented to the ER at 1:47 AM with shortness of breath, difficulty breathing, wheezing. Document titled Hospital (Name Redacted) dated 12/20/22 revealed Resident #1 presented to the ER at 4:25 AM with shortness of breath, difficulty breathing, choking, dry secretions and wheezes, the resident stated the tracheostomy ran out of humidity solution and had gotten dry. Document revealed that this visit was most likely due to decreased humidity and dry secretions with discharge instruction: It is extremely important that the humidity is filled at all times, without the humidity the patient's trach will dry out and get obstructed. During an interview on 12/28/22 at 4:29 PM, the ER Physician stated he treated Resident #1 on 2 occasions for a dried out tracheostomy and Resident #1 stated that she was afraid it will happen again and no one was paying attention to it at the facility. Interview on 12/27/22 at 10:22 AM, Staff B, LPN, stated she had knowledge of trach suctioning and cleaning before working at the facility, but no further training. Staff B stated resident #1 had thick drainage suctioned after her nebulizer treatments. Staff B stated supplies were not available when resident #1 first arrived for tracheostomy care and stated the trach was changed 12/26/22 and there was not a tracheostomy tube at bedside. Staff B stated, My concern is that we need more training and only 1 nurse knows how to change her trach. Random observations on 12/27/22 revealed the following: a. At 10:30 AM, Staff B, LPN, went to the supply closet and gathered up a tracheostomy tube, Bivona XL, several suction tubing packages and took to Resident #1's room. b. At 2:30 PM Resident #1's oxygen system had a small amount of fluid in the heated humidifier. c. At 4:15 PM, Resident #1's heated humidifier filled to full line and room humidifier not on. Interview on 12/27/22 at 9:51 AM, Staff C, RN, stated there should be an extra trach and suction equipment at bed side and she does not know how to change a tracheostomy tube but can suction the tracheostomy. Staff C stated no training had been offered for tracheostomy care. Interview on 12/27/22 at 10:25 AM Staff A, LPN/Assistant Director of Nursing (ADON), stated this facility didn't use humidification with oxygen use unless they get a Physician Order or if a resident complains of dryness. Staff A stated she had knowledge of tracheostomy cares. Staff A stated the previous ADON was able to change the tracheostomy tube, no one had asked for training and they have not offered training to the Nursing Staff. Interview on 12/27/22 at 1:20 PM, the Director of Nursing (DON) stated she had not changed a tracheostomy tube, would need a refresher training before she can do one and had not offered training for tracheostomy care for Nursing Staff. During a phone interview on 12/28/22 at 8:36 AM, Staff I RN, stated Resident #1 was cooperative and followed recommendations. Staff I stated she had knowledge of tracheostomy care and provided training to Staff H, LPN and the facility did not offer training to other Nursing Staff for tracheostomy care. Staff I stated in November 2022, Staff H changed Resident #1's tracheostomy tube, the next day Resident #1 went to hospital with blood in the tracheostomy. Staff I stated after Resident #1 went to the hospital on 11/19/22 with the intervention put into place was a heated humidity. Staff I stated, A nurse on day shift did ask me once what to fill that with. Interview on 12/28/22 at 1:12 PM, Staff H LPN stated Resident #1 complained about and worried about staff suctioning in a timely manner. Staff H stated he was trained by Staff I to change the tracheostomy tube and he has done this 3 - 4 times for Resident #1. Interview on 1/4/22 at 8:20 AM, Resident #1 stated she has been congested over the last few days and the room humidifier was not on for the last 2 days. Resident #1 stated she went to the Ear, Nose and Throat (ENT) clinic and a new tracheostomy tube was placed that had an inner cannula. Interview on 1/4/23 at 9:44 AM, the DON stated the oxygen tubing should be dated when changed and the room humidifier in Resident #1's room should be filled and turned on. Review of the Oxygen Policy dated October 2010 revealed: a. Oxygen equipment needed at point #3 - humidification bottle. b. Assessment at point #2 - look for signs and symptoms of hypoxia (lack of oxygen). c. Steps in procedure at point #9 - check mask, tank and humidifying jar to be sure there is water in the humidifying jar and water level is high enough that the water bubbles as oxygen flows through. d. At point #11 periodically re-check water level in the humidifying jar and document oxygen flow rate. Review of Tracheostomy Care Policy dated 2013 revealed: a. General guidelines at point #2 - gloves are to be clean and sterile. b. At point #6 - a replacement tracheostomy tube must be available at the bedside at all times. c. At point #7 - Suction machine and a supply of suction catheters, sterile gloves and flush solution must be at bed side at all times. d. Procedure guidelines at point #7 - listen to lung sounds with a stethoscope. e. Site and Stoma Care at point #2 - clean stoma site with peroxide soaked solution, rinse with saline soaked gauze, and disinfect stoma with antiseptic gauze, single sweep for each side, air dry, apply gauze around stoma site.

