Every finding on record at Life Care Center of Aurora

Based on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#2) of three residents reviewed for medication errors out of three sample residents.Specifically, the facility failed to ensure Resident #2 was administered antibiotic medications per physician's orders.Findings include:I. Facility policy and procedureThe Medication Administration policy, revised 2/13/23, was provided by the nursing home administrator (NHA) on 7/16/26 at 8:24 a.m. It read in pertinent part, The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.A significant medication error means one which causes the resident discomfort or jeopardizes his or her health and safety. Significance may be subjective or relative depending on the individual situation and duration.II. Resident # 2A. Resident statusResident #2, greater than 65, was admitted on [DATE] and discharged [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included sepsis (an extreme, life threatening response to an infection).The 5/14/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The assessment did not indicate the resident was receiving an antibiotic. B. Record reviewReview of the May 2026 CPO revealed the following physician's order:Amoxicillin-Pot Clavulanate oral suspension (an antibiotic) reconstituted 400-57 milligram (mg)/5 milliliter (ml). Give 6.3 milliliters by mouth two times a day for UTI (urinary tract infection) for five days, ordered 5/12/26 and discontinued 5/13/26.Amoxicillin-Pot Clavulanate oral tablet 875-125 milligrams (mg), give one tablet by mouth two times a day for UTI for five Days, ordered 5/13/26. The 5/12/26 administration note documented the antibiotic was not available in the emergency kit and the on call provider was notified and gave an order to start the medication on 5/13/26. The 5/13/26 nurse practitioner (NP) note documented Resident #2 was currently receiving the antibiotic for the UTI with no adverse reactions. The 5/14/26 nurse note documented Resident #2 continued on monitoring for the use of the antibiotic with no adverse reactions.The 5/14/26 infection preventionist (IP) note documented Resident #2 remained on the antibiotic two times a day for a diagnosis of a UTI. The documentation included the medication was administered without issue. The note revealed the provider wished to continue the full duration of the antibiotic as prescribed. The 5/15/26 nurse note documented Resident #2 continued to be monitored for the antibiotic and had no adverse reaction. -However, Resident #2 was not receiving the antibiotic.The 5/15/26 NP note documented Resident #2 had not received the prescribed antibiotic while residing at the facility due to a pharmacy supply issue. -Review of Resident #2's EMR did not reveal documentation regarding why Resident #2's antibiotic was not administered or why the provider was not notified. According to the May 2026 medication administration record (MAR) Resident #2 missed six out of six doses.III. Staff InterviewsLicensed practical nurse (LPN) #1 was interviewed on 7/15/26 at 2:23 p.m. LPN #1 said if a resident was admitted and a medication was not available the nurse should notify the provider to get further guidance to either hold the medication until it arrived, decide on an alternate medication and whether the medication should be continued. LPN #1 said she helped admit the resident to the facility, but did not administer any medications. She said she clarified the medication list with the provider upon Resident #2's admission.The infection preventionist (IP) was interviewed on 7/15/26 at 2:46 p.m. The IP said he was responsible for monitoring the use of antibiotics, the side effects and the effectiveness of the antibiotic. He said if there were any side effects or allergies he would notify the provider. He said he collected information from the 24-hour report and the nurses notes on how the resident was handling the antibiotic. The IP said he was not aware that Resident #2 had not received her antibiotic well she resided at the facility. The IP said he wrote the progress note after reviewing the 24-hour report and the nurse progress notes stating the resident was receiving the antibiotic and that there were no adverse effects. He said if an antibiotic was ordered, the antibiotic should be administered per the physician's order. He said if the medication was not available in the emergency kit, the pharmacy should be notified to deliver it urgently. He said if the medication was not available the provider should be notified in order to make a decision on the continued use of the antibiotic or an alternate antibiotic.Registered nurse (RN) #1 was interviewed On 7/15/26 at 3:25 p.m. RN #1 said she was the first nurse scheduled to administer Resident #2's antibiotic. She said the antibiotic was not available in the emergency kit so she called the on-call provider who gave an order to start the antibiotic the following morning. RN #1 said that was the only time she had worked with Resident #2.The NP was interviewed on 7/15/26 at 3:44 p.m. The NP said the first day she had assessed Resident #2 was on 7/13/26 and was not aware she had not received her antibiotic. She said the antibiotic was changed from liquid form to a tablet, but had never been delivered from the pharmacy. She said she did not become aware of the missed doses of the antibiotic until 7/15/26 when she spoke with the family representative and suggested an alternate antibiotic. At that time the family representative demanded the resident be sent to the emergency department for treatment.The regional director of clinical services was interviewed on 7/15/26 at 4:46 p.m. The regional director of clinical services said the director of nursing (DON), who was unavailable for an interview, was having problems with the pharmacy delivering medications. She said the DON was in constant contact with the pharmacy trying to get the medications delivered. The regional director of clinical services said however, the provider was not contacted after the initial call to the on-call provider to discuss an alternate medication or the continued use of the antibiotic. She said the medication should have been administered per the physician's order and if not administered the provider should have been notified after each missed dose. She said the IP should verify whether a resident was receiving an antibiotic and that the resident was being administered the antibiotic prior to documenting the progress note in the medical record. She said she would immediately provide education to the nurses and the IP regarding medication administration as well as provider notification if medication was not available.IV. Facility follow-upOn 7/15/26 at 6:40 p.m. the NHA provided documentation on education to the nurses on the unavailable medication and medication reordering protocol on. The facility also provided education to the IP regarding antibiotic stewardship documentation.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases on three of four units.Specifically, the facility failed to:-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner;-Ensure housekeepers performed hand hygiene appropriately while cleaning resident rooms;-Ensure chemical dwell times were followed during resident room cleaning;-Ensure resident vital signs equipment was disinfected; and,-Ensure staff followed enhanced barrier precautions (EBP) precautions while providing direct resident care. Findings include: I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 4/13/26 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 4/13/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. According to Sealed Air Diversey Care's Virex Tb Ready-To-Use Disinfectant Cleaner, revised 2017, retrieved on 4/13/26 from https://pdf.[NAME].com/operatingguides/807174540727_oper.pdf, Spray the area until it is covered with the Virex tuberculin (Tb) ready-to-use disinfectant cleaner. Allow the product to penetrate and remain wet for five minutes to kill all bacteria including Methicillin-resistant staphylococcus aureus (MRSA), Methicillin-resistant staphylococcus epidermidis (MRSE) and Vancomycin-resistant enterococci (VRE), norovirus (gastrointestinal virus), Tb, hepatitis B virus and HIV-1 viruses (acquired immunodeficiency syndrome - AIDS virus). Wipe the area with a clean cloth, sponge or paper towel. For heavily soiled areas, thoroughly clean the surface prior to disinfecting the area. A potable water rinse is required for surfaces in direct contact with food. B. Facility policy and procedure The Housekeeping policy, dated 4/1/26, was provided by the nursing home administrator (NHA) on 4/9/26 at 6:26 p.m. It read in pertinent part, It is the responsibility of the executive director through the environmental services director to assure that housekeeping policies are implemented and followed. All associates are required and expected to carry out all procedures safely and as instructed. C. Observations On 4/8/26 at 1:53 p.m. housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER], a single occupancy room in the skilled nursing unit on the first floor. HK #1 entered the resident's room with two clean rags and Diversey Virex Tb disinfectant spray. He sprayed one of the rags with the disinfectant spray then immediately wiped the surface of the resident's dresser/vanity. -HK #1 did not allow the disinfectant spray to make direct contact with the surface of the dresser/vanity and remain on the surface for the recommended five minute dwell time. HK #1 moved the resident's items off the bedside table before he sprayed the disinfectant spray on the surface. He immediately wiped the surface of the bedside table with a clean rag, then used the same rag to quickly wipe the call light. -HK #1 failed to allow the disinfectant to remain on the surface of the bedside table and the call light for the recommended five minute dwell time. At 2:06 p.m. HK #1 began cleaning the resident's bathroom. He sprayed the countertop around the sink, all surfaces of the sink, grab bars, toilet riser and toilet. At 2:06 p.m. HK #1 wiped the countertop, sink faucet handles and the interior of the sink with a rag. He collected a clean rag and re-wiped the countertop and all surfaces of the sink. At 2:07 p.m. HK #1 wiped the grab bars. He then sprayed disinfectant spray on the rag and wiped the toilet pipes and flush handle. At 2:08 p.m. HK #1 removed the toilet riser from the toilet. HK #1 sprayed the rag that was used to wipe the grab bars, toilet pipes and flush handle with disinfectant spray. He immediately wiped all surfaces of the toilet riser. -HK #1 failed to allow the surfaces in the resident's bathroom to remain wet with the Diversey Virex Tb disinfectant spray for the recommended five minute dwell time (see professional reference above) before he wiped the surface. On 4/9/26 at 9:58 a.m. HK #2 was observed cleaning room [ROOM NUMBER], a double occupancy room in the long-term care unit on the second floor. She began in the resident's bathroom. At 10:01 a.m. HK #2 sprayed the entire surface of the toilet and the toilet riser with the Diversey Virex Tb disinfectant spray. She then sprayed the disinfectant spray on a clean rag and wiped the windowsill and bedside table on side A. HK #2 sprayed the disinfectant spray into the sink and onto the sink's surrounding countertop in the resident's room. -HK #2 did not allow the disinfectant spray to make direct contact with every surface she was cleaning. -HK #2 did not allow the surface of the sink and surrounding countertop to remain wet with the Diversey Virex Tb disinfectant spray for the recommended five minute dwell time (see professional reference above) before she wiped the surface. HK #2 returned to her cleaning cart at the entrance of the resident's room, changed gloves and performed hand hygiene. She then returned to the resident's bathroom. At 10:05 a.m. HK #2 sprayed additional disinfectant spray on the entire surface of the toilet. She took a clean rag and wiped the toilet. HK #2 started with the toilet bowl rim, then wiped the toilet seat and finally the lid. -HK #2 failed to clean the toilet from the cleanest area to the dirtiest area. After she finished cleaning the toilet, HK #2 returned to her cleaning cart. HK #2 replaced the toilet brush on her cart, then grabbed the mop and removed the previously used mop head. She collected a dry mop pad, dunked it into the mop bucket, rang it out, then mopped the bathroom floor. HK #2 then removed the mop pad, replaced it with a dry mop pad and mopped the floor with a dry pad to dry the floor. -HK #2 failed to change her gloves and perform hand hygiene after cleaning the toilet and prior to reaching into the mop bucket to wet a mop pad and ring it out with her soiled gloves, which contaminated the cleaning solution. D. Staff interviews HK #1 and the housekeeping supervisor (HKS) were interviewed together on 4/8/26 at 2:20 p.m. HK #1 identified the disinfectant spray as Diversey virex Tb disinfectant spray. The HKS said he believed the chemical dwell time was three minutes. -However, according to the product's recommendations, the dwell time was five minutes (see professional reference above). HK #2 was interviewed on 4/9/26 at 9:58 a.m. HK #2 said the chemical dwell time for the Diversey Virex Tb disinfectant spray was five minutes. She said following the dwell time meant the surface had to be wet for five minutes and it was important to follow the dwell time to kill bacteria. HK #2 said the dwell time was maybe two to three minutes when she cleaned the sink and surrounding counter areas in room [ROOM NUMBER], but five minutes when she cleaned the toilet. She said she should have changed her gloves after cleaning the toilet and before touching the mop handle. The HKS was interviewed again on 4/9/26 at 11:00 a.m. The HKS said the process for cleaning included working from the cleanest area to the dirtiest area, so the bathrooms should be cleaned last as they were the dirtiest. He said the disinfectant spray should be sprayed on all surfaces and the surfaces should be allowed to remain wet for five minutes before being wiped with a rag. The HKS said it was important to follow chemical dwell times in order to kill all possible pathogens. The HKS said it was important to change gloves after touching the toilet to prevent cross contaminants, such as clostridium difficile (c. diff - bacteria that causes severe diarrhea) or norovirus around the room or within the facility. He said housekeeping staff were expected to change their gloves after dusting, taking out the trash, in between cleaning the bathroom and the main room and after cleaning the toilet. II. Failed to ensure resident vital signs equipment was disinfected and ensure staff followed EBP while providing direct resident care A. Professional reference According to the CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO), (4/2/24), retrieved on 2/5/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities.kj EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO. Examples of high contact resident care activities requiring gown and glove use for EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line urinary catheter, feeding tube, tracheostomy/ventilator), wound care (any skin opening requiring a dressing). B. Facility policy and procedure The Standard, Enhanced Barrier, and Transmission-Based Precautions policy, revised 6/2/25, was provided by the NHA on 4/9/26 at 6:02 p.m. It read in pertinent part, The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Additionally it said it was the goal to Ensure associates follow the IPCP's (Infection Prevention and Control Program) standards, policies and procedures (hand hygiene and appropriate use of PPE - personal protective equipment). C. Observations On 4/6/26 at 3:53 p.m. an unidentified nursing staff member entered a resident's room who was on EBP. The unidentified nursing staff member put on gloves and took the resident's vital signs and then left the resident's room. -The unidentified nursing staff member failed to put on a gown while taking the resident's vital signs. -The unidentified nursing staff member failed to sanitize the vital signs machine after taking the resident's vital signs. On 4/8/26 at 11:27 a.m an unidentified nursing staff member was observed assisting Resident #94 back into bed. A sign on the resident's door indicated the resident was on EBP. -The unidentified nursing staff member failed to put on gloves and a gown when assisting the resident back into bed. On 4/8/26 at 12:28 p.m. an unidentified nursing CNA and certified nurse aide (CNA) #5 entered Resident #77's room. The resident was on EBP for a pressure ulcer. The unidentified CNA and CNA #335 assisted Resident #77 from his wheelchair into his bed and brushed the resident's teeth. The unidentified CNA and CNA #5 exited the resident's room, after brushing his teeth, with a small trash bag containing incontinence supplies and the resident's lunch tray. -The unidentified CNA and CNA #5 failed to put on gloves and a gown while performing Resident #77's direct care. On 4/8/26 at 2:19 p.m. CNA #5 and an unidentified nursing staff member transferred Resident #26 from her bed to her wheelchair. There was a sign on the resident's door that indicated the resident was on EBP. -The unidentified nursing staff member and CNA #5 failed to put on a gown while transferring Resident #26. On 4/8/26 at 2:34 p.m. CNA #5 entered Resident #26's room and began assessing her vital signs using a vital signs machine. -CNA #5 did not perform hand hygiene or don any PPE prior to entering Resident #26's room. On 4/9/26 at 10:05 a.m. an unidentified nursing staff member was observed using a vital signs machine on a resident in their room. When the unidentified nursing staff member finished using the vital signs machine, the staff member wheeled the machine out of the resident's room and directly behind the nurses' station. -The unidentified nursing staff member failed to disinfect the vital signs machine prior to wheeling it behind the nurses' station. On 4/9/26 at 10:38 a.m. two unidentified nursing staff members were getting a resident up from bed using a mechanical lift. There was a sign on the resident's door indicating the resident was on EBP. -The unidentified nursing staff members failed to put on a gown or gloves prior to transferring the resident with the mechanical lift. On 4/9/2026 at 10:44 a.m. a vital signs machine was sitting in the hallway with no disinfectant supplies observed in the area. D. Staff interviews CNA #4 was interviewed on 4/9/26 at 12:30 p.m. CNA #4 said after obtaining vital signs for each resident, CNAs should sanitize vital signs machines with disinfectant wipes to prevent contamination. CNA #7 was interviewed on 4/9/26 at 12:36 p.m. CNA #7 said each CNA should clean vital signs machines with a bleach solution after obtaining residents' vital signs. CNA #7 said CNAs hands were to be washed before and after obtaining residents' vital signs. CNA #8 was interviewed on 4/9/26 at 12:45 p.m. CNA #8 said the vital signs machine was to be sanitized after each use, including the blood pressure cuff, pulse oximeter and thermometer. The infection preventionist (IP) was interviewed on 4/9/26 at 2:04 p.m. The IP said residents who had indwelling devices, such as catheters, feeding tubes, intravenous (IV lines and/or wounds should be on EBP. The IP said residents on EBP had signage on their doors which indicated they were on EBP and the appropriate PPE that staff were required to wear.The IP said staff should wash their hands and put on a gown and gloves when providing care to residents on EBP. The IP said staff should remove the PPE and wash their hands after exiting a room where the resident was on EBP. The IP said staff did not need to wear PPE for a resident on EBP if the staff members were not providing direct resident care. The IP said CNAs should disinfect the vital signs machine with a bleach solution or the blue top sanitizing wipes between obtaining vital signs on each resident. The IP said the sanitizing wipes should be on the vital signs cart.