Based on observation, clinical record review, resident interview, staff interviews and policy review, the facility failed to provide pain management for 2 out of 2 residents reviewed (Resident #2 and #3). The facility reported a census of 85. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 revealed diagnoses of spinal stenosis (narrowing) in the neck region, post-traumatic stress disorder (PTSD), depression, and anxiety, independent for bed mobility, toileting, and transfers, supervision with bathing. Resident #2 utilized a walker and a wheelchair for mobility. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The Care Plan dated 11/10/22 documented Resident #2 experienced pain and instructed staff to monitor, document and report to nurse as needed any sign and symptom of nonverbal pain which listed body tense, rocking, curled up and thrashing. Notify Physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experiences of pain. An observation on 12/29/22 at 8:28 AM, Staff A, Assistant Director of Nursing (ADON) asked Resident #2 if in pain and the response was a yes. Staff A stated I don't know if we have Lidocaine (pain reliever) patches, I will dig around in the supply room, if I do, I will bring it. The supplies have not arrived. Resident #2 stated he was an 8 pain out of 10 on a pain scale (scale is 0 to 10 with 0 no pain and 10 excruciating pain), and I know what a 10 is. Staff A left Resident #2's room after administering the resident's morning medications. An observation on 12/29/22 at 9:28 AM, noted Resident #2 was laying on his back drawing his legs up and sliding them straight. During an interview on 12/29/22 at 9:28 AM, Resident #2 stated he still hurt, with an 8 pain level in his lower back lumbar area, and no one has checked back with him and offered anything else for pain. Resident #2 stated this happens allthe time, waiting so long for pain relief. Resident #2 stated he was going to stay in bed, lying flat helps, and could get to the bathroom if needed to. Resident #2 stated he had an appointment on 12/27/22 and was to receive shots in his lower back first before conversations for surgery and the appointment for the shots won't be till next month. Observation on 12/29/22 at 9:38 AM, Staff A ADON knocked and entered the room and stated she did not find a Lidocaine patch and that the Director of Nursing (DON) was going to send someone after some. Resident #2 said ok, the nurse left, did not assess the current pain level and did not offer anything else for pain. During an interview on 12/29/22 at 10:45 AM, Resident #2 was sitting up in bed stated he still hurt and there were no Lidocaine patches available yet (2 hours after first pain assessment with a score of an 8 out of 10). Physician Orders for Resident #2 listed to assess pain level every shift, administer Tylenol Extra Strength 1,000 milligrams (mg) every 8 hours for pain and Lidocaine Patch 4% to be applied to lower back topically one time a day for chronic pain, may use 2 patches. A review of the Medication Administration Record (MAR) for Resident #2 revealed on 12/29/22, a pain assessment for day shift was at an 8. There was a blank space for the administration of the Lidocaine patch on 12/29/22 which indicated the patch not applied. The evening shift assessed the resident's pain at a 6 and administered Tylenol 1,000 mg at 11:06 PM (nearly 15 hours since first pain assessment with a score of an 8 out of 10). During an interview on 1/3/22 at 10:50 AM, the DON stated she sent someone after the Lidocaine patches and they had received the patches at 9:30 AM on 12/29/22. Review of a Local Health Clinic Report revealed Resident #2 was seen on 12/27/22 for a cough & sinus Tachycardia, a Chest X-ray, Electrocardiogram, labs drawn and COVID test done. Appointment set up for the Neurosurgeon Clinic on 2/13/23. 