Based on record review and interviews, the facility failed to develop and implement a comprehensive care plan for one (#87) of seven residents reviewed for care plans out of 49 sample residents. -Specifically, the facility failed to ensure individualized, person centered interventions were identified and documented in Resident #87's behavior/mood care plan.Findings include:I. Facility policy and procedureThe Care Planning - Baseline, Comprehensive and Routine Updates policy, revised 12/4/25, was provided by the nursing home administrator (NHA) on 4/9/26 at 6:26 p.m. It read in pertinent part, Identify and implement interventions and treatments to address the individual's physical, functional, and psychosocial needs, concerns, problems and risks. Identify specific symptomatic and cause-specific interventions (physical, functional, and psychosocial).II. Resident #87A. Resident statusResident #87, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included Alzheimer's dementia, depression, limited mobility progressive neurological conditions and multiple chronic conditions. The 4/2/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident used a manual wheelchair for mobility and had impairment to one side of the upper extremity and lower extremity. The MDS assessment revealed the resident reported frequent pain she received scheduled and as needed medication for pain management.The MDS assessment revealed the resident had a PHQ-9 (patient health questionnaire - a multi-purpose tool used for screening, diagnosing, monitoring and measuring the severity of depression) score of 12 out of 27, which indicated moderate depression.B. Record review Resident #87's behavior/mood care plan, initiated 7/17/25 and revised 3/21/26, revealed the resident was at risk for a change in mood or behavior due to medical conditions documented as Alzheimer's/dementia. The care plan documented the resident was assessed by a primary care provider and primary care network and the medication regimen had been managed for chronic pain syndrome (a complex, long-term condition where persistent pain is often accompanied by symptoms such as depression, anxiety, fatigue, and functional disability which can severely diminish quality of life).Interventions included administering medications, anticipating the resident's needs and consulting with the resident on preferences regarding customary routine.-However, the care plan failed to include recommendations from direct care staff regarding resident-specific interventions which were effective for managing the resident's behaviors (see interviews below).III. Staff interviewsRegistered nurse (RN) #3 was interviewed on 4/9/26 at approximately 3:00 p.m. RN #3 said she regularly provided care for Resident #87 and was familiar with her needs. RN #3 said she could not remember when she had last provided input into Resident #87's behavior/mood care plan.RN #3 said Resident #87 responded positively to personal, individual care. RN #3 said she did not rush with the resident's care.RN #3 said Resident #87 was diagnosed with dementia and sometimes asked for help she may have already requested. RN #3 said the resident did not display behavior problems if staff provided personal and kind care for the resident. RN #3 said she responded quickly every time Resident #87 called for help, which helped to keep the resident's trust in her care. RN #3 said privacy was very important to Resident #87. RN #3 said she was careful not to discuss the resident's medication or other personal care in public areas in the facility. She said she respected the privacy of Resident's #87 and always knocked before entering the resident's room and closed the door as requested when leaving the resident's room to show her respect for the resident's privacy requests.RN #3 said clean hygiene and appearance was very important to Resident #87. RN #3 said she always responded to the resident's request for personal care support and ensured the resident and her oxygen and catheter equipment had been kept clean. RN #3 said she frequently checked Resident #87's oxygen tubing and settings in order to alleviate the resident's anxiety about possible problems with the oxygen.-However, the resident-specific interventions were not updated on Resident #87's behavior/mood care plan (see record review above).The social services assistant was interviewed on 4/9/26 at approximately 4:30 p.m. The social services assistant said she was not certain about the development of the behavior/mood care plans and how interventions were determined for residents. She said the facility's social services director would have more information about the care plans, but she was currently out of the office and unavailable. The director of nursing (DON) was interviewed on 4/9/26 at approximately 6:20 p.m. The DON said individualized, person-centered care plans for residents were important. He said he was not specifically aware of Resident #87's behavior/mood care plan and the generalized, nonspecific interventions included on the resident's care plan. He said the social services staff helped to develop the residents' behavior/mood care plans.

Based on observations, record review and interviews, the facility failed to ensure residents received necessary respiratory care and services per physician orders for one (#77) of two residents reviewed for respiratory care out of 49 sample residents.Specifically, the facility failed to administer Resident #77's supplemental oxygen per physician's orders.Findings include:I. Resident #77A. Resident statusResident #77, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included cognitive communication deficits, acute respiratory failure with hypoxia (inability of the respiratory system to maintain an adequate blood oxygen level), congestive heart failure, shortness of breath, sleep apnea and dependence on supplemental oxygen.The 2/6/26 minimum data assessment (MDS) assessment revealed the resident had significant cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required supervision to maximal assistance from staff for most activities of daily living (ADL).B. ObservationsOn 4/6/26 at 11:26 a.m. Resident #77 was lying flat on his bed wearing a nasal cannula. Resident #77's room oxygen concentrator was on and the oxygen flow rate was set on 4.5 liters per minute (LPM). At 3:33 p.m. Resident #77 was lying in bed with the head of his bed elevated and his nasal cannula on. Resident #77's oxygen concentrator was set to a flow rate of 4.5 LPM.On 4/7/26 at 9:24 a.m. Resident #77 was sitting up in his wheelchair with his nasal cannula on. Resident #77's oxygen concentrator was set to a flow rate of 4.5 LPM.At 1:07 p.m. Resident #77 was lying in bed with the head of his bed elevated and his nasal cannula on. Resident #77's oxygen concentrator was set to a flow rate of 4.5 LPM.On 4/8/26 at 12:47 p.m. Resident #77 was lying in bed with the head of his bed elevated and his nasal cannula on. Resident #77's oxygen concentrator was set to a flow rate of 4.5 LPM.On 4/9/26 at 8:43 a.m. Resident #77 was sitting up in his wheelchair eating breakfast and wearing his nasal cannula. Resident #77's oxygen concentrator was set to a flow rate of 4.5 LPM.At 12:58 p.m. registered nurse (RN) #6 entered Resident #77's room, adjusted the resident's oxygen flow rate on his room concentrator, and said the resident's flow rate was at 4 LPM. RN #6 then turned Resident #77's flow rate on his room oxygen concentrator to 2 LPM before leaving the resident's room see interviews below).C. Record reviewThe oxygen care plan, revised 9/18/25, revealed Resident #77 received oxygen therapy due to his diagnoses of congestive heart failure and acute respiratory failure. Pertinent interventions included having Resident #77's oxygen settings at 2 LPM via nasal cannula continuously, administering medications as ordered and observing the resident for any signs or symptoms of respiratory distress and reporting them to the resident's physician.Review of Resident #77's April 2026 CPO revealed the following physician's orders:-Oxygen at 2 LPM continuously per nasal cannula, document every shift, ordered 8/29/25 and discontinued 4/9/26 at 1:34 p.m. (during the survey process); and,-Oxygen at 2 to 4 LPM to maintain oxygen saturations above 90 percent (%) via nasal cannula, document every shift, ordered 4/9/26 at 1:34 p.m. (during the survey process).Review of Resident #77's April 2026 medication administration record (MAR), from 4/1/26 through 4/9/26, revealed the following:The physician's order for Resident #77 to receive 2 LPM continuous supplemental oxygen was marked completed each shift (three times per day) from 4/1/26 to the morning of 4/9/26.-However, observations on 4/6/26, 4/7/26, 4/8/26 and 4/9/26 revealed the resident's oxygen flow rate was set at 4.5 LPM (see observations above). Resident #77's oxygen saturation levels were measured each shift (three times per day) from 4/1/26 to the morning of 4/9/26. Resident #77's oxygen saturation levels were documented as measuring between 93% and 98% each shift during this time period.A progress note, dated 4/8/26 at 2:40 p.m., revealed Resident #77 had generalized weakness and was unable to maintain an upright position for the duration of time he normally could. Resident #77's vital signs were measured and the resident's physician was notified.-However, the progress note did not document Resident #77's oxygen saturation level or any concerns of hypoxia.A progress note, dated 4/8/26 at 10:54 p.m., revealed Resident #77 still had tiredness and fatigue. Resident #77 had bloodwork drawn and the results were pending. The director of nursing (DON) and the resident's representatives were notified.A progress note, dated 4/9/26 at 6:33 a.m., revealed Resident #77's bloodwork results were reported to the physician and no new orders were received from the physician at the time. Resident #77 slept most of the night with even, non-labored respirations. A progress note, dated 4/9/26 at 7:00 a.m., revealed Resident #77 was being monitored by the nursing staff for weakness. Resident #77 slept most of the night, and his plan of care was continued. Resident #77's vital signs were measured and the resident had an oxygen saturation level of 98%.A progress note, dated 4/9/26 at 7:50 a.m., revealed Resident #77 had a change in condition initiated and his representative was notified.A progress note, dated 4/9/26 at 1:20 p.m., revealed Resident #77 had a change in condition initiated the day prior (4/8/26) for generalized weakness. Resident #77 had bloodwork completed, which was reported to the physician. Resident #77 had an occasional cough and wheezing was heard when the resident's lung sounds were auscultated (an exam performed to listen to the sounds of the heart and lungs). Resident #77's supplemental oxygen flow rate was increased to 4 LPM to keep the resident's oxygen saturation level above 90%, and the order was confirmed by the resident's physician. An order for a chest Xray was placed by Resident #77's physician for his wheezing.-However, review of Resident #77's electronic medical record (EMR) did not reveal any oxygen saturation levels below 90%.A change in condition evaluation, dated 4/8/26 at 3:52 p.m., revealed Resident #77 was being evaluated for a change in condition due to generalized weakness. The change in condition started on 4/8/26. Resident #77's oxygen saturation level was measured to be 94% at the time. The assessment documented no respiratory changes were noted. Resident #77's physician was notified on 4/8/26 at 11:00 a.m., and new interventions included encouraging oral intake of food and beverages.-The change in condition evaluation did not document any respiratory changes for Resident #77.-Review of Resident #77's EMR did not reveal any documentation of his supplemental oxygen flow rate needing to be titrated up, or any documentation revealing the resident's physician was contacted regarding his oxygen needing to be titrated.II. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 4/9/26 at 9:15 a.m. CNA #5 said oxygen was a medication, so the CNAs could not adjust the residents' oxygen flow rates. CNA #5 said if a resident's oxygen flow rate needed to be adjusted, a nurse would need to do so. CNA #5 said Resident #77's oxygen flow rate was set to 4 LPM.-However, observations during the survey revealed the resident's oxygen flow rate was set at 4.5 LPM (see observations above).-Additionally, the resident's physician's order for oxygen revealed the resident's oxygen flow rate was to be set at 2 LPM (see physician's orders above).CNA #6 was interviewed on 4/9/26 at 11:08 a.m. CNA #6 said the CNAs did not adjust residents' oxygen flow rates. CNA #6 said the facility nurses had to check the residents' oxygen flow rates and ensure they were receiving the correct oxygen flow rate or adjust it.RN #2 was interviewed on 4/9/26 at 12:26 p.m. RN #2 said residents receiving supplemental oxygen had to have physician orders for the oxygen. RN #2 said the facility's nursing staff needed to know what the resident's baseline oxygen need was and the condition the oxygen was being used to treat. RN #2 said nurses needed to check the residents' oxygen saturation levels and communicate with their doctor consistently. RN #2 said in order to titrate a resident's supplemental oxygen flow, the nurse needed to have a physician's order to titrate the oxygen and a reason to titrate the oxygen. RN #2 said she would then need to communicate with the resident's physician to let them know the resident's oxygen needed to be titrated up and begin figuring out what was causing the resident to desaturate (a drop in blood oxygen saturation). RN #2 said oxygen was a medication.RN #6 was interviewed on 4/9/26 at 12:44 p.m. RN #6 said CNAs could set up residents' oxygen and nasal cannulas. RN #6 said if a resident needed to have their oxygen flow rate titrated up, the nursing staff would assess the resident to see why they had an increased oxygen need and call the resident's physician in order to get a physician's order to titrate the oxygen. RN #6 said Resident #77's oxygen never needed to be titrated up or down, and said the resident was on a continuous oxygen flow rate. RN #6 said he was not sure what LPM Resident #77's physician ordered but said he could check the resident's EMR. RN #6 reviewed Resident #77's EMR and said the resident's April 2026 CPO had a physician's order for 2 LPM continuous oxygen. RN #6 said he did not see any physician's orders to titrate Resident #77's oxygen, and said he wanted to ask the unit manager about the titration orders. RN #6 entered Resident #77's room and said he was receiving 4 LPM of supplemental oxygen, then turned his oxygen flow rate down to 2 LPM before leaving the room (see observations above). The unit manager was interviewed on 4/9/26 at 1:03 p.m. The unit manager said Resident #77 was having a change in condition as of the day prior (4/8/26) and was being monitored by the nursing staff. The unit manager said Resident #77 had a fluid overload and his oxygen saturations tended to drop as a result. The unit manager said she was waiting for the physician to provide orders to titrate Resident #77's oxygen flow rate. -However, Resident #77 had been observed receiving a higher oxygen flow rate than what was ordered by his physician on 4/6/26 and 4/7/26, prior to his documented change in condition.The DON was interviewed on 4/9/26 at 4:15 p.m. The DON said supplemental oxygen orders were typically received from the hospital on admission and verified with the resident's physician. The DON said the facility generally tried to avoid using oxygen flow rate ranges, and tried to use one continuous numeric flow rate for the residents instead. The DON said physicians sometimes added orders to titrate residents' oxygen flow rates to ensure their oxygen saturation levels remained above 90% as needed. The DON said the physician had to provide a physician's order to titrate residents' oxygen in order for the nursing staff to do so. The DON said the nursing staff needed to communicate with the residents' physicians on a daily basis to see how the resident was doing on their current oxygen orders.The DON said oxygen was a medication and the nursing staff's goal was to titrate the residents' supplemental oxygen as low as possible. The DON said a resident should not receive a greater supplemental oxygen flow rate than what their physician ordered, as oxygen was a medication and it would be the same as giving someone too much oxycodone or duloxetine. The DON said the nursing staff and the resident's physician needed to evaluate the root cause of why the resident's oxygen needed to be titrated up.The DON reviewed Resident #77's April 2026 CPO and said he saw there was a physician's order for supplemental oxygen ranging from 2 to 4 LPM, ordered that day (4/9/26). The DON said he would not want to continue using that physician's order as it had a LPM oxygen flow rate range. The DON said the nursing staff were supposed to keep Resident #77's oxygen concentrator set to the flow rate the physician ordered. The DON said Resident #77 was not able to tamper with his oxygen concentrator. The DON said the nursing staff should have contacted Resident #77's physician and documented their conversation regarding titrating the resident's oxygen.

Based on record review and interviews, the facility failed to ensure two (#7 and #123) of seven residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 49 sample residents. Specifically, the facility failed to ensure Resident #7 and Resident #123, who had identified indicators of depression were provided with mental health services.Findings include: I. Facility policy and procedure The Behavior Health Services policy, reviewed 9/2/25, was provided by the regional support team member on 4/9/26 at 6:26 p.m. It revealed in pertinent part, Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care. The facility should identify residents who develop decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, and may have made verbalizations indicating these and evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable. Identify if the resident would benefit based on assessment in conjunction with; mental health history, and current medication regimen additional mental health consultation (psychiatry, psychology, clinical social work). If a determined need is present, the facility should consult with the attending physician to make a referral to a mental health professional for assessment and potential for ongoing follow-up. Initiate Behavior Monitoring, Behavior Management Care Plan, and Kardex (tool used to assist with providing consistent care) as indicated by assessment findings, use of psychoactive medications, resident/responsible party conversations, and observations. The social worker is primarily responsible for initiation of the Behavior Management Care Plan. II. Resident #7 A. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included thrombotic stroke (brain cell death caused by a blood clot forming in an artery on the brain), left sided hemiplegia and hemiparesis (left sided paralysis and weakness), traumatic hemorrhage (brain bleed), depression and anxiety. The 3/12/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. He was dependent on staff for assistance with bathing, dressing, and transferring. The resident was incontinent of bowel and bladder and required two-person total assistance in toileting care. The MDS assessment indicated the resident had felt down, depressed and hopeless nearly every day (12 to 14 days) during the assessment look-back period. B. Resident observation and interview Resident #7 was interviewed in his room on 4/7/26 at 11:06 a.m. The resident said prior to his stroke, he had been an active firefighter for six years. Resident #7 expressed his pride and sense of accomplishment related to his job and said it was the only job that he had ever loved doing. Resident #7 said it was painful when his fellow firefighters came to visit him in the facility because he did not want them to leave him and it was a reminder of his current health condition. He said his wife and son lived out of state and he had suffered his stroke while working in this state. Resident #7 said he only saw his family one time a week now and it had been very difficult for him to see his son have to be in the position of acting as the power of attorney for him. He said he had an upcoming cranioplasty (a surgery to repair cranial defects caused by injuries or operations) and he expressed fear and concern regarding the upcoming surgery. Resident #7 talked in great length about all his lifelong accomplishments and responsibilities and how much he had lost due to the stroke. He said he had been experiencing depression and sadness that had been escalating, but he said he had not asked for psychological services because he said it was difficult for him to ask for. Resident #7 said he would be willing to visit with a psychologist or counselor to discuss his depression. However, he said the services had never been offered to him. During the interview, Resident #7 became tearful five times. C. Record review The psychosocial care plan, revised 3/16/26, revealed Resident #7 had a diagnosis of depression. Interventions (initiated 3/16/26) included arranging a psychological consultation. Review of the April 2026 CPO revealed the following physician's orders: Duloxetine (an antidepressant medication) 30 milligrams (mg). Give two capsules via gastrostomy tube (a device inserted through the abdomen into the stomach to deliver nutrition and medications) one time a day for depression, ordered 11/11/25. -The April 2026 CPO failed to reveal physician's orders for a psychological consultation or a physician's order to monitor for potential signs and symptoms of depression for Resident #7. Review of Resident #7's electronic medical record (EMR) revealed the following: A long-term care physician note, dated 10/2/25, revealed the nursing staff reported concerns for poorly controlled depression as Resident #7 lacked interest in activities and communicating with staff. His most recent depression score was a 10 out of 27 (indicating moderate depression). The resident was taking mirtazapine (an antidepressant medication) 15 mg daily. The physician increased the mirtazapine to 30 mg daily. A case management note, dated 10/2/25, revealed the case manager had communicated to the physician that Resident #7 was feeling down and would close his eyes when taken to the common area television room. He refused to join activities or leave his room. The resident's antidepressant medication was increased by the physician. A case management note, dated 10/6/25, revealed the case manager had communicated with the physician that Resident #7 was observed to be crying and preferred to remain in bed. His antidepressant medication had recently been increased and staff were to monitor the resident. A long-term care physician note, dated 10/23/25, revealed Resident #7 reported that the current antidepressant medication was not helping with his depression. The resident reported that the current medication, mirtazapine, did not seem to help with depression and he experienced no noticeable improvement. A case management note, dated 10/28/25, revealed Resident #7's physician's order for mirtazapine was discontinued and replaced with duloxetine 30 mg for depression. A readmission note, dated 12/23/25, revealed Resident #7 had returned from being sent out to the hospital related to his tracheostomy. The resident had a diagnosis of depression and was utilizing duloxetine for mood and behaviors. The resident was to be referred for a psychological evaluation if needed. -However, review of the resident's EMR revealed no further documentation regarding the status or treatment for the resident's depression. -Despite the resident expressing signs and symptoms of depression, the EMR failed to reveal psychological services were offered to Resident #7. III. Resident #123 A. Resident status Resident #123, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included spinal stenosis (narrowing of the spinal canal causing pressure on the spinal cord or nerves), cognitive communication deficits and chronic pain. The 3/26/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required supervision to moderate assistance from staff for most activities of daily living (ADL). The MDS assessment indicated the resident felt down, depressed or hopeless and had trouble falling or staying asleep nearly every day during the assessment look-back period B. Resident interview Resident #123 was interviewed on 4/6/26 at 10:58 a.m. Resident #123 said she did not want to be at the facility and wanted to go back home. Resident #123 said she would be better off dead than at the facility. Resident #123 said her physician wanted her to go see a psychiatrist but she had not wanted to talk to anyone. Resident #123 said she was a loner and did not like to go to activities. Resident #123 was interviewed a second time on 4/8/26 at 12:48 p.m. Resident #123 said her mental health had gone down the toilet since she was admitted to the facility, as the facility felt foreign to her. Resident #123 said nothing at the facility made her happy, and said she would be better off dead than at the facility. Resident #123 said she hated to have to ask for help from the staff, as it made her feel not herself. Resident #123 said she had previously never asked anyone for help and did everything on her own. Resident #123 said she felt sad and frustrated and was overall unhappy about living in the facility. Resident #123 said the facility staff had never offered her any mental health or psychiatric services. Resident #123 said her outside physician had offered to refer her to a psychiatrist, but she had declined this at first because she did not like talking to people about her problems. Resident #123 said she had been thinking about accepting the referral because she thought it might be helpful. -However, the resident's outside physician had suggested the referral to the resident instead of the facility. C. Record review The behavior care plan, revised 4/6/26, revealed Resident #123 had a behavior problem and was attention seeking, as evidenced by her using her call light to ask staff what they were doing and attempting to engage them in conversation. Resident #123 made false accusations about staff, saying the staff avoided staying in her room as a companion and saying they did not want to stay in the room with her. Pertinent interventions included encouraging Resident #123 to participate in group/community activities to assist in her psychosocial need of companionship, and observing for behavioral episodes and attempting to determine the underlying cause. The pain medication care plan, revised 11/12/25, revealed Resident #123 received pain medication therapy due to her chronic pain. Pertinent interventions included observing Resident #123 for, and reporting as needed, any adverse reactions, including anxiety or depression. The black box medication (medications which can cause serious adverse effects) care plan, revised 2/26/26, revealed Resident #123 was at risk for adverse reactions due to taking black box medications. Pertinent interventions included observing Resident #123 for possible signs or symptoms of adverse drug reactions, including fatigue, agitation or depression. A PHQ-9 assessment, dated 7/9/25, revealed Resident #123 said she did not feel down, depressed or hopeless. Resident #123's total score on the assessment was zero out of 27, which indicated the resident did not have depression. A physician's note, dated 9/15/25, revealed Resident #123 was seen by her physician to evaluate oral pain. The physician documented Resident #123's mood and affect were not happy. An outside physician's visit note , dated 9/23/25, revealed Resident #123's physician was concerned about her memory and mood. Resident #123 had a PHQ-9 assessment score of 13 out of 27, indicating the resident had moderate depression, when assessed by the outside physician. The physician documented Resident #123 had additional diagnoses of frailty and major depression. The physician documented a follow-up for Resident #123 with psychiatry. A progress note, dated 9/23/25 at 4:39 p.m., revealed Resident #123 had returned to the facility following an outside physician's appointment. Resident #123 came back with a recommendation from her physician to follow up with psychiatry, and a referral for behavioral health services. -However, review of Resident #123's EMR did not reveal any documentation of any attempts made by the facility to schedule the resident for psychiatry or behavioral health services. A PHQ-9 assessment, dated 10/8/25, revealed Resident #123 said she did not feel down, depressed or hopeless. Resident #123's total score on the assessment was zero out of 27, which indicated the resident did not have depression. A PHQ-9 assessment, dated 1/7/26, revealed Resident #123 said she felt down, depressed or hopeless nearly every day. Resident #123 said she had trouble falling or staying asleep nearly every day. Resident #123's total score on the assessment was seven out of 27, which indicated the resident had mild depression. -Review of Resident #123's EMR did not reveal any new interventions related to her increase in the PHQ-9 assessment score. A PHQ-9 assessment, dated 3/25/26, revealed Resident #123 said she felt down, depressed or hopeless nearly every day. Resident #123 said she had trouble falling or staying asleep nearly every day. Resident #123's total score on the assessment was seven out of 27, which indicated the resident had mild depression. IV. Staff interviews CNA #5 was interviewed on 4/9/26 at 9:15 a.m. CNA #5 said Resident #123's mood was hit or miss. CNA #5 said sometimes Resident #123 was calm and nice, but other times the resident exhibited behaviors. Certified nurse aide (CNA) #3 was interviewed on 4/9/26 at 9:57 a.m. CNA #3 said Resident #7 did not have any behaviors and kept to himself in his room. CNA #3 was not aware of what signs or symptoms of depression to observe for or report for Resident #7. The second floor unit manager was interviewed on 4/9/26 at 10:10 a.m. The unit manager said the staff had observed signs and symptoms of depression when Resident #7 first admitted to the facility and it was reported to the physician. The unit manager said the resident had an upcoming cranioplasty appointment that was difficult to secure, so the staff had provided him with numerous updates to give him hope. She said she did not know if he received psychological services or what specific signs to monitor for ongoing depression for Resident #7. CNA #6 was interviewed on 4/9/26 at 11:08 a.m. CNA #6 said when Resident #123 had bad days, the resident had a very bad mood. CNA #6 said Resident #123 had had more periods of having a bad mood over the last month. CNA #6 said Resident #123 had started yelling more during the night, which other residents complained about because they were trying to sleep. Registered nurse (RN) #6 was interviewed on 4/9/26 at 12:44 p.m. RN #6 said Resident #123 complained a lot to the facility staff and asked the staff for things frequently. RN #6 said the nursing staff tried to reassure Resident #123 she was taking the right medications for the health issues she was concerned about, or brought her medications when she requested them. RN #6 said Resident #123 did not really seem sad, but maybe frustrated. The MDS nurse was interviewed on 4/9/26 at 1:04 p.m. The MDS nurse said she had put in the care plan intervention for psychological services for Resident #7 because of his antidepressant use and his circumstances. The MDS nurse said when this happened, she communicated to the social services director (SSD) in the residents at-risk meeting that a referral needed to be sent for behavioral health services. The MDS nurse looked up her meeting minutes from the meeting after she put in the psychological care plan intervention for Resident #7 on 3/16/26. -The meeting minutes, dated 3/26/26, failed to indicate that the MDS nurse mentioned to the SSD in the meeting that Resident #7 needed psychological services for depression. The social services assistant was interviewed on 4/9/26 at 2:00 p.m. The social services assistant said she had been working at the facility for six months in her current role. The social services assistant said the process for setting up psychological services for residents was to request a physician's order and then send a referral to the facility's mental health provider. She said things that would indicate that a resident needed services would be if the resident was having increased behavioral problems, increased depression screening scores or non-verbal signs or symptoms of depression, such as isolating themselves or crying. The social services assistant said the type of questions the resident responded to in the depression screen assessment, such as feeling down, depressed or hopeless would trigger a referral for behavioral health services. -However, the 3/12/26 MDS assessment for Resident #7 indicated he had felt down, depressed or hopeless on multiple days during the assessment look-back period, but the facility failed to offer behavioral health services to the resident (see resident status above). The social services assistant said Resident #7 originally lived in a different state but had driven an hour into this state to work as a firefighter. She said she did know how he was emotionally handling the circumstances of his condition and placement into a nursing facility. The social services assistant said she had not offered the resident psychological services and was not aware of the intervention in his care plan to obtain a consultation for him. She said her department would be responsible for sending the referral and someone like Resident #7 (younger age, unforeseen significant life event, trauma) should have been offered psychological services. She said she would send a referral for him to be seen before his upcoming major surgery. The social services assistant said she had worked with Resident #123 before to help her fill out her dining menus. The social services assistant said Resident #123 had not expressed any depression or concerns to her before. The social services assistant said, based on the information regarding Resident #123's change in PHQ-9 assessment score (see record review above) and the information the resident shared in her interview (see resident interview above), she would want to send out a referral for mental health services for the resident.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards of practice for one of three medication administration carts and one of two medication storage rooms.Specifically, the facility failed to ensure medications, such as eye drops, inhalers and insulin pens, were labeled and dated appropriately with the resident's name and the date the medication was opened.Findings include:I. Observations and interviewsOn 4/9/26 at approximately 5:00 p.m. the first floor [NAME] medication cart one was observed with registered nurse (RN) #3. The following was observed:-One multi-dose bottle of Latanoprost ophthalmic solution (medication used to treat certain kinds of glaucoma) was stored inside an appropriately labeled pharmacy medication box. -However, the individual bottle of medication inside the box was not labeled with the resident's name and the date the medication was opened. -One inhaler of Incruse Ellipta Inhalation Aerosol Powder (a medication used to treat chronic obstructive pulmonary disease) was stored inside an appropriately labeled pharmacy medication box.-However, the individual bottle of medication inside the box was not labeled with the resident's name and the date the medication was opened. On 4/9/26 at approximately 5:30 p.m. the second floor [NAME] medication storage room was observed with RN #5. The following was observed: -There were individual boxes of Ozempic pens (a weekly injectable medication used to improve blood sugar in adults with type 2 diabetes and often aiding weight loss) stored in the refrigerator in appropriately labeled pharmacy medication boxes. The pharmacy boxes were opened.-However, the Ozempic pens in each box were not individually labeled with the specific resident name and the date the medications were opened.RN #5 said the Ozempic pens were used once every week and did not need to be individually labeled since the pharmacy labeled box was labeled with the resident's name. II. Additional staff interviewsThe director of nursing (DON) was interviewed on 4/9/26 at approximately 6:30 p.m. The DON said Ozempic pens administered weekly did not need to be labeled with a resident's name, because the pens were used only once and discarded.The DON said that medications inside the Latanoprost and the Ellipta inhaler pharmacy boxes should be labeled with the resident's name so staff would know who the medication belonged to if the medication got separated from the box.

Based on observations, record review and interviews, the facility failed to ensure two (#4 and #80) of four residents reviewed for ancillary services, such as dental services, out of 49 sample residents received routine dental care obtaining routine and 24-hour emergency dental care.Specifically, the facility failed to:-Provide dental services for Resident #4 who had broken and missing teeth; and,-Provide dental services for Resident #80 who had identified dental decay.Findings include: I. Facility policy and procedure The Dental Services policy and procedure, revised 9/3/25, was provided by the regional support team member on 4/9/26 at 6:26 p.m. It read in pertinent part, The facility is responsible for obtaining needed dental services, including routine dental services. Upon admission, the facility will obtain the name of the resident's dentist and if none is provided, will select a dentist to provide dental services as needed. Arrangements will be made promptly for routine and emergency dental services. Residents will be assisted with making appointments and arranging transportation to and from the dentist's office if necessary. II. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE], discharged to the hospital on 1/29/26 and readmitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included acute respiratory failure, protein-calorie malnutrition, chronic obstructive pulmonary disease and heart failure. According to the 2/11/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required setup or cleanup assistance from staff for oral hygiene and was independent for personal hygiene and eating. The assessment did not document the resident had any broken or missing teeth. B. Resident observation and interview Resident #4 was interviewed on 4/6/26 at 3:19 p.m. Resident #4 said she had fallen and broken her teeth two years prior after she fell and hit her mouth on her sink. Resident #4 said she had been without her teeth for two years, and said she would be interested in getting dentures. During the interview, Resident #4 was observed to be missing most of her upper teeth and had some broken or damaged teeth. Resident #4 was interviewed a second time, in the presence of the MDS nurse and the MDS coordinator on 4/9/26 at 4:36 p.m. Resident #4 said she wanted to get permanent dentures. Resident #4 said no one from the facility had talked to her about dentistry or offered to have her see the dentist since she was admitted to the facility. During the interview, the MDS nurse performed an oral exam on Resident #4 which revealed multiple missing teeth and one broken tooth on her upper palate (see record review and interviews below). C. Record review The comprehensive care plan, revised 4/3/26, revealed Resident #4 was at risk for oral/dental health problems as a result of her aging process. Pertinent interventions included providing mouth care daily, observing and reporting any signs or symptoms of oral or dental problems which needed attention, including pain or teeth observed to be missing, broken, loose, eroded or decayed. An admission assessment tool, dated 12/27/25 at 3:00 p.m., revealed Resident #4 was assessed by a member of the facility's nursing staff on admission. Resident #4's oral health status was able to be examined at the time, and it was documented the resident did not have any broken or missing teeth. -However, observations revealed the resident was missing multiple teeth and had some damaged teeth (see observations above). The admission MDS assessment, dated 12/29/25, documented Resident #4's oral status was able to be assessed. The assessment documented Resident #4 did not have any broken or loose teeth. -However, observations revealed the resident was missing multiple teeth and had some damaged teeth (see observations above). An MDS note, dated 12/29/25 at 8:53 p.m., revealed Resident #4 received a mini nutritional assessment and a pain assessment by a member of the facility's MDS staff. Resident #4 had some bottom teeth and had no upper teeth. The note documented Resident #4 had previously fallen and broken her upper teeth. -However, these missing and broken teeth were not correctly documented on the 12/29/25 MDS assessment (see assessment above). Review of Resident #4's April 2026 CPO revealed the following physician's order: Resident may have dental, podiatry, audiology and optometry care as needed, ordered 2/9/26. An MDS note, dated 4/9/26 at 5:11 p.m., revealed Resident #4 had an oral exam completed by the MDS nurse. The exam identified Resident #4 had dental caries (cavities) and a broken/chipped tooth in the upper left palate, and revealed the resident's upper palate was otherwise edentulous (toothless). After a conversation with Resident #4, it was established the resident would like to proceed with seeing the facility's dental services to discuss getting dentures. The note documented the MDS department would notify the social services department to schedule Resident #4 with the facility's dentist so the resident could be seen the next time the dentist visited the building. -However, the exam and discussion with Resident #4 occurred during the survey process and 59 days after Resident #4 was readmitted to the facility. Review of Resident #4's electronic medical record (EMR) did not reveal any care conference documentation or any documentation pertaining to dentistry referrals prior to the 4/9/26 MDS note. D. Staff interviews The regional nurse consultant and the social services assistant were interviewed together on 4/9/26 at 2:23 p.m. The social services assistant said the social services department scheduled residents' ancillary appointments, including dentistry. The social services assistant said the social services department was informed of which residents needed ancillary services by the nursing staff or the residents' families, and asked the residents about ancillary services during their care conferences. The regional nurse consultant said the facility had experienced issues with their prior social services director scheduling ancillary services. The social services assistant said she was not sure when Resident #4's last care conference was. The social services assistant reviewed Resident #4's EMR and said she could not find any care conference notes. The social services assistant said the facility's dentist came in each week to examine whichever residents were on the list to be seen. The director of nursing (DON) was interviewed on 4/9/26 at 4:15 p.m. The DON said the facility used an as-needed dentistry program and had a dentist who visited the facility weekly. The DON said if a resident had any broken teeth, it would trigger the nursing staff to put the resident on the list to be seen by the facility dentist. The DON said he would want Resident #4 to be seen by the dentist if she had any broken teeth in order to determine if there was any tooth decay as a result. The MDS coordinator and the MDS nurse were interviewed together on 4/9/26 at 4:36 p.m. The MDS coordinator and the MDS nurse both said they had not spoken with Resident #4. The MDS nurse said Resident #4 had an MDS assessment completed on 2/11/26 which did not reveal any dental problems at the time. The MDS nurse said MDS staff completed the oral evaluation portion of the MDS assessment by examining the resident, looking at nurse admission assessments, and conducting a mini nutritional assessment where they discussed any oral or dentition problems with the resident. The MDS nurse said if a resident had missing or broken teeth, she would want to have the resident be evaluated by the dentist. The MDS nurse said the MDS department would refer the resident to the social services department to have the resident's name added to the facility's dentist's list to be seen. The MDS nurse said when the MDS department referred a resident to the dentist, they added the referral information to the resident's progress notes, emailed the social services department and spoke directly with the social services department. The MDS nurse said the facility also discussed residents with dental needs in the facility administration's residents-at-risk meetings. The MDS nurse and the MDS coordinator entered Resident #4's room and completed an oral examination on the resident (see observations above). The MDS nurse said Resident #4 had one broken tooth on her upper palate along with several missing teeth. The MDS nurse said she would add Resident #4 to the list of residents who needed to be seen by the facility's dental services. III. Resident #80 A. Resident status Resident #80, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included Parkinson' s disease, anxiety and diabetes type 2. The 1/24/26 MDS assessment revealed the resident was unable to complete the BIMS assessment. Per the staff assessment for mental status, the resident had short and long term memory loss with severely impaired decision making. The resident was dependent on staff to assist with toileting, bathing, and transfers. The resident required moderate staff assistance (staff must complete half of the task) with oral hygiene and personal hygiene. The assessment revealed the resident complained of difficulty or pain when swallowing with no natural teeth. B. Resident observation and interview On 4/8/26 at 12:56 p.m. Resident #80 was sitting in the common area watching television. Upon observation, he had lower natural teeth and no natural upper teeth. The resident's teeth revealed one area on the lower teeth with a blacked area on the side, food debris in between several teeth, and red and swollen lower gums. Resident #80 was interviewed, using a Spanish translator, on 4/8/26 at 1:00 p.m. When he was asked if he had pain, Resident #80 pointed to his mouth and one of his arms. The MDS nurse was interviewed on 4/9/26 at 4:00 p.m. The MDS nurse acknowledged that she marked cavities in Resident #80's admission MDS assessment and conducted an observation as well as a resident interview when she completed the oral status section for him. Upon the MDS nurse's observation of Resident #80's teeth on 4/9/26, she identified two distinct black spots on the resident's lower center teeth, with one of the black spot taking up 40% of the resident's tooth. The MDS nurse said Resident #80 had obvious cavities, based on her observations, and she should have marked that in his 1/24/26 MDS assessment and reported it to social services to schedule him a dental exam. C. Resident's representative interview Resident #80's representative was interviewed on 4/8/26 at 1:08 p.m. The resident's representative said Resident #80 was able to express himself in Spanish. The resident's representative said that Resident #80 had told her that he had pain in his mouth and lower teeth. She said his oral pain has worsened since he came to the facility and she had told the nursing staff he needed to see a dentist, but no one ever followed up with her on making him a dental appointment. D. Record review The activities of daily care plan, revised 1/17/26, revealed Resident #80 had deficits in self care related to a diagnosis of Parkinson's disease. Interventions, initiated 12/26/25, revealed the resident required one-on-one staff assistance with feeding, was completely dependent on staff for oral hygiene, and had natural lower teeth. The dental care plan, initiated 12/26/25, revealed Resident #80 was at risk for oral/dental health problems related to natural lower teeth and no upper teeth with self care deficits due to Parkinson's disease. Interventions, initiated 12/26/25, included coordinating arrangements for dental care, transportation as needed/as ordered, observing and reporting any signs or symptoms of oral/dental problems needing attention (such as pain, debris in mouth, eroded or decayed teeth) and providing oral care daily. Review of Resident #80's April 2026 CPO revealed the following physician orders: May have dental, podiatry, audiology, optometry care as needed, ordered 12/24/25. Provide oral care with toothbrush and toothpaste, three times a day after meals, ordered 1/1/26. A review of Resident #80's EMR revealed the following: An admission note, dated 12/24/25, revealed Resident #80 would be seen by all ancillary services. The 12/30/25 MDS assessment indicated the resident had no natural teeth, however, it additionally identified the resident as having obvious or likely cavities during the oral status interview and observation. A health status note, dated 1/3/26, revealed that oral care was provided to Resident #80 and built-up plague was noted. The 1/24/26 MDS assessment indicated during the oral status interview and observation that the resident had no natural teeth and no obvious or likely cavities. -Review of Resident #80's EMR failed to reveal any progress notes from a dentist to indicate that the resident had been seen and treated by a dentist during his stay at the facility. A review of pain assessments from 12/24/25 to 4/3/26 failed to document any assessment of Resident #80's oral pain. E. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 4/9/26 at 9:57 a.m. CNA #3 said the CNAs completed oral care and sometimes the nurses would do it. She said Resident #80 did not refuse oral care and she said she had not noticed any dental decay for the resident. The second floor unit manager was interviewed on 4/9/26 at 10:10 a.m. The unit manager said the CNAs completed residents' oral care and if there was a dental concern, the CNAs reported it to her and she let the social services department know the resident needed to see the dentist. The unit manager said that no one had reported to her that Resident #80 needed to see the dentist. The regional nurse consultant and the social services assistant were interviewed together on 4/9/26 at 2:23 p.m. The social services assistant said she was not sure when Resident #80's last care conference was. The social services assistant reviewed Resident #80's EMR and said she could not find any care conference notes. The social services assistant said the facility's dentist came in each week to examine whichever residents were on the list to be seen. She said she would add Resident #80 to the list to be seen the following week.