2. The MDS dated [DATE] for Resident #3 revealed diagnoses of arthritis, complete rotator cuff tear right shoulder, injury to nerve to lower legs, and needs extensive assist for bed mobility and toileting with total assist for transfers to wheelchair by a mechanical lift, assistance of 2 people. Resident #3 is incontinent of both bowel and bladder. Resident #3 had a BIMS score of 15 out of 15, indicating intact cognition. The Care Plan dated 12/19/22 for Resident #3 instructed Occupational Therapy (OT) and Physical Therapy (PT) to evaluate and treat, instructed staff to assist with activities of daily living with 2 persons to assist with toileting and repositioning with a mechanical lift. The Care Plan also addressed opioid medication to be given on a scheduled and as needed basis (PRN) for pain from the left lower leg fracture, evaluate for effectiveness and to notify the physician if unsuccessful. The Physician Orders dated 12/15/22 for Resident #3 revealed an order for Tylenol 975 mg, 3 times a day and Hydromorphone 1 mg every 6 hours as needed for pain. On 12/29/22 at 7:00 AM a new order for Cyclobenzaprine 5 mg (muscle relaxer) to be given 3 times a day. On 12/29/22 at 11:45 PM orders added for heat therapy to right neck for 20 minutes every 8 hours as needed and ice therapy to right neck, left shoulder and arm for 20 minutes every 8 hours as needed for pain and Bio-freeze to right neck, left arm and shoulder every 6 hours. A review of the Medication Administration Record (MAR) dated 12/2022 revealed Resident #3 received Hydromorphone 1 mg last at 11:35 PM on 12/28/22 and received Tylenol 975 mg at 6:00 AM on 12/29/22. A review of the Treatment Administration Record (TAR) dated 12/2022 revealed Resident #3 had ice therapy and heat therapy available, not documented as administered, and Bio-freeze to right neck, left arm and shoulder every 6 hours, also not documented as administered. An observation on 12/29/22 at 9:50 AM Staff F, Licensed Practical Nurse, LPN administered Resident #3 medication, asked Resident #3 if she was in pain and Resident #3 responded yes and rated her pain at an 8 in left leg, neck and left arm. Staff F left Resident #3's room. During an interview on 12/29/22 at 9:50 AM, Resident #3 stated she told the Nurse Practitioner about the pain yesterday, and wanted to know what caused the pain, wanted to see someone who will treat it and stated she felt the pain was not being treated here. Resident 3# stated This pain really can escalate and I told the Head Nurse yesterday that when the Certified Nursing Assistants (CNA's) turn me, the pain is bad and stays a while. During an interview on 12/29/22 at 10:10 AM, Staff F stated Resident #3 gets a scheduled Tylenol. Staff F stated the Cyclobenzaprine had not arrived from the Pharmacy. A review of the MAR revealed Hydromorphone 1 mg given on 12/29/22 at 4:38 PM for pain rated at an 8 on the pain scale, and at 11:11 PM the pain was re-evaluated and rated at a 2 on pain scale. Interview on 1/4/23 at 9:45 AM, the DON stated the facility has time frames set up for Medication Administrations and an hour before and an hour after is the Acceptable amount of time for the medications to be given in. Interview on 1/10/23 at 9:36 AM, Staff G, Director of Rehabilitation, stated Resident #3 is not currently treated by PT or OT and was last treated in September 2022. Staff G stated she was not aware of an order for massage therapy to Resident #3's neck. Staff G stated therapy is notified by nursing of a new order either by the DON or ADON by a hard copy of the order or by the nurse if a resident returns from the hospital with an order. Follow-up interview on 1/10/23 at 11:28 AM, Staff G, Director of Rehabilitation, stated she was not aware of the Physician Order on 12/13/22 to evaluate Resident #3 for neck message, initiated now. Staff G stated This is the first time I have heard of an order getting missed, they are good at putting orders in and the Nurse Practitioner is good at coming in to tell us. Staff G stated the Nursing Staff does not have heat packs to administer heat to the neck of Resident #3 but it will be addressed in the morning meeting. Follow-up interview on 1/10/23 at 11:18 AM, the DON stated the expectation of Nursing Staff was to control a resident's pain, use the as needed (PRN) medication and ask the Nurse Practitioner if needed adjusting. The DON stated I would expect them to follow Physician Orders. The DON stated they will have to ask therapy for the heat pack. Policy review of the Pain Policy Statement dated September 2017 revealed that Physicians shall help manage individuals with pain, including identification and management of causes. At Outcome point #3 revealed a pain medication will be ordered and used appropriately. At Monitoring point #11 revealed the staff will reassess the individual's pain and its consequences at regular intervals.

Based on observation, record review, staff and resident interviews and review of manufacturer's operational manual, the facility failed to provide adequate supervision and use appropriate assistive devices when transferring a resident with a mechanical stand lift (Resident #5). The sample consisted of 5 residents and the facility reported a census of 85 residents. Findings include: 1. Resident #5 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 12/29/16. The MDS indicated the resident scored a BIMS (Brief Interview for Mental Status) of 15. A score of 15 represented the resident had no cognitive problems. The MDS identified Resident #5 had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance of two staff members for bed mobility, transfers, and toilet use. The MDS indicated the resident had an impairment of one side of the body, both upper and lower extremities. The Care Plan with the goal dates of 1/13/17 and 4/12/17 identified the resident at risk for falls due to left sided [DIAGNOSES REDACTED] (paralysis), and a seizure disorder. The Care Plan directed two staff members to transfer the resident with the stand lift, and to use a strap under the resident's buttocks (4/121/17) . The Care Plan identified a problem with the resident at risk for injury related to seizure disorder, [DIAGNOSES REDACTED] and a fractured left tibia. The approaches directed 2 staff members to use a mechanical EZ stand for transfers. A form titled, Physical Therapy Recommendation for Restorative/Functional Maintenance Program, dated 6/27/16, directed two staff members to use the stand lift with a strap under the (resident's) buttocks when transferring from the bed or wheelchair or traveling to and from the bathroom. A Physical Therapy Evaluation & Plan of Treatment, with a start of care dated 6/27/17, documented that the resident had flaccid muscle tone to the left extremity. The evaluation indicated the resident had poor standing balance, and unable to shift weight. The Physical Therapy Evaluation impression indicated the resident presented with difficulty in stand lift transfers due to fatigue intermittently; this date the resident stood excellent, however benefits from the caregiver training could improve safety with transfer consistency. The manufacturer's operator's instructions titled, The EZ Way Stand Operator's Instructions, revised on 3/11/09, directed the following: On page 7, additional accessories are available as a seat trap, and stand support strap. The operator's instructions documented the seat strap is to be used for additional lower body support, and can be used for transferring or ambulation. The directions indicated the stand support strap is used for additional lower body support and effective in helping patients stand in an upright position. The resident's Care Plan lacked description of which strap should be used. The Incident/Accident/Unusual Occurrences Form dated 1/21/17 at 7:30 p.m. indicated a Certified Nurse's Aide (CNA) reported Resident#5 had difficulty with transfers in the stand lift. The form documented the resident had difficulty with weight bearing and gripping of the handle during a transfer. The form indicated the resident complained of left shoulder pain on a scale of 10 out of 10 with movement, but no pain with palpation. The form documented absence of redness, warmth or swelling to the left upper extremity. Observation on 3/20/17 at 12:01 p.m. identified the resident's bed up against the window in the room. The approximate distance from the toilet to the bed measured 25 feet. On 3/21/17 at 10:30 a.m. Resident#5 was interviewed and stated the CNAs transferred her on 1/21/17, like they always did with the EZ stand, strap under my arms. Resident#5 reported that his/her arms just started to hurt, she yelled, and a nurse came in and told the CNAs to stop. Resident#5 reported no problems with transfer before. During an interview on 3/21/17 at 12:26 p.m. Staff B, CNA reported the resident sat on the toilet and Staff A, CNA assisted with the transfer. Staff B stated Staff A, CNA assisted