Based on record review and interviews, the facility failed to ensure the residents' environment remained as free from accident hazards as possible and prevent falls with major injury for two (#46 and #76) of four residents reviewed for falls out of 53 sample residents. Resident #46, who had a known history of falls, had a diagnosis of obesity which required the use of a bariatric (to support substantial weight) bed with extensions to enable the bed frame to be made larger. On 1/29/24, the resident sustained a witnessed fall from her bed when she was being rolled on her side with the assistance of staff during a bed bath. Resident #46 was sent to the hospital for evaluation of left knee pain following the fall where she was discovered to have a fracture of her left femur (thigh bone), which was surgically repaired on 1/30/24. The resident returned to the facility on [DATE] and was placed in the same bed she fell from on 1/29/24. The facility did not inspect the bed to ensure the extensions were pulled out appropriately and the mattress fit correctly prior to placing the resident back in the bed. On 2/5/24 (4 days after Resident #46's readmission to the facility), a rental supply company came to the facility to install bed canes (a device which can be utilized to assist a person to reposition themselves in bed). The rental supply company's personnel discovered the extensions on Resident #46's bed had not been pulled out prior to the resident's fall from the bed and the facility had failed to pull the extensions out prior to the resident's readmission to the facility. Additionally, Resident #76, who had diagnoses of muscle weakness and unsteadiness on her feet, was admitted to the facility on [DATE]. The resident had a history of falls with injuries in the 12 months prior to her admission to the facility. She required partial assistance with her toileting, bathing and moving from a sitting position to a standing position. The facility failed to implement appropriate person-centered fall interventions for the resident upon her admission to the facility. On 10/20/23, Resident #76 sustained a fall after tripping while she was attempting to get clothes from her closet. The resident complained of pain in her right wrist and x-rays were obtained which revealed she sustained a fracture to her right pinky finger and right thumb. The facility put an intervention in place to educate the resident to remember to turn on the overhead light before moving around in her room, however, the resident sustained five more falls following the 10/20/23 fall. The facility failed to put new and effective interventions into place after each fall to prevent the resident from sustaining further falls. Due to the facility's failure to properly evaluate Resident #46's bed frame and mattress for appropriate functionality and fit and the failure to implement timely and effective person-centered fall interventions for Resident #76, both residents sustained falls with major injury and experienced pain. I. Findings include A. Policy and procedure The Fall Management policy and procedure, reviewed 11/30/22, was provided by the nursing home administrator (NHA) on 2/26/24 at 2:19 p.m. It read in pertinent part: To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indications. The facility must ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Residents will be assessed for fall indications upon admission, readmission, quarterly, change in condition, and with any fall utilizing the Fall Risk Assessment. II. Resident #46 A. Resident status Resident #46, age 71, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses include chronic respiratory failure, insomnia, chronic pain, bed confinement, colostomy, low back pain, muscle weakness, lack of coordination, history of falling and body mass index of 45.0 to 49.9 (obesity). The 2/2/24 minimum data set (MDS) assessment revealed the resident had normal cognition with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required two person assistance with dressing, toileting, bathing/showering, bed mobility and use of a mechanical lift with two staff members for transfers. The resident required one person assistance with personal hygiene and was independent for eating. B. Resident interview Resident #46 was interviewed on 2/21/24 at 11:26 a.m. The resident said she had fallen out of bed on 1/29/24. The resident said the problem was the bed. She said she felt as if she were sliding out of the bed when being turned onto her side. She said the staff had not pulled the slide outs/extensions out so the mattress fit correctly. She said she had been in the center of the bed, had started slipping and was unable to catch herself before falling to the floor. She said when she returned from the hospital the bed rental company personnel came to install bed canes and discovered the extensions had not been pulled out. C. Record review A nursing note dated 1/29/2024 at 6:51 p.m. documented a witnessed fall. A certified nurses aide (CNA) had yelled for help due to a resident falling from her bed while receiving a bed bath. Upon entering the room the resident was found on the left side of the bed on the ground. The resident was screaming in pain. The resident had swelling and a scrape on her left knee and was not able to move it. The resident was sent to the hospital for evaluation of her left knee. An emergency department (ED) note, dated 1/29/24, documented the resident fell out of bed during a bed bath landing on her left knee which was bruised with joint effusion (swelling). A diagnostic radiology (x-ray) note, dated 1/29/24, documented Resident #46 sustained a comminuted (broken in three or more places) mildly displaced and impacted (a break where the ends are driven into each other) distal (near the knee) femoral fracture. The operative report, dated 1/30/24, documented the operation/procedure of an open reduction (repositioning of pieces of fractured bone) and nailing of the femur fracture. A [NAME] 13 by 1340 millimeter (mm) nail locked the knee with three advanced locking screws and locked proximally (nearer the body) with one screw. Hospital discharge documentation, dated 2/1/24, documented the resident was discharged back to the facility. A facility readmission note, dated 2/1/24, at 3:35 p.m. documented the resident returned to the facility by stretcher. A bed rental company report, dated 2/5/24, documented the service to Resident #46's bed for placement of assist bars (bed canes). D. Staff interviews Licenced practice nurse (LPN) #2 was interviewed on 2/26/24 at 1:21 p.m. LPN #2 said the staff should check the bed before residents were admitted to ensure the bed was working properly and the mattress fit correctly. LPN #1 was interviewed on 2/26/24 at 2:06 p.m. LPN #1 said the bariatric (large size) beds, which was the type of bed Resident #46 used, had extensions to make the bed frame larger. She said the bariatric beds with the extensions were delivered to the residents' rooms from the facility's central supply (CS). She said CS personnel were supposed to check the bed to ensure the bed was working properly and the extensions were pulled out to accommodate the mattress. She said the mattress should fit inside the bed frame. LPN #1 said the extensions could be adjusted while the resident was in the bed, however, she said it was better to adjust them before the resident got into the bed. She said if a resident felt something was wrong with the bed, nursing staff should call maintenance to check the bed. The central supply director (CSD) was interviewed on 2/26/24 at 3:03 p.m. The CSD said Resident #46's bed had not been checked due to the resident being readmitted on [DATE] to the facility after she had left work for the day. She said the nursing staff should check the frame if the CSD was not available. She said the bed rental personnel had reported the extension bars were not all the way out on one side on 2/5/24 when they came to install the bed canes. The CSD said the extensions were not hard to pull out. She said the staff should report if the mattress was too small for the bed. She said there was no report of problems with the bed until the bed canes were put on by the service provider on 2/5/24. The director of nursing (DON) was interviewed on 2/27/24 at 11:33 a.m. The DON said if a resident was reporting a feeling of slipping in the bed it should be reported and the facility should look into the cause. He said the admissions staff and the CSD ensured the resident had the correct size bed. He said nursing staff was responsible for ensuring the extensions on the bed frame were pulled out and the mattress fit the bed appropriately. He said nurses should look at the frame. He said Resident #46 slipping from the bed could have been a bed frame problem. 40960 III. Resident #76 A. Resident Status Resident #76, age 80, was admitted on [DATE] and readmitted [DATE]. According to the February 2024 CPO, diagnoses included fracture of the sacrum, fracture of the left pubis (pelvis), multiple fractures of the ribs, history of falling, muscle weakness, unsteadiness on feet, fracture of the fifth metacarpal bone (pinky) and thumb on the right hand, depression, and anxiety. The 12/29/24 MDS assessment revealed, the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. She had impairment to both sides of her lower extremities. She used a walker and wheelchair. She had falls prior to admission as well as falls in the facility. She had a fall with a fracture. She required partial assistance with toileting, bathing, and sitting to standing. B. Resident interview Resident #76 was interviewed on 2/21/24 at 11:15 a.m. She said she had many falls. She said she fell and broke her thumb and pinky when she tripped over the wheel on her wheelchair. She said she also slid off the mattress and asked staff for a different one. She said staff told her all the mattresses were the same. She said when she stood up, she had nothing to hold onto. She asked staff if she could have a side rail and was told facilities were not allowed to put side rails on a resident's bed. C. Record review A physician's order, dated 10/20/23, instructed staff to send the resident to the hospital for abnormal x-ray results. A physician's order, dated 10/27/23, documented a fractured right fifth digit (pinky finger). Put the fourth digit together with the fifth digit as a guardian, apply a long cast from the fifth digit to the forearm, secure with ace wrap from finger to forearm. Let the thumb, middle, and ring finger be free from the ace wrap. Leave in place at all times every shift for a right fifth digit fracture. A physician's order, dated 10/27/23, documented a right thumb fracture. Apply an aluminum cast, U shaped and secure with coban. Leave in place at all times for thumb fracture. The hospitalization care plan, initiated 10/16/23, revealed Resident #76 was at risk for rehospitalization due to a history of injurious falls in the past 12 months. The interventions included labs as ordered, provide medications as ordered, registered dietician to evaluate and staff to provide timely communication to the physician regarding any change in resident condition. The fall risk care plan, initiated on 9/30/23 and revised on 10/16/23 revealed Resident #76 had a history of falls with injuries. Interventions included: -Assess if the resident wanted her bed made frequently and place the bed against the wall, initiated 2/12/24; -Assess toileting needs frequently, initiated 1/2/24; -Assist with activities of daily living as needed, initiated 9/30/23; -Bathroom lights to remain on at all times and remind resident to turn overhead light on when walking around the room, initiated 10/20/23; -Keep call light, reacher, and frequently used items within reach, initiated 9/30/23; -Complete a fall risk assessment, initiated 9/30/23; -Provide appropriate footwear/non-skid socks when ambulating, initiated 1/19/24; and, -Physical therapy to evaluate and treat, initiated 1/19/24. Review of Resident #76's falls were reviewed from 10/20/23 to 2/9/24. 1. 10/20/23 fall An event progress note, dated 10/20/23 at 11:15 a.m., revealed Resident #76 was found lying on her right side next to her bed. Her call light was within reach but not activated. The room had poor lighting and the resident did not turn on the light. The resident stated she was trying to get clothes from her closet and tripped. The resident expressed pain to her right wrist and bruising was noted to the left wrist. The physician was notified and x-rays of both wrists were ordered. The intervention was to educate the resident to remember to turn the overhead light on before movement in the room. -There was no fall investigation provided for the 10/20/23 fall. 2. 11/17/23 fall A health status progress note, dated 11/17/23 at 7:45 p.m., revealed the registered nurse (RN) supervisor was called to the unit because Resident #76 was on the floor. She required maximum assistance of two staff members to be lifted off the floor. An abrasion was found to the resident's mid lower back. The fall investigation dated 11/17/23 revealed the resident was found sitting on the floor after losing her balance at bedside. The resident stated she was reaching for an item near her bedside night stand. The intervention was to place frequently used items in reach of the resident. 3. 12/1/23 fall A health status progress note, dated 12/1/23 at 7:08 p.m., revealed Resident #76 had a fall. She was found while eating her dinner. She was sitting in a chair. There was no complaint of pain. The fall investigation dated 12/1/23 revealed the resident's roommate was able to activate the call light and call the nurses station from her cell phone. Resident #76 said she was seated in front of her bedside table and stood up to retrieve her purse. She said she felt she might fall and backed up to her bed. The resident assisted herself up from the floor. She had no injuries. -The intervention was to continue to remind the resident to use her call light to get items at a distance, which was the same intervention implemented for the fall on 11/17/23. -There were no new fall interventions put into place. 4. 12/22/23 fall An event progress note, dated 12/22/23 at 1:14 p.m,. revealed Resident #76 was found on the floor next to her bed in a sitting position. The resident stated she had tried to reach for her grabber and slid off the bed. The fall investigation dated 12/22/23 revealed the resident had no injuries. The intervention was to make sure her grabber and belongings were within reach. All the staff were aware to check the resident regularly. The resident was reminded to use her call light. -Despite the fall investigation documenting that all staff were aware to check the resident regularly, frequent checks were not implemented as a fall intervention on the resident's care plan. 5. 1/2/24 fall An event progress note, dated 1/2/24 at 12:33 a.m., revealed Resident #76 was found on the floor by a certified nurse aide (CNA). The resident was lying prone (face down) between the bathroom and the foot of her bed. She had pillows beneath her face. The call light was not activated. The resident's walker was approximately one foot away from her. The bed was soaked with urine. She had a small scratch to her left knee and complained of pain to her left leg and buttocks. The resident stated she exited the bathroom and her weakened hands led to a fall. She was assisted back to bed by three staff members. The fall investigation dated 1/2/24 revealed the resident fell after exiting the bathroom. The intervention was to assess the residents' toileting needs frequently. -The intervention did not document how frequently the resident should be offered toileting. 6. 2/9/24 fall An event progress note, dated 2/9/24 at 8:50 p.m., revealed Resident #76 was found on the floor at her bedside. She acknowledged she fell while trying to reach the call button as she was making her bed. There were no injuries noted. The fall investigation dated 2/9/24 revealed the resident was found on the floor and initially denied falling. The intervention was to have staff offer to make her bed when it was untidy or upon the resident's request. She was currently working with therapy to improve strength. D. Staff interviews CNA #1 was interviewed on 2/26/24 at 1:55 p.m. CNA #1 said Resident #76 was a stand by assist (SBA) for transfers and ambulation. She said the resident used her call light when she needed help. She said she did not know what interventions were put into place to help her from falling. LPN #2 was interviewed on 2/26/24 at 2:07 p.m. LPN #2 said she had worked with Resident #76 a couple weeks ago but was not told what fall interventions were put into place. She said if a resident had a fall, a new intervention should be put into place for each fall. The DON was interviewed on 2/26/24 at 2:29 p.m. The DON said Resident #76 liked to be independent. He said interventions that had been put into place were making sure the bathroom light was on, making her bed regularly, and making sure her grabber was in reach. He said he had thought about placing a bed cane on her bed but was afraid she would hit her head. He said he had not thought about placing a transfer pole at her bedside.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 14.29%, which was five errors out of 35 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. According to the Instructions for use Alvesco Inhalation Aerosol, retrieved on 2/27/24 from: https://www.alvesco.us/_resources/Alvesco-InstructionsForUse.pdf. It revealed in pertinent part, Rinse your mouth out with water and spit it out. Do not swallow. II. Facility policy and procedure The Administration of Medications policy, revised 7/14/21, was received from the nursing home administrator (NHA) on 2/26/24 at 11:01 a.m. It revealed in pertinent part, All medications were administered safely and appropriately per physician order to address residents' diagnosis and signs and symptoms. Medication error means the observed or identified preparation for administration of medication or biologicals which is not in accordance with the prescribers order. III. Observations and staff interviews On 2/26/24 at 8:03 a.m. licensed practical nurse (LPN) #2 was observed preparing and administering medications to Resident #23. LPN #2 dispensed a 100 milligram (mg) tablet of Seroquel (antipsychotic) to the medication cup and checked off Glipizide (used for high blood glucose) 10 mg. The order indicated Glipizide 10 mg to be administered twice daily and according to the resident's medication administration record (MAR) administered at 7:30 a.m. and 4:30 p.m. The Seroquel 100 mg was ordered twice daily and ordered to be administered at 6:00 a.m. and 8:00 p.m. according to the resident's MAR. LPN #2 dispensed Sertraline (antidepressant) 100 mg into the medication cup and checked off Losartan (blood pressure medication). The MAR documented Losartan 100 mg daily at 8:00 a.m. and Sertraline 100 mg daily at 8:00 p.m. LPN #2 dispensed one Senna (used for constipation) 8.6 mg tablet into the medication cup and checked off Senna plus (used for constipation) 50-8.6 mg in the resident's MAR. LPN #2 dispensed three medications ordered incorrectly. LPN #2 said she was ready to go administer the medication in the cup to Resident #23. LPN #2 reviewed the medications in the medication cup after being prompted. LPN #2 failed to identify what the medications were in the cup and had to be prompted to identify the medication using the tablet identifiers engraved on the tablets. The Seroquel, Sertraline and Senna were removed from the medication cup and replaced with the correct medications ordered one Glipizide 10 mg tablet, one Losartan 100 mg and one Senna plus 50-8.6 mg tablet. LPN #2 entered Resident #23 room for medication administration. LPN #2 started with an Alvesco inhalation aerosol solution that instructed the resident to take two puffs/inhalations of the medication. Resident #23 completed the two inhalations and then took all other medications to complete her morning medications. -LPN #2 failed to have Resident #23 rinse and spit after the administration of the Alvesco inhaler. LPN #2 was interviewed directly after administration of the medication. She said Resident #23 should have rinsed out her mouth after the inhaler to help prevent the resident from developing thrush (a yeast infection in her mouth). LPN #2 said she should have looked at the MAR and the cards she dispensed the medication from more closely to ensure she was dispensing and administering the correct medications to the residents. LPN #2 said it was her responsibility to follow the seven rights of medication administration. LPN #2 was observed administering medications on 2/26/24 at 8:43 to Resident #102. LPN #2 applied a Lidocaine 4 % patch to the resident's right hip. The order documented the Lidocaine 4% patch was to be applied to Resident #102 right ribs. -LPN #2 applied the lidocaine patch to the incorrect location on the resident. LPN #2 went back to Resident #102 room at 9:05 a.m. and informed the resident she applied the patch to the wrong location. LPN #2 then removed the patch from the resident's right hip and placed it on her right side ribs. LPN #2 said it was important to place a topical medication in the correct place on a resident's body to ensure it was being used correctly. The director of nursing (DON) was interviewed on 2/27/24 at 10:21 a.m. He said nurses were to follow the seven rights of medication administration otherwise a medication error could occur. The DON said if a medication error occurred it placed a resident at risk for interactions or complications. The DON said if a medication error occurred the resident, power of attorney and physician needed to be notified and the resident was to be monitored for side effects. The DON said some inhalers require the resident mouth be rinsed out to prevent thrush. The DON said medication orders for topicals should indicate the location it was to be applied and should only be applied to the indicated site to be effective for the resident's needs.