with the transfer and the resident had straps around the legs and under the arms and hung onto the lift with one hand. Staff B stated the resident had a stroke with paralysis of the left arm and could not hang onto the lift. Staff B stated the resident was up in the lift and out the bathroom door, when the resident reported his/her arm hurting. Staff B reported that she and Staff A put the resident in a chair outside of the bathroom door and then Staff A left to get the nurse. Staff B stated Staff C, Registered Nurse, performed an assessment of the resident. Staff B stated the resident wanted to try and stand again, and the resident complained of pain again. Staff B stated she put the resident down and the resident wanted to try again. Staff B stated Staff C provided education to the resident why they should use the Hoyer (another type of lift) and the resident refused. Staff B stated they tried again and the resident made it to the bed. On 3/21/17 at 2:44 p.m. Staff A was interviewed and stated Staff A helped her transfer Resident #5 out of the bathroom. Staff A stated the resident went up in the lift, and complained of loss of strength, and said he/she couldn't stand well, so they put the resident in a chair. Staff A stated the nurse assessed the resident, and the resident refused to use the Hoyer lift. Staff A stated the resident voiced of hand hurting. Staff A reported the resident wanted to use the EZ stand, and was able to get to the bed after two attempts. Staff A reported they use a Hoyer lift now with the resident. The resident wears an arm sling at all times now. On 3/21/17 at 11:10 a.m. Staff C, Registered Nurse, was interviewed and stated Staff A and Staff B were present when the resident could not grab onto the EZstand lift. Staff C stated the resident could not grab the lift with either hand very well and she told the CNAs to stop the transfer. Staff C stated the resident refused the Hoyer lift on 1/21/17. On 3/23/17 at 11:52 a.m. Staff C, Registered Nurse, was interviewed and stated the staff did not use a lift that went under the resident's buttocks. Staff C stated the facility does have buttock slings. On 3/23/17 at 11:56 a.m. Staff B, CNA was interviewed and stated they did not use a buttock sling on the resident when the resident fell , only the shoulder sling. Staff B stated the facility had two mechanical lift options (with the EZ stand) which is the buttock sling (seat strap) or the shoulder sling. Staff B stated the facility did have seat straps. On 3/23/17 at 12:06 p.m. Staff A, CNA reported that with the transfer of the resident they used a shoulder strap, leg strap, but not a strap that went under the buttocks (seat strap). On 3/23/17 at 12:10 p.m. Staff D, CNA was interviewed and stated the facility has about four seat slings, and showed the surveyor three of them. The seat slings appeared to be new. On 3/24/17 at 10:11 a.m. the resident's primary care physician was interviewed and stated the resident had a history of [REDACTED]. The resident's primary care physician could not say if the use of the seat sling would have prevented the fracture. The x-ray report dated 1/21/17 identified a proximal humeral (upper arm) neck fracture with transverse orientation. The area showed minimal displacement and the clavicle (collar bone) appeared intact. The report documented osteopenia had been present. A Clinic Note dated 2/3/17 documented the physician evaluated the resident for a left proximal humerus fracture. The note documented the resident was given a sling but it had not been terribly comfortable. The note indicated the resident had taken Tylenol and ibuprofen for pain but neither had been helpful. Review of the MAR (Medication Administration Record), identified medication given as needed for pain. The resident requested Ibuprofen 600 milligrams on the following dates and times: 1/21/17 at 9:00 p.m., 1/24/17 at 8:50 p.m., 1/27/17 at 3:30 p.m., 1/27/17 at 1:30 a.m., 1/29/17 at 8:20 a.m., 1/29/17 at 5:45 p.m., 2/1/17 at 6:15 p.m., and 2/26/17 at 11:30 p.m. for left arm and shoulder pain.