Based on observation, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#40) resident out of 53 sample residents. Specifically, the facility failed to: -Ensure Resident #40 was assessed for the appropriateness and safety of self-administration of topical medications; and, -Ensure there was a physician order for self-administration of topical medications. Findings include: I. Professional reference According to the Vicks Vaporub drug fact, retrieved on 2/26/24 from: https://assets.ctfassets.net/nvoox4konz4a/2UQyJBdjHzFWUzLsLPELjn/efb8f4729c2477450e30c1defa14e144/VapoRub-Topical-Ointment-Drug-Facts.pdf, Do not use by mouth, in nostrils, on wounds or damaged skin. II. Facility policy and procedure: The Self Administration of Medication policy and procedure, revised on 11/28/16, was received from the NHA on 2/27/24 at 11:26 a.m. It revealed in pertinent part, The facility, in conjunction with the interdisciplinary care team, should assess and determine, with respect to each resident, whether self-administration of medication was safe and clinically appropriate, based on residents functionality and health condition. To ensure safe and appropriate self-administration, the facility should educate resident to ensure that the resident was able to: state name, dose, strength, frequency, and purpose of his/her medications; understand the possible side effects of his/her medications and that he/she should notify facility staff if he/she experiences any such side effects; correctly administer, inject or apply his/her medications; correctly store his/her medications in a locked compartment. The facility should document in the residents care plan whether the resident or facility staff were responsible for storage of the residents medications. If the resident was responsible for the storage of his/her medications, the facility should provide a secured compartment for storage of such medications. The medication storage compartments should be located in the residents room so that another resident was not able to access the medications. The storage compartment should be locked when not in use. The facility staff should document the self administration of medications on the resident's medication administration record (MAR) according to the medication administration schedule. III. Resident #40 A. Resident status Resident #40, older than 65, admitted on [DATE]. According to the February 2024 CPO, diagnoses included multiple sclerosis (disease affecting the central nervous system), peripheral vascular disease (disease affecting circulation of the lower body), dependent on oxygen, hypertension (high blood pressure) and dysphagia (difficult swallowing). The 2/7/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required two person assistance with bed mobility, transfer, dressing and needed set up assistance for personal hygiene and eating. B. Observations and resident interview On 2/21/24 at 10:13 a.m. a container of Vicks Vaporub, a box of Icy Hot lidocaine 4% patches with one patch in the box were on the residents night stand and one bottle of saline nasal spray was on the resident's bedside table Resident #40 said she used the saline nasal spray for her dry nose because she wore oxygen and it dried it out. Resident #40 did not know how many times a day she could use the saline nasal spray. Resident #40 said the Icy Hot patches help her with shoulder or neck pain but had not used them in a while. Resident #40 said she applied the Vicks Vaporub to her dry cracked lips at least twice a day but sometimes more than that. On 2/26/23 at 12:09 p.m. a saline nasal spray, container of Vicks Vaporub and Icy Hot lidocaine patches were in Resident #40's room. C. Record review Review of February 2024 revealed an order for: -Lidocaine external patch 4% to be applied to the right shoulder topically every 12 hours as needed. -There were no orders for saline nasal spray or the Vicks Vaporub. -Review of the Resident #40's care plan did not identify the resident ability to self administer medications. -Resident #40 was not assessed to self administer medications. IV. Staff interviews LPN #1 was interviewed on 2/26/24 at 12:12 p.m. She said residents were not to have medications in their rooms. LPN #1 said if a resident wanted to self administer medications they need to have an order from the physician, ensure the pharmacy knows about the medications to ensure no drug-to-drug interactions and the resident ability to self administer the medications hdto be evaluated. LPN #1 reviewed Resident #40's CPO and identified there was only an order for the lidocaine patches and it did not indicate Resident #40 was able to self administer. LPN #1 said there was no order for the Vicks Vaporub or the saline nasal spray. LPN #1 reviewed assessments for Resident #40 and there was no assessment for self administration of medications completed. LPN #1 was unaware of the hazards of using vicks vaporub and oxygen. LPN #1 was interviewed again at 1:59 p.m. She said she went into Resident #40's room and located the three medications. LPN #1 said Resident #40 told her she used the nasal spray for dry nose from oxygen use and she kept it on her bedside table for easy access. LPN #1 reported Resident #40 threw the box of lidocaine patches in the trash can as she had not used them in a long time after she was questioned about them. LPN #1 said she tried to educate Resident #40 about cracked lips was a sign of dehydration and should drink more fluids instead of using the vicks vaporub on her lips. LPN #1 said Resident #40 refused to give up her medications and she would contact the physician for orders and complete an assessment for self administration of medications for Resident #40. The DON was interviewed on 2/26/24 at 2:51 p.m. He said there were to be no medications in a resident room unless they have been assessed for self administration and the physician has approved self administration. The DON was unaware of the risks of using Vicks Vaporub and oxygen. The NHA was interviewed on 2/26/24 at 2:54 p.m. She said Vicks Vaporub should not be used when oxygen was in use due to risks of injury. The DON was interviewed on 2/27/24 at 10:41 a.m. He said Resident #40 had been assessed for self administration of the Vicks Vaporub and saline nasal spray and the physician approved the medications for use. The DON said he spoke with Resident #40 in the morning to educate on the medications and risks. Resident #40 wished to continue use of the vicks despite her use for oxygen. The DON said it would be the responsibility of nursing staff to monitor for the storage of medication in resident rooms but should be kept in a secure place like a drawer to prevent other residents from having access to them.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (#33) of five residents reviewed out of 53 sample residents. Specifically, the facility failed to ensure Resident #33 received her scheduled showers, who was dependent on staff for bathing. Findings include: I. Facility policy The Activities of Daily Living (ADL) policy, revised 8/23/23, was provided by the nursing home administrator (NHA) on 2/26/24 at 2:19 p.m. It read in pertinent part: The resident will receive assistance with ADLs (bathing, dressing, grooming, and oral care). II. Resident #33 A. Resident status Resident #33, age below 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included multiple sclerosis, muscle weakness, abnormalities of the gait and mobility, dependence on a wheelchair, contracture of the right hand, major depressive disorder and a history of falling. The 2/2/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She was dependent on staff for toileting and bathing. B. Resident interview Resident #33 was interviewed on 2/21/24 at 11:27 a.m. She said she usually did not receive her shower on Sundays. She said the previous Sunday she did not get her shower because the facility was short staffed. She said she finally received a shower the following Tuesday because she had vomited all over herself. C. Record review Review of the January and February shower logs revealed she received only 11 showers and refused one time out of 16 opportunities. -The missing showers were on a Sunday. The ADL care plan, revised on 7/18/22, revealed Resident #33 had a self care performance deficit related to her disease process of multiple sclerosis. Interventions included the resident required assistance by two staff members with bathing/showering twice weekly and as necessary. -Review of the medical record failed to show the resident received her two showers a week according to her care plan. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 2/26/24 at 1:57 p.m. She said the CNA was responsible for giving the residents their showers. She said if staff did not have time to complete the scheduled shower, they would be offered a bed bath or wait until their next scheduled shower. She said showers should be given on the scheduled days to keep the resident clean and odor free. Licensed practical nurse (LPN) #2 was interviewed on 2/26/24 at 2:06 p.m. She said the CNA was responsible for completing scheduled showers. She said the shower was then logged into the medical record. She said if the shower was missed, staff needed to document why it was missed. She said showers should be given on the scheduled days for skin integrity and to keep the resident free from infections. The assistant director of nursing (ADON) was interviewed on 2/26/24 at 2:24 p.m. She said showers should be given on their scheduled days and as needed. She said it was very important for skin integrity and infections. The director of nursing (DON) was interviewed on 2/26/24 at 2:27 p.m. He said management conducted weekly audits and the results were discussed weekly on Thursdays. He said he did not know why Resident #33 had missing showers. He said showers should be given on the scheduled days and as needed for skin integrity.

Based on observations, interviews and record review, the facility failed to assist residents with making appointments and arranging transportation for one (#89) of three residents reviewed for vision/ancillary services out of 53 sample residents. Specifically, the facility failed to offer and make an appointment for optometry services for resident #89. Findings include: I. Facility policy The Podiatry policy and procedure, revised 9/8/23, was provided by the nursing home administrator (NHA) on 2/27/24 at 11:26 a.m. It revealed in pertinent part, The facility will ensure residents receive proper treatment and assistive devices to maintain vision abilities. II. Resident status Resident #89, age greater than 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included non-pressure chronic ulcer of the left calf with unspecified severity, history of falling and adult failure to thrive. The 12/21/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with eating. She required setup help with oral hygiene, and partial/moderate assistance with toileting. She required substantial/maximal assistance with showers. The 11/29/23 MDS assessment revealed the resident had impaired vision but did not wear any corrective lenses. III. Resident observation and interview Resident #89 was interviewed on 2/22/24 at 8:50 a.m. The resident was not wearing glasses at the time of the interview. Resident #89 said she had a hard time seeing.She said she could barely read anything on the television and she was unable to read any documents. She said she typically wore glasses, however, she said she did not have any. She said she had contacts with her but they were dried out and the prescription on them needed to be updated. Resident #89 said she had told nursing staff she needed to see the eye doctor a few months ago but no one had followed up with her about an appointment. She said her vision had gotten worse since she was admitted and she would love to see the eye doctor and get a new prescription or updated glasses in order to see again. IV. Record review The February 2024 CPO revealed the following physician's order: Resident may have dental, podiatry, audiology and optometry care as needed. Ordered 11/28/23 The nursing progress note dated 11/28/23 at 3:45 p.m. documented in pertinent part, The resident's vision was impaired for regular print. She can see large print without glasses. She does not have her contacts with her, they are at home. Said she needs to see her eye doctor for a new eye exam. Review of Resident #89's care plan, revised 12/11/23, revealed the resident had impaired visual function related to the aging process. Interventions included: arrange consultation with eye care practitioner as required, observe and report as needed any signs and symptoms of acute eye problems: change in ability to perform activities of daily living (ADL), decline in mobility, sudden visual loss, pupils dilated, gray or milky, complaints of halos around lights, double vision, tunnel vision, blurred or hazy vision and tell the resident where you are placing their items and to be consistent. Review of Resident #89's electronic medical record (EMR) did not reveal the resident was offered or provided access to optometry services until 2/27/24 (during the survey). V. Staff interviews Registered nurse (RN) #1 was interviewed on 2/26/24 at 2:04 p.m. RN #1 said she was not aware that Resident #89 had any issues with her vision since she was new to the wing the resident resided on. She said if the resident complained of vision problems she would notify the social services director (SSD) so she could put the resident on the list to be seen by the eye doctor. The SSD was interviewed on 2/26/24 at 2:27 p.m. She said residents and/or the residents' responsible party should be offered ancillary services upon admission and every quarter during the care plan conference. She said it should be documented in the progress notes that ancillary services were offered. She said she was unable to find documentation to indicate Resident #89 and/or her representative were offered optometry services since the resident's admission on 11/27/23. Certified nurse aide (CNA) #2 was interviewed on 2/27/24 at 9:58 a.m. CNA #2 said she was unsure if Resident #89 wore glasses or if she had impaired vision. She said if the resident complained to her about impaired vision she would let the nurse know. She said sometimes it was hard to remember to tell the nurse if she got busy and had to provide care to other residents. RN #2 was interviewed on 2/27/24 at 10:05 a.m. RN #2 said Resident #89 could see without any issues and she wore glasses sometimes. She said she had worked with the resident since her admission to the facility and it was never reported on the nursing report sheet that the resident had impaired vision. The director of nursing (DON) was interviewed on 2/27/24 at 10:46 a.m. The DON said if a resident experienced changes in their vision or had impaired vision the nursing staff should contact the physician for orders. He said nursing staff should notify the SSD in order to place the resident on the ancillary services list to ensure the resident was seen by the optometrist. The DON said he needed to provide an all staff education related to ancillary services. The nursing home administrator (NHA) was interviewed on 2/27/24 at 11:55 a.m. The NHA said the Resident #89 should have been offered all ancillary services which included vision. She said if the resident complained of any vision impairment, nursing care staff should have notified the SSD and the resident would have been placed on a list to be seen by the eye doctor in order to receive vision care.

Based on observations, record review and interviews the facility failed to ensure one (#89) of three residents reviewed for ancillary services, such as podiatry services, out of 53 sample residents received proper foot care and treatment according to standards of practice. Specifically, the facility failed to ensure podiatry care was provided timely and as requested by Resident #89. Findings include: I. Facility policy The Nail Care policy and procedure, revised 9/8/23 was provided by the nursing home administrator (NHA) on 2/27/24 at 11:26 a.m. It revealed in pertinent part The facility will provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. I. Resident status Resident #89, age greater than 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included non-pressure chronic ulcer of the left calf with unspecified severity, history of falling and adult failure to thrive. According to the 12/21/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with eating. She required setup help with oral hygiene, and partial/moderate assistance with toileting. She required substantial/maximal assistance with showers. II. Resident observation and interview On 2/22/24 at 8:49 a.m., Resident #89 was in her room. The toenails on both of the resident's feet were thick and approximately three inches long. Resident #89 said she liked to keep her toenails cleaned and trimmed. She said she maintained regular visits with the podiatrist before she was admitted to the facility. Resident #89 said she had asked nursing staff to cut her toenails, however, she said the nursing staff told her they are unable to cut her toenails. She said the nursing staff had not told her why they were unable to cut her toenails. She said she did not know why she could not see a podiatrist. Resident #89 said her toenails bothered her and she would love to get them cut. III. Record review The February 2024 CPO revealed the following physician's order: Resident may have dental, podiatry, audiology and optometry care as needed. Ordered 11/28/23. Review of Resident #89's care plan, revised 12/11/23, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to weakness, pain and decreased mobility. Interventions included: checking the resident's nail length and trimming and cleaning nails on bath days and as necessary and t reporting any changes to the nurse. Review of Resident #89's electronic medical record (EMR) did not reveal the resident was offered or provided access to podiatry services until 2/27/24 (during the survey). IV. Staff interviews Registered nurse (RN) #1 was interviewed on 2/26/24 at 2:04 p.m. RN #1 said she was not aware that Resident #89 had any issues with her toenails since she was new to the wing the resident resided on. She said if the resident complained of long toenails then nursing staff were able to cut them unless the toenails were too thick and/or too long. RN #1 said nursing staff should not cut a resident's toenails if the resident was a diabetic. She said if the resident had toenail issues that could not be addressed by nursing staff she would notify the social services director (SSD) so she could put the resident on the list to be seen by the podiatrist. The SSD was interviewed on 2/26/24 at 2:27 p.m. The SSD said residents and/or the residents' responsible party should be offered ancillary services upon admission and every quarter during the care plan conference. She said it should be documented in the progress notes that ancillary services were offered. She said she was unable to find documentation to indicate Resident #89 and/or her representative were offered podiatry services since the resident's admission on 11/27/23. Certified nursing assistant (CNA) #2 was interviewed on 2/27/24 at 9:58 a.m. CNA #2 said she was unsure if Resident #89 had long toenails because showers occurred during the evening time. She said if the resident complained to her about long toenails she would let the nurse know. She said sometimes it was hard to remember to tell the nurse if she got busy and had to provide care to other residents. RN #2 was interviewed on 2/27/24 at 10:05 a.m. RN #2 said she did not know if Resident #89 had long toenails because it was never reported to her by CNA staff and it was never passed on to her through nursing report sheets. RN #2 observed the resident's toenails and said she would need to have her seen by a podiatrist to get her toenails cut because the resident's toenails had become too thick and long. The director of nursing (DON) was interviewed on 2/27/24 at 10:46 a.m. The DON said if a resident had long toenails then CNA staff should have informed the nurse. He said nurses were supposed to document long nails on the skin check form. He said nurses were the only staff members allowed to cut nails. He said if a nurse was uncomfortable cutting a resident's nails and/or the resident had toenail issues staff should notify him and contact the physician for podiatry orders. The DON said nursing staff should notify the SSDl in order to place the resident on the ancillary services list to ensure the resident was seen by the podiatrist. The DON said he needed to provide an all staff education related to ancillary services and documentation expectations for the skin check forms. The nursing home administrator (NHA) was interviewed on 2/27/24 at 11:55 a.m. The NHA said the resident should have been offered all ancillary services which included podiatry. She said if the resident complained of any nail issues nursing staff should attempt to cut them only if there were no complex comorbidities such as diabetes. She said the staff should have notified the SSD and the resident would have been placed on a list to be seen by the podiatrist in order to receive foot care.

Based on observations, record review, and interviews, the facility failed to ensure residents with a gastrostomy tube received appropriate treatment and services to prevent complications for one (#18) of three residents reviewed for tube feeding management out of 53 sample residents. Specifically, the facility failed to label Resident #18's tube feeding bag with the date and time the tube feeding bag was hung, the initials of the nurse hanging the tube feeding bag, the type of tube feeding the resident was receiving and the flow rate for the tube feeding administration. Findings include: I. Facility policy and procedure The Enteral Nutrition Therapy (Bolus) policy, dated 8/8/23, was provided by the nursing home administrator (NHA) on 2/27/24 at 12:35 p.m. It read in pertinent part, The facility will provide bolus enteral nutrition therapy in accordance with physician orders and professional standards of practice. The facility will utilize the Lippincott procedure. II. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, pressure ulcer of left buttock, stage 4,unspecified severe protein-calorie malnutrition, encounter for attention to gastrostomy, multiple sclerosis and dependence on wheelchair. According to the 12/27/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required setup help with oral hygiene and required substantial/maximal assistance with showers and toileting. The assessment revealed the resident had a feeding tube. III. Observations On 2/22/24 at 8:05 a.m., the resident's tube feeding pump was observed connected to her while she laid in bed. The tube feeding pump was connected to an intravenous (IV) pole with one tube feeding bag hanging from the pole. The tube feeding formula bag was transparent without any labels. The tube feeding appeared to be a brown colored liquid that was not identified. -The tube feeding bag was not labeled with the date and time the tube feeding was hung, the initials of the nurse that hung the tube feeding bag, the type of tube feeding the resident was receiving and the flow rate for the tube feeding administration. III. Record review The 12/27/23 physician's order documented in pertinent part, Enteral Feed at bedtime for PEG (percutaneous endoscopic gastrostomy) tube Jevity 1.5 (tube feeding formula) at 70 ml (milliliters) per hour for 12 hours, on at 9:00 p.m. and off at 9:00 a.m Water 100 ml every four hours for 12 hours. Total of 840 ml tube feeding and 300 ml free water flush. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 2/22/24 at 8:15 a.m. RN #1 said she had not connected Resident #18's enteral nutrition since she came on shift at 6:00 a.m. She said when the tube feeding formula was hung a label should be placed on the bag with the nurse's initials, time it was initiated, the formula and rate. She said she was unable to identify the fluid that was inside the tube feeding bag. She said when she disconnected the tube feeding connector from the PEG tube she ensured the connector was cleaned and stored away covered with no residual left on it. The assistant director of nursing (ADON) was interviewed on 2/22/24 at 8:30 a.m. The ADON said she identified the unlabeled tube feeding bag and relabeled it. She said she was able to identify the liquid was Jevity 1.5 because she called the nurse that hung it and verified that she poured Jevity 1.5 but she forgot to label the tube feeding bag. The director of nursing (DON) was interviewed on 2/27/24 at 3:20 p.m. The DON said the tube feeding should have been paused once the day shift nurse identified the unlabeled bag and then contacted the physician to notify them and followed the physician's instructions.

Based on observations, record review and interviews, the facility failed to ensure two (#62 and #68) of four residents who required respiratory care received care consistent with professional standards of practice out of 53 sample residents. Specifically, the facility failed to: -Follow manufacturer recommendations to maintain, clean, sanitize and store Resident #62 and Resident #68's continuous positive airway pressure (CPAP) mask and machine; -Accurately complete section O in the minimum data set (MDS) assessment under respiratory treatments for Resident #62 and Resident #68; -Ensure a care plan was in place to include settings, cleaning, disinfecting and storage of the CPAP for Resident #62; and, -Ensure Resident #68's CPAP mask sealed properly because it was torn. Findings include: I. Facility policy and procedures The BiPAP/CPAP Administration policy, revised 9/26/23, was provided by the nursing home administrator (NHA) on 2/26/24 at 11:01 a.m. The policy revealed in pertinent part: The reservoir should be filled daily with sterile or distilled water to the fill line. Each day when the resident is removed from the machine the reservoir should be emptied and left to air dry. To clean the face mask, alcohol prep pads or warm soapy water can be used as needed. If the mask/tubing is washed with warm soapy water, they should be air dried completely. II. Resident #62 A. Resident status Resident #62, age above 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included congestive heart failure, atrial fibrillation (abnormal heart beat), pulmonary hypertension (affects arteries in the lungs), dependence on supplemental oxygen, shortness of breath and obstructive sleep apnea. The 12/4/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She was dependent on staff for toileting, showering, and personal hygiene. She used oxygen. -The use of the CPAP was not triggered/coded on the MDS assessment under section O. B. Resident interview Resident #62 was interviewed on 2/21/24 at 2:20 p.m. She said she did not know how often her CPAP mask was supposed to be cleaned by staff. She said she cleaned the mask herself daily. She said she cleaned the mask with a skin wash towelette that she kept in a Styrofoam cup on her overbed table. She said the mask was always stored on top of her CPAP machine but not in a plastic bag. C. Observations The CPAP was observed on 2/21/24, 2/22/24 and 2/26/24 on the resident's night stand next to her bed. The CPAP mask was attached to the tubing and placed on top of the night stand laying across the CPAP machine. D. Record review Review of the February 2024 treatment administration record (TAR) revealed the following orders: -Clean mask with warm soapy water, rinse, set out to dry every day shift. The order was dated 12/5/23. -Clean reservoir with warm soapy water, rinse, set out to dry everyday shift on Saturday. The order was dated 12/2/23. -There was not a care plan addressing the use of the CPAP. III. Resident #68 A. Resident status Resident #68, age above 65, was admitted on [DATE] and readmitted [DATE]. According to the February 2024 CPO, diagnoses included severe morbid obesity, acute and chronic respiratory failure, dependence on supplemental oxygen, anxiety disorder and obstructive sleep apnea. The 1/5/24 MDS assessment revealed the resident was cognitively intact with a BIMS of 15 out of 15. She required maximum assistance with transfers. She used oxygen. -The use of the CPAP was not triggered/coded on the MDS assessment under section O. B. Resident interview Resident #68 was interviewed on 2/21/24 at 10:53 a.m. She said she did not know when or if her CPAP tubing had been changed. She said she did not know how often the mask should be cleaned or cleaned with. She said she had not seen staff clean her mask. She said her mask had been torn for a while and did not seal properly. She said she was embarrassed because it made so many noises from not sealing properly. She said she had let staff know she needed a new mask. C. Observations The CPAP was observed on 2/21/24, 2/22/24, and 2/26/24 before noon on the resident's night stand next to her bed. The CPAP mask was attached to the tubing and placed on top of the night stand laying across the CPAP machine. D. Record review Review of the February 2024 TAR revealed the following orders: -Clean mask with warm soapy water, rinse, set out to dry every day shift. The order was dated 12/5/23. -Clean reservoir with warm soapy water, rinse, set out to dry every seven days. The order was dated 11/13/23. The CPAP care plan, revised on 12/5/23, revealed Resident #68 used a CPAP for obstructive sleep apnea. The interventions included: -Assess for signs and symptoms of hypoxia (low oxygen). -BiPAP on when sleeping and off while awake -BiPAP with following settings: AVAPS, Tidal volume 500mL, FiO2% 40, Measured IPAP 23 cmH2O, set EPAP/CPAP 10 cmH2O, set rate 24, P max 25 cmH2O, P min 15 cmH2O, I-time 0.9 sec, rise time 3 sec. -Wash BIPAP mask with warm soapy water, rinse and air dry. -Wash BIPAP Reservoir with warm soapy water, rinse and air dry. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 2/26/24 at 1:50 p.m. She said the nurse was responsible for cleaning and storing the CPAP mask. She said she did not know how the mask should be stored. Licensed practical nurse (LPN) #2 was interviewed on 2/26/24 at 2:05 p.m. She said the nurse was responsible for cleaning the CPAP mask daily. She said the mask should be stored in a clear plastic bag. -LPN #2 observed the CPAP mask for Resident #62 and Resident #68 not stored in a plastic bag. LPN #2 said if a mask had a tear in it, or did not fit properly, the nurse would call the physician and get an order for the resident to be refitted for a new mask. The assistant director of nursing (ADON) was interviewed on 2/26/24 at 2:12 p.m. She said the nurses were responsible for cleaning and storing the CPAP and mask. She said the mask should be cleaned daily according to the physician's order. She said the reservoir should be cleaned weekly on Sunday with warm soapy water. She said the tubing should be changed weekly. She said the mask should fit properly to avoid leaks. The ADON said Resident #68 last had a respiratory visit in November 2023. She said the mask should be cleaned daily and stored in a clear plastic bag to avoid respiratory infections. The director of nursing (DON) was interviewed on 2/26/24 at 2:22 p.m. He said the nurses were responsible for cleaning and storing the CPAP and mask. He said the mask should be cleaned daily according to the physician's order. He said the mask should fit properly to avoid leaks. The DON said the mask should be cleaned daily and stored in a clear plastic bag to avoid respiratory infections. V. Facility follow up A progress note dated 2/24/24 at 5:06 p.m. documented the respiratory company was notified of the torn mask and a new mask would be sent overnight for Resident #68. A progress note dated 2/26/24 at 3:09 p.m. documented the respiratory company was notified a second time of the torn mask and a new mask would be sent overnight for Resident #68.

Based on observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of four medication carts. Specifically, the facility failed to: -Ensure medication was not left unattended on the medication cart; and, -Ensure tuberculin (medication to test for tuberculosis, a lung bacteria) vials were dated with open dates. Findings include: I. Professional reference According to the Tubersol package insert, retrieved [DATE] from: https://www.fda.gov/media/74866/download, A vial of Tubersol which has been entered and in use for 30 days should be discarded. II. Facility policy and procedures The Storage and Expiration Dating of Medications and Biologics policy and procedures, revised [DATE], received from the nursing home administrator (NHA) on [DATE] at 11:01 a.m. It revealed in pertinent part, The facility should ensure that all medications and biologics, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors. Once any medication or biologic package was opened, the facility should follow manufactures/suppliers guidelines with respect to expiration dates for opened medications. The facility should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. If a multiple dose vial of an injectable medication has been opened or accessed (needle puncture), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for the opened vial. III. Observations and staff interviews On [DATE] at 12:27 p.m. the second floor medication room was reviewed with registered nurse (RN) #4. There was one vial of Tubersol open and undated. RN #4 was not sure when the vial was opened and she was unsure how many days the vial was good for before expiring after it was opened. RN #4 said vials should be dated once opened because they did expire before the expiration date the manufacturer places on the vial. On [DATE] at 8:20 a.m. licensed practical nurse (LPN) #2 one 100mg tablet of Seroquel (antipsychotic) and one 100 mg tablet of sertraline (antidepressant) on her medication cart unattended. An unidentified certified nurse aide (CNA) walked by the unattended medication. LPN #2 was interviewed on [DATE] at 8:30 a.m. She said she should have not left the medication on the cart. LPN #2 said she should have locked up the medications until she could place them in the drug buster for destruction. LPN #2 said a resident could have picked up the medication left on the cart and taken it. LPN #2 said if a resident took a medication not ordered for them they could have a medication interaction and sustain side effects. The director of nursing (DON) was interviewed on [DATE] at 10:21 a.m. He said he was not aware of the tuberculin expiration date once the vial was opened. He said multi-dose vials should be dated so nurses know when it expired because a medication may not be as effective if used past the expiration date. The DON said medications should not be left unattended because a resident could get ahold of them and take them leading to possible side effects if not prescribed to them. The DON said the facility had residents, who had cognitive impairment, that could potentially get ahold of medications if left unattended.

Based on observations, record review and interviews, the facility failed to ensure one (#89) of three residents reviewed for ancillary services, such as dental services, out of 53 sample residents received routine dental care obtaining routine and 24-hour emergency dental care. Specifically, the facility failed to refer Resident #89 to the dentist to replace lost dentures and repair loose fitting dentures. Findings include: I. Facility policy The Dental Services policy and procedure revised 8/23/23, was provided by the nursing home administrator (NHA) on 2/27/24 at 11:26 a.m. It revealed in pertinent part, The facility will assist residents in obtaining routine and 24-hour emergency dental care. The facility will provide and obtain routine and emergency dental services to meet the needs of each resident. The facility will assist the resident as necessary or as requested in making appointments; and by arranging for transportation to and from the dental services location; and promptly refer residents with lost or damaged dentures for dental services. I. Resident status Resident #89, age greater than 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included non-pressure chronic ulcer of the left calf with unspecified severity, history of falling and adult failure to thrive. According to the 12/21/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with eating. She required setup help with oral hygiene, and partial/moderate assistance with toileting. She required substantial/maximal assistance with showers. II. Resident observation and interview On 2/22/23 at 8:49 a.m., Resident #89 was in her room. The resident was missing her bottom set of dentures and her top dentures were loose and moved as she talked. Resident #89 said she lost her dentures before she was admitted to the facility. She said she needed to get her bottom dentures replaced and have her top denture readjusted because they were loose. Resident #89 said she was unaware the facility was able to assist her with dental care. III. Record review The February 2024 CPO revealed the following physician's order: Resident may have dental, podiatry, audiology and optometry care as needed. Ordered 11/28/23. A nursing progress note, dated 11/28/23 at 3:45 p.m., documented in pertinent part, The resident was missing her bottom dentures, has the top dentures. Eating softer food here. Denied swallowing problems, answered all swallowing questions with a no. Review of Resident #89's care plan, revised 12/11/23, revealed the resident had oral/dental health problems related to the aging process. Interventions included: the resident will comply with mouth care at least daily, administer medications as ordered, coordinate arrangements for dental care, transportation as needed/as ordered, diet as ordered and consult with dietitian as needed. Review of Resident #89's electronic medical record (EMR) did not reveal the resident was offered or provided access to dental care. IV. Staff interviews The social services director (SSD) was interviewed on 2/26/24 at 2:27 p.m. The SSD said residents and/or the residents' responsible party should be offered ancillary services upon admission and every quarter during the care plan conference. She said it should be documented in the progress notes that ancillary services were offered. She said she was unable to find documentation to indicate Resident #89 and/or her representative were offered dental services since the resident's admission on 11/27/23. Certified nursing assistant (CNA) #2 was interviewed on 2/27/24 at 9:58 a.m. CNA #2 said she was unsure if Resident #89 had issues with her dentures. Registered nurse (RN) #2 was interviewed on 2/27/24 at 10:05 a.m. RN #2 said she was aware Resident #89 had lost her bottom dentures prior to being admitted to the facility. She said the resident's diet had been changed to a mechanical soft texture (diet which needs very little chewing) to help her eat. RN #2 said she did not refer the resident to the dentist and Resident #89 did not complain of any issues about her top dentures. The director of nursing (DON) was interviewed on 2/27/24 at 10:46 a.m. The DON said Resident #89 should have been referred to the dentist upon admission to replace her bottom dentures and to ensure the top dentures were not loose. The DON said it was not an appropriate intervention to change her diet in lieu of replacing her dentures. The DON said the nursing staff should notify the SSD in order to place the resident on the ancillary services list to ensure the resident was seen by the dentist if she had any dental complaints. The DON said he needed to provide an all staff education related to ancillary services. The nursing home administrator (NHA) was interviewed on 2/27/24 at 11:55 a.m. The NHA said Resident #89 should have been offered all ancillary services which included dental services. She said if the resident complained of any dental issues nursing staff should have notified the SSD and the resident would have been placed on a list to be seen by the dentist in order to have her dentures readjusted and replaced.