Based on observation, record review, staff interviews, and review of facility documentation, the facility failed to appropriately assess and implement interventions for a resident (Resident #2) following a change of condition. The facility identified a census of 87 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 06/09/16, indicated Resident #2 to have [DIAGNOSES REDACTED]. The MDS revealed the resident with a (BIMS) score of 15 out of 15. The MDS indicated that the resident required assist of one staff for bed mobility, transfer, locomotion ambulation in their room and corridor, dressing, eating and personal hygiene. The MDS indicated the resident balance during transitions and walking as steady. The MDS indicated the resident had no functional limitation in range of motion in range motion. The MDS documented the resident had one fall with injury since admission or prior assessment. The MDS indicated the resident admitted to the facility on [DATE]. The Care Plan dated 09/15/15 , informed staff that Resident #2 is at risk for falls. The goal that resident will not experience and major injuries related to falls, and included instructions for staff to: 1. Staff is to monitor for changes in resident's condition that may warrant increased supervision/assistance and notify physician. 2. Staff is to assist resident to toilet frequently. 3. 09/17/15, resident wheelchair with auto locks brakes. 4. Resident is independent with transfers and ambulation, and uses a cane at times to ensure alternate call light system in place. 5. On 11/27/15, Staff is to ensure resident's room is de-cluttered. 6. On 12/7/15 send resident to emergency room for evaluation and treatment. 7. On 12/09/15, Staff is to ensure resident to have a safety reminder note in room. 8. On 3/14/16, resident's fall is an isolated incident, acute illness, Staff is to assist resident until better. 9. 4/13/16, medication review and send to emergency room for further evaluation and treatment. 10. Resident with an acute illness. Review of the facility' s Incident/Accident/Unusual Occurrences Form dated 06/30/16 at 4:10 a.m., for Resident #2 indicated Staff heard resident yelling for help and resident found on hands and knees in doorway of his/her room. By the time Staff got to resident, resident had got his/her self-up of the floor to bed. Resident noted to with a 8 centimeters (cm) by 4 cm area of left elbow with scattered bruising and 3 of the bruises with open areas and bleeding. Resident stated he/she got up to get assist due to being incontinent and slipped in his/her socks. Resident denies pain, gait noted as unsteady but able to ambulate without difficulties. Resident denied any injury and no abnormal rotation noted to bilateral upper and lower extremities. Review of Nurse's Notes dated 6/29/16 at 10:20 p.m. indicated resident back from the emergency room with [DIAGNOSES REDACTED]. New orders received for [MEDICAL CONDITION] and warm washcloths to be used to left eye. First does of antibiotic administered, resident voiced complaints of pain to left eye. Review of Nurse's Notes dated 6/30/16 at 5:35 a.m. revealed Resident #2 resident got up to get assist due to be incontinent and soiled his/her bed. When resident got up he/she stated socks kept slipping on the floor. Resident denies any pain or discomfort, gait noted as unsteady. Resident relates fall from lack of sleep the last couple days due to his/her having shingles outbreak of left eye. Review of Nurse's Notes dated 6/30/16 at 10:30 a.m. indicated Resident #2 vital signs assessed, and resident denies any new injury from fall, however resident does complain of back achy. Staff administered Tylenol as ordered for back pain. No other complaints noted at present time. Review of Nurse's Notes dated 6/30/16 at 10:00 p.m. revealed post follow-up fall assessment done, Resident #2 complains of pain to left eye and back this shift, Tylenol administered for pain and treatment done to left eye as ordered. Review of Nurse's Notes dated 7/1/16 at 2:00 p.m. indicated Resident complaining of lower back pain of 6 out of 10 (1 being minimal pain and 10 being the greatest pain). Tylenol given as ordered for pain. Review of Nurse's Notes dated 7/1/16 at 8:50 a.m. revealed Resident #2 up multiple times walking around using a walker at this time and resident stating he/she feels weaker. The note lacked indication of any further assessment being done at this time. Review of Nurse's Notes dated 7/2/16 at 2:00 p.m. indicated Resident #2 using a walker to assist in ambulation and unsteady gait. Review of Nurse's Notes dated 7/3/16 at 10:30 a.m. indicated Resident #2 complaining of pain and stating it hurts like hell. Tylenol given as ordered for pain. Review of Nurse's Notes dated 7/2/16 at 9:00 p.m. revealed Resident #2 reports his/her left eye feels better . Review of Nurse's Notes dated 7/4/16 at 3:30 p.m. revealed Resident #2 came to Nurses' Station requesting Tylenol for back pain and states no discomfort related to shingles around eye. Review of portable radiology (x-ray) report dated 7/5/16 reviewed clinical information of Resident #2 of pain and decreased range of motion. Procedures included [MEDICATION NAME] of spine 2 views and lumbosacral 2 of 3 views. Impression of procedures included osteoporotic compression of L1 vertebra of undetermined age, grade 1 spondylolisthesis of L4 and L5. The resident's clinical record lacked indication of an assessment or resident's pain of back. Interview on 7/26/16 and 7/27/16 with the Assistant Director of Nursing (ADON), indicated the x-ray ordered due to Resident #2 ongoing increase pain to lower back and due to resident's family member requested the x-ray due to pain. Review of facsimile dated 7/6/16, addressed to resident #2 physician, revealed x-ray report ent and resident is requesting something for back pain control, currently only has Tylenol order for pain. The physician respond with a new order for [MEDICATION NAME] 50 milligrams (mg) every 6 hours as needed for pain. Review of Nurse's Notes dated 7/6/16 at 10:30 p.m. indicated a facsimile sent to Resident #2 physician regarding increase pain and the physician gave new order for pain medication of [MEDICATION NAME] 50 mg every 6 hours as needed for pain. Review of Nurse's Notes dated 7/7/16 at 3:30 p.m. indicated a new order for received by Resident #2 physician for physical therapy. The clinical record lacked indication of assessment for therapy being done. Review of Nurse's Notes dated 7/8/16 at 3:45 p.m. revealed a new order for Resident #2 of a urine analysis and culture and sensitivity (urine sample) to be done. The resident's clinical record lacked assessment or any documentation why this order obtained. Interview with the ADON (Assisted Director of Nursing) on 7/26/16 indicated the physician order [REDACTED].#2 obtained due to back pain. ADON stated the staff reported obtaining the urine sample for this on 7/10/6, however did not send it to the lab for testing, as staff dumped it out, and due to resident's family taking resident to the emergency room for ongoing increase back pain. The ADON stated nothing documented that staff followed this order for urine sample or that the urine sample dumped out and resident's physician notified of this. The ADON stated the physical therapy order of 7/7/16 for evaluation and treat for physical therapy for Resident #2 had not been done as ordered, due to family member taking resident to the hospital on [DATE]. Review of the next entry of the Nurse's Notes for Resident #2 dated 7/10/16 at 10:15 a.m., lacked indication of urine sample obtained as ordered from 7/8/16 and indicated Resident #2 family member informed staff they are taking the resident to the emergency room to be evaluated by a physician for still having ongoing complainants of lower back pain. Staff did state to family member shingles is very painful and family member replied, I want a doctor to tell me that and family member replied concern the back pain may be from previous fall. Review of the Hospitals notes dated 7/10/16, indicated Resident #2 presents with mid low back pain following 3 falls in the past few weeks. Resident describes the pain as severe, and aggravated with movement. Resident reports the pain only present in the mid-low back, not radiating elsewhere. Resident tried Tylenol and [MEDICATION NAME] for the pain, but found no relief. A Computer Tomography Scan (CT), x-ray testing, revealed New mild anterior wedge compression deformities of T11 and L1 with chronic wedge deformity of T12. Resident admitted to the hospital for monitoring of vital signs and pain control. Review of Nurse's Notes dated 7/12/16 at 9:00 p.m. indicated Resident #2 readmitted for m the hospital with [DIAGNOSES REDACTED]. Sign in room to for resident to call for help, assessment completed. Interview with the Assistant Director of Nursing (ADON) on 7/26/16 and 7/27/16 indicated staff assessments of Resident #2 are to be documented in the Nurse's Notes. The ADON stated staff thought the resident's back pain had been caused by his/her [DIAGNOSES REDACTED]. ADON indicated the resident's family did tell staff of the resident's ongoing back pain after the fall and did request he/she be sent to the emergency room for this.