Based on record review and interviews the facility failed to clarify basic life support choices, including cardiopulmonary resuscitation (CPR), prior to the arrival of emergency medical personnel according to the advance directive for one resident (#2) out of three residents reviewed for CPR out of six sample residents. Specifically, the facility failed to: -Follow the advance directive on Resident #2's medical orders for scope of treatment (MOST) form by having emergency medical personnel perform CPR on the resident when her code status was Do Not Resuscitate (DNR); -Assist the roommate and family out of the room while CPR was being performed on Resident #2 until prompted by emergency medical services (EMS); and, -Ensure resident's MOST forms were readily accessible and in the right location. Findings include: I. Facility policy The Cardiopulmonary Resuscitation (CPR) policy and procedure, reviewed [DATE], provided by the nursing home administrator (NHA) on [DATE] at 6:09 p.m. It read in pertinent part, Definitions: Do Not Resuscitate (DNR) order refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. The facility should ensure resident preferences and physician orders related to CPR and other advanced directive issues are communicated so that staff know immediately what action to take or not take when an emergency arises. The Area of Focus: Resident Rights policy and procedure, reviewed [DATE], provided by the NHA [DATE] at 1:57 p.m. It read in pertinent part, A resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The Advance Directives and Advance Care Planning policy and procedure, reviewed [DATE], provided by the NHA on [DATE] at 6:09 p.m. It read in pertinent part, The director of nursing or designees establishes a system to inform all direct care staff of the resident's DNR status. II. Resident #2 A. Resident status Resident #2, age 70, was admitted on [DATE] and passed away [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included alcoholic cirrhosis of liver, hepatic failure (liver) and chronic pain syndrome. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required supervision assistance with two persons for bed mobility, transfers, dressing, toilet use and personal hygiene. The resident was not in hospice care. B. Record review The emergency medical services (EMS) patient care report was reviewed for the date of service on [DATE] for Resident #2. It revealed in pertinent part, the paramedics were dispatched to the facility at 5:30 p.m. Nature of call: Unconscious/fainting (near) ineffective breathing. Response was immediate with lights and siren. Arrived at the patient at 5:34 p.m. Patient was found lying supine on the ground with a blood pressure cuff on. Paramedics reported that facility staff did not start CPR. The facility staff was attempting to produce DNR paperwork but did not have it immediately available. Medics started compressions and ventilated with a bag valve mask. Facility staff presented a valid DNR form showing the patient was a DNR. Physician approved the cessation of effort. Time of death was called at 5:37 p.m. The police report was reviewed for date of service [DATE] at 5:28 p.m. It revealed in pertinent part, the facility activated 911 and the caller said patient was trying to use the bathroom and fell on the floor and was unresponsive. The police arrived on scene at approximately 5:33 p.m. and it was a confirmed cardiopulmonary resuscitation. Police were later advised by the facility that the patient had a DNR. The Medical Orders for Scope of Treatment (MOST) form for Resident #2 revealed No CPR: Do not attempt resuscitation and was signed by the resident and physician [DATE]. The advanced directive care plan, initiated [DATE], revealed the resident had an advanced directive DNR. The goal was for the advanced directive to be honored. The interventions included that the code status would be reviewed quarterly and as needed and the resident had signed a DNR, date initiated [DATE]. A review of Resident #2's progress notes on [DATE] revealed in pertinent part, At 7:32 a.m. nurse practitioner follow-up visit to assess pain and weakness. Nursing staff did report the patient was very weak this morning and did require assistance with transfers. Patient does state that she is tired today but otherwise denies further acute specific complaints. At 1:38 p.m. health status note, resident reported feeling weak. She was not able to help herself through her ADLs (Activities of daily living) without assistance from the CNA (certified nurse aide). Her baseline is completely independent. She also has not been taking her medication as prescribed and has been educated about the importance of doing so many times by myself and other nurses. The physician is aware of this behavior as well as her continued decline. At 7:56 p.m. event note, resident passed away at 5:37 p.m. provider was notified as well as family, DON (director of nursing) and administrator. Coroner forms faxed, pending coroner arrival. At 8:21 p.m. event note, resident was very weak during the day shift reported by the outgoing nurse. Nurse practitioner came to see the patient and recommended her Tizanidine medication to be increased. Patient was getting up by herself when the CNA (certified nurse aide) saw her and helped patient to the bathroom. After she finished from using the toilet, she sat in the w/c (wheelchair). The CNA came and informed the nurse that the patient was in the chair because she was trying to get up and was too weak. Nurse went to the patient room and reminded her that she needed to call for help. Minutes after coming out of the patient's room, the roommate's son came and informed the nurse that the patient was on the floor. Nurse called the weekend supervisor (RN #1), and the paramedic. Patient had no vital signs and was pronounced dead. On call physician pronounced the patient deceased at 5:37 p.m. and the patient's son was contacted to choose the mortuary and he said the patient's body will be given to (mortuary name). County coroner paper was completed and faxed. -However, there was no documentation by the nurse staff of when the paramedics arrived, or what care they gave. There was no documentation of the resident's DNR status and if the resident's wishes were honored. There was no documentation of the nursing staff starting CPR while the code status was being determined. At 8:49 p.m. event note, weekend nurse (RN #1) informed the DON (director of nursing), executive director of the incident. On [DATE] at 2:32 a.m. health status note, resident's remains were picked up by (mortuary name) at approximately 2:30 p.m. Son is aware, has spoken to (mortuary name), and given consent. On [DATE] at 10:05 a.m. health status note, at approximately 6:00 p.m. on [DATE] said writer was informed by team member that resident #2 had passed, said writer entered Resident #2's room and there two law enforcement officers were standing directly inside of the door to her room. Said writer asked, I wanted to check with you how soon we might be able to complete her post mortem care, officer states, we already have a call into the coroner's office and we will complete our investigation. At that time Resident #2 was in view of said writer, be aware Resident #2 is lying on the floor next to the bed, lying vertical to bed with her head at the foot of the bed. Resident #2's eyes are wide open, mouth is wide open, both hands are on her chest with her hands open. Said writer directs question to officer's, so you will let us be aware when you are completed and then we can complete our care. Officer's state, yes we will. -On [DATE] at 4:42 p.m. requested the facility investigation, risk management report, IDT (interdisciplinary team) notes, police report, or incident report. The NHA verified the facility did not have any of the requested documents and there had been no review of the incident by the facility. III. Facility observations On [DATE] at 2:05 p.m. observation of East nurse station revealed the resident hard charts which held the original MOST forms were not placed in the designated room number slots, they were placed in random slot boxes with room numbers that did not match the room numbers for the chart. At 2:24 p.m. observation of the [NAME] nurse station revealed the hard charts that hold each of the resident's original MOST forms were disorderly on two bookshelves at the nurses station. Slot box labeled room [ROOM NUMBER]A held chart for room [ROOM NUMBER]; Slot box labeled room [ROOM NUMBER] held chart for room [ROOM NUMBER]; Slot box labeled for room [ROOM NUMBER]A held chart for room [ROOM NUMBER]B. IV. Interviews RN #2 was interviewed on [DATE] at 2:28 p.m. at the [NAME] nurse station. She said she was not sure why the charts were disorganized; it had always been that way. RN #2 said the staff should put the charts in the room number slot to match with the chart room number for better organization. RN#2 said if she needed to find a resident's hard chart she would need to look at two entire book cases of hard charts one by one in order to find the correct resident. RN #2 said it could lead to confusion when needing to find the hard chart quickly. The NHA and DON were interviewed on [DATE] at 3:03 p.m. They said when there was a medical emergency the nurse called 911, another nurse stayed with the resident and another nurse printed medical records such as medication list and copied MOST form. They said the nurse would make sure if a full code to initiate CPR if needed, while waiting for the paramedics. They said the staff should clear the hallway for the paramedics and if the resident had a roommate the staff would ask them to leave for the privacy of the resident having the emergency. They said it could be traumatic for the roommate to see. They said when the paramedics arrived the facility had a staff member stay with the paramedics in case they needed something and another nurse would get the paperwork. They said the original MOST form was in the hard chart and the nurse would take out and copy. They said the incident would be documented in the progress notes and the note would document very detailed times, and interventions. They said the nurse would document in detail if they started CPR, used an automated external defibrillator (AED), Ambu bag or oxygen. The NHA and medical records director (MR) #1 were interviewed on [DATE] at 4:42 p.m. They said the facility did not have a police report, incident report, risk management report, IDT note, or report of an unexpected death. They said we would rely on the nurses to document completely what happened but there was no information about the paramedics after they were called and if they provided any care. They said there was no documentation of when the paramedics arrived and when they left or what care the facility staff gave. They said the progress notes said the nurse called 911 but they were not sure why the nurses would call if she thought she was a DNR. Licensed practical nurse (LPN) #2 was interviewed on ,d+[DATE] /23 at 5:51 p.m. She said had called 911 for Resident #2. She said roommates son came and told her the resident was on the floor and she went to Resident #2 first. She said then she called her supervisor (RN #1) with her portable phone. She said RN #1 came and stayed with Resident #2 and that was when she went to the nurses station to call 911. LPN #2 said she thought she was the one who looked for the MOST form but she was not sure. She said she thought the paramedics needed a copy to look at. She said she was not sure if any staff initiated CPR with Resident #2 because she was not with the resident. LPN #2 said she was not sure if the paramedics initiated CPR because she was not there with them. LPN #2 said the police arrived with the paramedics and went to assess the resident. LPN #2 said when the paramedics came the paramedics did what they needed and the nurses stepped out and the nurses did not stay with them. LPN #2 said Resident #2 had a roommate and the staff had taken them out of the room. LPN #1 was interviewed on [DATE] at 6:03 p.m. She said the paramedics had left when she came by the nurse station so she did not see them. The clinical consultant (CC) #1 and NHA were interviewed on [DATE] at 12:09 p.m. The CC#1 said there was no policy or procedure for when 911 was activated. CC #1 said once that happened EMS showed up, and the staff stepped back and took orders from the paramedics. CC#1 said the nurse did what she could for the resident and the nurse's role would be to maintain safety. CC#1 said there was nothing that said who was to greet the EMS and all that. CC#1 said there was no procedure of what to do when EMS was called. The NHA said there was no facility policy and procedure for when 911/EMS was called and when the paramedics came to the facility. Paramedic (PAR) #1 was interviewed on [DATE] at 10:45 a.m. He said upon arrival to the facility for Resident #2, the facility did not provide advanced directive information to the paramedics so they started CPR. He said later the facility provided the DNR documentation. He said when he arrived the facility staff were standing around, they did not have the advanced directive information yet but however the staff had not initiated CPR. He said when he had walked into the facility he had asked various staff members about Resident #2's code status and he received an answer of I don't know, not my patient multiple times. RN #1/weekend supervisor was interviewed on [DATE] at 2:21 p.m. She said she remembered the event and that LPN # 2 called her because the Resident #2 was found unconscious in the room. She said she went into the room with LPN #2 and an unnamed CNA and the resident had passed out from the wheelchair onto the floor. She said LPN #2 went to call 911. RN#1 said she and the CNA straightened out the resident on the floor. RN #1 said she got the vitals machine and started an assessment. RN#1 said she took blood pressure, oxygen saturation and pulse and she was not breathing. RN #1 said she was not aware of what Resident #2's CPR status was. RN #1 said she was waiting for LPN #2 to verify if the resident was full code or a DNR before starting CPR, but then the paramedics came so she had not started CPR. RN #1 said she let the paramedics know there was no pulse and no vitals showing. RN #1 said LPN #2 still had not told her what the code status was at that time. RN #1 said she did not remember if the paramedics started CPR but they probably did. RN #1 said in seconds the paramedics came and took over and asked right away for the code status but it was not available yet. RN #1 said later LPN #2 came and told the paramedics Resident #2 was a DNR and gave them a copy of the MOST form to verify. RN #1 said when the paramedics arrived she had to usher the roommate and guest out of the room because the paramedics had asked her to and they needed the room. RN #1 said had not had the experience of removing a roommate and guest for an emergency before. She said after the paramedics arrived no other nurse staff had stayed to check if the paramedics needed anything. She had gone to take the roommate and guest to the television room. Medical director (MD) #1 was interviewed on [DATE] at 12:22 p.m. She said she was not familiar with the facility's process or procedure when EMS services were called. She said as the medical director she had not been involved with that process. MD #1 said CPR should not be given to a resident with a DNR order. MD #1 said after calling 911 the code status should be determined while the paramedics were on their way if not before. MD #1 said a staff member should be getting the code status, while another staff member called EMS. MD #1 said the facility should have the medical paperwork ready for EMS when they arrive. MD #1 said the nurses and care staff should have up-to-date CPR certification as they were required to know that. MD #1 said during a medical emergency if the resident had a roommate they should be escorted out to give the resident privacy, give room to the EMS staff and because it was frightening and could be traumatizing for those that were not involved. MD #1 said finding charts in the facility could be a problem; she said they were messy in the facility. She said in an emergent situation having the charts organized would be helpful in finding important information such as the resident's MOST forms.

Based on record review and interviews, the facility failed to implement an effective discharge planning process for four (#1, #2, #3 and #4) of six residents reviewed out of nine sample residents. Specifically, the facility failed complete the following for Resident #1, #2, #3 and #4: -Focus on the resident's discharge goals; -Ensure the discharge needs were identified that resulted in the development of a discharge plan; and, -Involve the interdisciplinary team in the ongoing discharge process. Findings include: I. Facility policy and procedure The Discharge Plan policy, last revised on 8/18/22, was received from the nursing home administrator on 5/4/23. The policy read in pertinent part, The discharge planning process will address each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan. The discharge plan is incorporated into the interdisciplinary care plan. It originates on the baseline care plan and will be included on the patient's comprehensive care plan, once developed. II. Failure to ensure discharge planning was completed 1. Resident #4 A. Resident status Resident #4, age 94, was admitted on [DATE]. According to the May 2023 CPO diagnoses included dementia, atrial fibrillation, kidney disease and malnutrition. The 4/19/23 MDS assessment showed the resident had moderate cognitive impairment with a score of seven out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Resident representative interview The power of attorney (POA) was interviewed on 5/4/23 at 11:00 a.m. The POA said when Resident #4 was first admitted the plan was for her to return home, where he provided the care. However, he said that both he and Resident #4 had decided she would need to transition to long term care after being discharged from skilled services. He said he could not provide the care to her that she required. The POA said he had one discussion with the case manager (CM), but otherwise had not heard any further plans for the resident to transition to the long term care rather than return home. C. Record review The care plan dated 4/19/23 showed a discharge care plan and the resident's desire to return home. The goal was to develop and follow a full discharge plan. -There were no approaches listed on the care plan. The care plan has not been updated. -Review of the resident's progress notes failed to show any additional discharge planning for Resident #4. The progress notes were as follows: The progress note dated 4/24/23 documented, spoke with son (name of son) about his mother needing more help. He has been her care giver and is realizing that he may not be able to meet her care needs. I referred him to (name of agency) for living options. Referral packet faxed. 2. Resident #1 A. Resident status Resident #1, age 80, was admitted on [DATE] and discharged [DATE]. According to the January 2023 computerized physician orders (CPO) diagnoses included osteoarthritis and prosthetic joint infection. The 11/30/22 minimum data set (MDS) assessment showed the resident had no cognitive impairments with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Resident representative interview The daughter was interviewed on 5/3/23 at 4:11 p.m. The daughter said the family had decided it was best for Resident #1 to stay in the facility. She said she had spoken to the CM about transitioning to the long term care section of the facility. She said she was told they did not have any rooms but would find her alternative placement. She said she thought the arrangement had been made, then she was notified that Resident #1 was being discharged on [DATE] to home. C. Record review The care plan dated 12/2/22 showed a discharge care plan and the resident's desire to return home. The goal was to develop and follow a full discharge plan. -There were no approaches listed on the care plan. The care plan was not updated. -Review of the resident's progress notes failed to show that discharge planning was completed. When the resident was admitted , returning home was the goal. However, the goal from the family was to have the resident transition to long term care when she was discharged from skilled nursing. The resident was discharged home on 1/17/23 and the medical record failed to show how the resident went from referrals to long term care facilities to home. The progress notes were as follows: -12/16/22 documented the daughter was spoken with regarding the transition to long term care when discharged from the skilled nursing. -1/12/23 at 11:45 a.m. documented referral packets were sent to three long term care facilities to find alternative placement. -1/12/23 at 3:11 p.m. documented another facility could accept Resident #1 but not until the following week. -1/17/23 documented the resident was discharged home with home health services. D. Interview The CM was interviewed on 5/4/23 at 10:00 a.m. The CM said the resident's initial goal was to go home when skilled nursing was completed. After reviewing the medical record, she acknowledged she had sent referrals to other long term care facilities. She said she could not remember the reason for the resident discharging home. She acknowledged the resident's medical record failed to show the sequence of events that led to the resident discharging home. 3. Resident #3 A. Resident status Resident #3, age 77, was admitted on [DATE] and discharged [DATE]. According to the April 2023 CPO diagnoses included fractures of the neck of the right femur (hip) and history of falling. The 4/21/23 MDS assessment showed the resident had no cognitive impairment with a score of 15 out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Record review The care plan dated 4/24/23 showed a discharge care plan and the resident's desire to return home. The goal was to develop and follow a full discharge plan. -There were no approaches listed on the care plan. The care plan was not updated. -Review of the resident's progress notes failed to show a discharge plan for Resident #3. The initial goal was for the resident to return home. However, the progress notes showed the resident was discharged to another long term care facility. The medical record failed to show the reasons for the discharge and who had made the decision. The progress notes were as follows: -4/21/23 documented the resident had expressed many customer service based complaints about the care she was receiving. -4/25/23 at 7:28 a.m. documented the resident was seen by the primary care geriatric provider, and the resident was being discharged to another long term care facility. The resident was frustrated she was unaware of this transfer per her report. -4/25/23 at 2:24 p.m. the resident was discharged to the alternate long term care facility. 4. Resident #2 A. Resident status Resident #2, age 91, was admitted on [DATE] and discharged [DATE]. According to the February 2023 CPO diagnoses included pneumonia, congestive heart failure, atrial fibrillation and hypokalemia (decreased potassium levels). The 1/20/23 MDS assessment showed the resident had mild cognitive impairment with a score of 12 out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Record review The care plan dated 1/5/23 showed a discharge care plan and the resident's desire to return home. The goal was to develop and follow a full discharge plan. -There were no approaches listed on the care plan. The care plan was not updated. -Review of the resident's progress notes failed to show a discharge plan for Resident #2. The initial goal was for the resident to return home. However, the progress notes showed the resident was discharged to her independent living community with hospice. The medical record failed to show the reasons for the discharge with hospice services. The progress notes were as follows: -2/24/23 progress note documented the resident was being discharged home with hospice services later in the afternoon. III. Additional interviews The CM was interviewed on 5/4/23 at 10:00 a.m. The CM said for skilled services she was the primary discharge planner. She said she did not involve the social service department. She said that she made the arrangements for any outside agencies the resident may need upon discharge. She was the one who spoke to the families in regards to discharge planning. She said the care plans were to be updated by the nursing or social service department. The social service director (SSD) and social service assistant were interviewed on 5/4/23 at 11:34 a.m. The SSD said the CM handled all the discharge planning for residents while they were receiving the skilled services. She said the social service department primarily worked with the long term care residents.

Based on record review and interviews, the facility failed to ensure a discharge summary was in place for four (#1, #2, #3 and #5) out of five sample residents reviewed for discharge out of nine sample residents. Specifically, the facility failed to ensure discharge summaries included a recapitulation of the resident's stay, a final summary of the resident's status, and recapitulation of the residents stay at the facility for Resident #1, #2, #3 and #5. Cross-reference F660 discharge planning Findings include: I. Facility policy and procedure The Discharge Summary policy, last revised on 8/18/22, was received from the nursing home administrator on 5/4/23. The policy read in percent part, The Social Services and Nursing staff, as members of the interdisciplinary team (IDT), participate in developing a discharge summary when a resident is discharged to a private residence, another nursing facility, or another type of residential facility. The discharge summary provides a recapitulation of the resident's stay and the resident's status at the time of discharge to ensure continuity of care. Facilities will complete the Discharge Summary located in (name of electronic medical record) unless state policy request the use of a state mandated Discharge Summary form. II. Failure to complete a complete and though discharge summary 1. Resident #5 A. Resident status Resident #5, age 89, was admitted on [DATE]. She was discharged on [DATE]. According to the February 2023 computerized physician orders (CPO) diagnoses included pain left leg and history of falling. The 2/19/23 minimum data set (MDS) showed the resident had mild cognitive impairment with a score of 12 out of 15 on the brief interview for mental status (BIMS). The resident required limited assistance with activities of daily living. B. Record review The discharge summary dated 4/22/23 documented the resident was discharged to another long term care facility. The discharge summary failed to show all areas on the form were completed. The following were missing: -Physical and mental functional status including activities of daily living (ADLs) -Continence -Skin condition -Vision -Special treatment and procedures -Dental -Activities pursuit -Resident needs, strengths and goals -Resident's customary routine -Summary information on and additional areas -Pertinent lab test results -Rehabilitation follow up or potential -Recapitulation of stay specifically social service and activities The resident was discharged with Eliquis (blood thinner). -The discharge summary did not include any information about the risks and benefits of this medication. 2. Resident #1 A. Resident status Resident #1, age 80, was admitted on [DATE] and discharged [DATE]. According to the January 2023 CPO diagnoses included osteoarthritis and prosthetic joint infection. The 11/30/22 MDS showed the resident had no cognitive impairments with a score of 15 out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Record review The discharge summary dated 1/17/23 documented the resident was discharged to another long term care facility. The discharge summary failed to show all areas on the form were completed. The following were missing: -Physical and mental functional status including ADLs, -Special treatments and procedures -Nutritional Status/requirements and current diet -Skin condition -Special treatment and procedures -Activities pursuit -Resident needs, strengths and goals -Resident's customary routine -Summary information on and additional areas -Pertinent lab test results -Rehabilitation follow up or potential -Recapitulation of stay specifically social service and activities -The discharge summary sent with the resident to home failed to give directions on the use of the Eliquis (blood thinner). 3. Resident #3 A. Resident status Resident #3, age 77, was admitted on [DATE] and discharged [DATE]. According to the April 2023 CPO diagnoses included fractures of the neck of the right femur and history of falling. The 4/21/23 MDS showed the resident had no cognitive impairment with a score of 15 out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Record review The discharge summary dated 4/25/23 documented the resident was discharged to another long term care facility. The discharge summary failed to show all areas on the form were completed. The following were missing: -Physical and mental functional status including ADLs -Mental, psychosocial and behavior status -Cognitive status -Special treatment and procedures -Activities pursuit -Resident needs, strengths and goals -Resident's customary routine -Summary information on and additional areas -Pertinent lab test results -Rehabilitation follow up or potential -Recapitulation of stay specifically social service and activities The medical record showed the resident had an order for oxygen 2 liters per minute. -However, oxygen was not on the summary. 4. Resident #2 A. Resident status Resident #2, age 91, was admitted on [DATE] and discharged [DATE]. According to the February 2023 CPO diagnoses included pneumonia, congestive heart failure, atrial fibrillation and hypokalemia (decreased potassium levels). The 1/20/23 MDS showed the resident had mild cognitive impairment with a score of 12 out of 15 on the BIMS. The resident required extensive assistance of two with activities of daily living and personal hygiene. B. Record review The discharge summary dated 2/22/23 documented the resident was discharged home and would be evaluated for hospice care. The discharge summary failed to show all areas on the form were completed. The following were missing: -Physical and mental functional status including ADLs -Special treatment and procedures -Activities pursuit -Resident needs, strengths and goals -Resident's customary routine -Summary information on and additional areas -Pertinent lab test results -Additional discharge planning information The medical record showed the resident had an order for oxygen between 8 to 10 liters per minute, ted hose to be worn, hospice evaluation, she had pertinent lab test results 2/6/23. -These areas (above) were not included in the discharge summary. III. Interviews The case manager (CM) was interviewed on 5/4/23 at 10:00 a.m. The CM said she opened the discharge summary for when a resident was discharging and informed the interdisciplinary team. She said the section she completed included the primary care physician information, diagnoses and home health information. She said the summary was to be completed on the resident's day of discharge. She said that the discharge summary and the medication list was provided to the family or the receiving facility. She said the health information manager was responsible to review the summary to ensure it was complete. Licensed practical nurse (LPN) #1 was interviewed on 5/4/23 at 11:00 a.m. LPN #1 said she completed the discharge summaries when residents were discharged from the facility. She said the section she completed was the vision, communication, dental, communication and continence. The health information manager (HIM) was interviewed on 5/4/23 at 11:45 a.m. The HIM said she was responsible for reviewing the resident discharge summaries. She said she had been auditing the discharge summaries and the therapy department, activities and the social service were the departments that were mostly non-compliant in completing their portions. She acknowledged the resident discharge summaries were not complete and missing pertinent information. She said she had brought it to quality assurance (QA) in December 2022. She said she would begin to complete audits once again, however, in order to make change, she said accountability for ensuring the summary was completed would need to be enforced. She said that was where the failure was, lack of accountability.

Based on interviews, record review, document review, and facility policy review, the facility failed to ensure a resident was provided with an environment that was free of accident hazards and adequate supervision/assistance to prevent an accident for 1 (Resident #56) of 3 sampled residents reviewed for accidents. Specifically, Certified Nursing Assistant (CNA) #4 transferred Resident #56 on 12/09/2021 using a sit-to-stand lift (a mechanical device utilized to assist a person from a sitting to a standing position) when Resident #56 had not been assessed for the use of the lift. Additionally, CNA #4 performed the transfer without the assistance of a second staff member, when two staff were required for the transfer. Further, the facility failed to complete a thorough investigation to determine the root cause of the incident. As a result of the improper transfer, Resident #56 slipped from the sling of the lift and sustained an avulsion injury (skin avulsion - a wound that occurs when skin is torn from the body during an accident or other injury) to the left wrist, the resident expressed fear of transfers since the incident, and staff reported the resident preferred to stay in bed. Findings included: Review of a facility policy titled, Mechanical Lift Use, revised 07/22/2021, revealed, The facility will provide mechanical lifts for transfers of residents who are determined to need this type of transfer to meet their needs. The facility will ensure that two associates should be present during the transfer of residents who require a mechanical lift, and at least one of the two associates must be over the age of 18. Review of a facility policy titled, Fall Management, revised 04/07/2022, revealed, Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs. The policy also defined an avoidable accident as an accident that occurred because the facility failed to, 3. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident. Review of an Admission Record revealed Resident #56 had diagnoses that included atrial fibrillation (disorder of the heart characterized by an irregular and often faster heartbeat), dependence on supplemental oxygen, shortness of breath, muscle weakness, and difficulty in walking. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance of two or more staff with bed mobility and transfers. Review of a care plan, dated as initiated on 11/03/2020 and revised 10/14/2021, revealed Resident #56 had an activities of daily living (ADL) self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited mobility, and pain. The interventions/tasks indicated that for transfers, the resident required the assistance of two staff with the use of a transfer belt and a front-wheeled walker (FWW) to move between surfaces as necessary. The care plan did not indicate any type of mechanical lift was to be utilized to transfer the resident. Review of an Occupational Therapy (OT) Evaluation & Plan of Treatment, dated as initiated 12/08/2021, revealed Resident #56 received OT services from 12/08/2021 through 01/04/2022 to assess safety and independence with self-care and functional tasks of choice. The goals included for the resident to complete transfers with moderate assistance to decrease dependence on caregivers and increase independence with functional tasks. There was no evidence on the OT evaluation that indicated Resident #56 was assessed for the use of a sit-to-stand mechanical lift. Review of Progress Notes, dated 12/09/2021 at 5:25 PM, revealed a health status note that indicated Resident #56 was assisted from the bed to the toilet in preparation for a shower. The note indicated that after the resident was momentarily placed on the toilet, the resident was being transferred to the shower chair utilizing a mechanical lift when the resident slipped from the sling support. The note indicated the CNA performing the transfer attempted to support Resident #56 during the fall; however, Resident #56 sustained a large skin tear to the left forearm near the lower part of the arm, and an, irregular skin lump tissue swelling to left forearm and right lower leg. The note indicated staff provided first aid and notified the family and physician. According to the note, the resident was transported to the hospital via ambulance at 4:50 PM. Review of an incident report, dated 12/09/2021, revealed Resident #56 was assisted from the bed to the toilet preparing for a shower and, while the resident was being assisted from the toilet using a mechanical lift, the resident slipped from the sling support. The report indicated the CNA attempted to support the resident during the fall. Resident #56 sustained a large skin tear to the left forearm near the lower part of the arm and left forearm/LLE [left lower extremity] irregular lump in tissue or swelling. The report indicated that Resident #56 stated, All I know is I was being lifted from the toilet and then I ended up down here. The report indicated first aid was provided to the left forearm skin tear. Review of the hospital ED [Emergency Department] Provider Note, dated 12/09/2021, revealed Resident #56 was brought to the ED from the nursing home after a fall during a mechanical lift transfer from the toilet. The note indicated that Resident #56 presented with an avulsion to the left wrist, which was bandaged on scene with the bleeding mostly controlled. The note indicated the resident complained of pain in the left wrist and both legs. Further review of the ED records revealed x-rays were completed of the bilateral lower extremities as well as the left wrist, and there was no evidence of fractures. The notes indicated the avulsion wound was dressed with Xeroform gauze (a fine mesh gauze impregnated with petrolatum to maintain a moist wound bed and prevent the gauze from adhering to the wound). Review of Progress Notes, dated 12/09/2021 at 10:55 PM, revealed Resident #56 returned from the hospital at approximately 10:30 PM. The note indicated the resident's x-rays were negative for fractures and the resident had a soft tissue bruise to the left forehead and left lateral calf with swelling. Review of a Wound Observation Tool, dated 12/14/2021, revealed the left arm wound was measured as 10 centimeters (cm) long by (x) 10 cm wide x 0.1 cm deep. Review of Risk Management Meeting notes, dated 12/16/2021, revealed Resident #56 fell on [DATE] during staff assistance and sustained a skin tear to the left forearm. The notes indicated the CNA was transferring the resident off the toilet with a sit-to-stand lift when the resident slipped from the sling and injured the left arm. The planned intervention to address the incident was, Hoyer mechanical lift only for transfers. Review of Resident #56's most recent quarterly MDS, dated [DATE], revealed Resident #56 had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required the extensive assistance of two or more staff with bed mobility and transfers. Observations on 11/29/2022 at 10:20 AM and 11/30/2022 at 3:24 PM revealed Resident #56 lying in bed watching television. During an interview on 11/30/2022 at 9:29 AM, Resident #56 stated CNA #4 was getting the resident off the toilet using the lift, and when CNA #4 rolled Resident #56 out of the bathroom on the lift, the resident did not recall whether the resident's legs gave out or their hands slipped. Resident #56 indicated that before the incident, they were walking with a walker with physical therapy. Resident #56 said that since the incident, they were scared to go to the shower and preferred a bed bath. During an interview on 11/29/2022 at 2:01 PM, CNA #1 indicated she obtained information on how to care for the residents by going to the computer to review the care plans and/or from verbal reports. CNA #1 indicated two staff were required for any mechanical lift transfer. During an interview on 11/29/2022 at 2:11 PM, CNA #2 indicated she went to the computer to review the care plans or received information from verbal reports regarding how to take care of the residents. CNA #2 indicated she did not witness the incident on 12/09/2021. CNA #2 stated that when using any mechanical lift, two staff were required. During an interview on 11/29/2022 at 3:26 PM, CNA #3 indicated Resident #56 required the assistance of two people with a mechanical lift for transfers. She revealed most of the time, Resident #56 did not want to get out of bed, but a mechanical lift was used when the resident had to be weighed. CNA #3 stated she did not witness the incident on 12/09/2021. She indicated she went to the computer to review care plans and received information from verbal reports regarding how to take care of the residents. CNA #3 stated when using any mechanical lift, two staff were required. During an interview on 11/29/2022 at 3:38 PM, Licensed Practical Nurse (LPN) #5 indicated Resident #56 was bedbound and required a mechanical lift with at least two staff for transfers. LPN #5 indicated the CNAs used the computer system or received a verbal report to know how to take care of the resident. LPN #5 indicated Resident #56 did not trust staff due to a fear of falling and the resident would choose staff they felt safer with for transfers. LPN #5 stated CNA #4 transferred Resident #56 during the 12/09/2021 incident and that the sit-to-stand lift was used for the transfer. LPN #5 indicated that to the best of her knowledge, there was only one CNA that transferred the resident with the sit-to-stand lift, and that was CNA #4. LPN #5 stated two CNAs should always be used when transferring a resident with any mechanical lift. LPN #5 revealed she was called to Resident #56's room after the 12/09/2021 incident, and Resident #56 was on the floor and the shower chair was in the room. LPN #5 indicated a registered nurse (RN) assessed the resident and applied a dressing to the resident's arm. The LPN stated she completed the incident report, and the Director of Nursing (DON) evaluated the incident reports and recommended therapy if needed. LPN #5 indicated education was provided to CNA #4 that two CNAs should be used during a transfer utilizing a sit-to-stand lift. The LPN indicated she had no prior knowledge that CNA #4 was using the sit-to-stand lift and did not know of any other time the sit-to-stand lift was used on Resident #56. During a follow-up interview with LPN #5 on 11/30/2022 at 5:08 PM, LPN #5 stated CNA #4 was made aware that two people were required for any transfer utilizing a lift. During an interview on 11/30/2022 at 8:38 AM, the Interim DON/Staff Development Coordinator indicated she was the Staff Development Coordinator on 12/09/2021 and was not working as the DON at the time. The Interim DON indicated that Resident #56 was in bed most of the time and required a lot of assistance with transfers. She indicated Resident #56 spent a lot of time in bed prior to the fall on 12/09/2021. The Interim DON stated a total-body mechanical lift was put into place as an intervention for transfers for Resident #56 after the 12/09/2021 incident. She indicated that complete investigations with a root-cause analysis were only completed for falls with major injury. During an interview on 11/30/2022 at 9:51 AM, the Rehabilitation (Rehab) Director indicated the therapy department provided guidance on how a resident should be transferred through skilled assessment during admission. The Rehab Director indicated the nurse could also make clinical judgements and look at the assessment and see how they were transferring the resident in the hospital. The Rehab Director indicated there should be at least two staff assisting when operating any mechanical lift. The Rehab Director indicated the resident should be provided the highest functional and safest transfer. The Rehab Director indicated OT was initiated for Resident #56 on 12/08/2021 and 12/13/2021. The Rehab Director indicated Resident #56 required moderate assistance with transfers before the incident on 12/09/2021 and maximum assistance after the incident. The Rehab Director indicated the therapy department did not assess Resident #56 for the use of a sit-to-stand lift. During a telephone interview on 11/30/2022 at 4:44 PM, the previous DON, who was the DON at the time of the 12/09/2021 incident, revealed staff notified the DON of all falls, and the DON reviewed the incident report, observed the resident, updated the care plan, and put in an interdisciplinary team note. The previous DON indicated she did not remember the incident with Resident #56. She indicated physical therapy evaluated and decided which lift was appropriate for a resident. The previous DON indicated all the mechanical lifts in the facility required two staff and stated the CNAs were trained on that requirement. During a telephone interview on 11/30/2022 at 5:18 PM, CNA #4 indicated she transferred Resident #56 during the incident on 12/09/2021 utilizing the sit-to-stand lift and the resident fell during the transfer. CNA #4 indicated she was oriented by another CNA that used the sit-to-stand lift for Resident #56. CNA #4 indicated the incident was her fault because she was trained that two staff were required to operate any mechanical lift but stated there was no help available to assist her with transferring Resident #56. (Review of staffing for 12/09/2021 revealed the facility was adequately staffed). CNA #4 stated that when she checked the computer on a later date, there was no information on which mechanical lift to use for Resident #56. During a follow-up telephone interview on 12/01/2022 at 2:32 PM, CNA #4 revealed she provided the previous DON with a written statement on the 12/09/2021 incident. CNA #4 indicated Resident #56 let go of the handles during the transfer and she lowered Resident #56 to the floor. CNA #4 indicated she normally transferred the resident with the sit-to-stand lift with another staff and knew that the procedure should involve at least two staff. The CNA indicated the facility provided training every other month on how to use the mechanical lifts and stated she had knowledge of how to transfer the resident using the stand-to-sit lift. CNA #4 indicated she saw Resident #56 bleeding but did not know how the skin tear happened. CNA #4 indicated she really felt bad that Resident #56 got hurt, and she knew that two staff should have been used with all mechanical lifts. CNA #4 indicated she had training in September 2022 on the mechanical lifts by the therapy department. CNA #4 indicated the full-body mechanical lift was put into place for Resident #56 after the 12/09/2021 incident. CNA #4 indicated Resident #56 did not like any of the lifts and preferred to take bed baths after the incident on 12/09/2021. During a follow-up interview on 12/01/2022 at 11:31 AM, the Interim DON/Staff Development Coordinator indicated Resident #56 had pain and was sent out to the hospital, and this incident should have been considered a significant injury for which an adverse event packet would have been completed. The Interim DON/Staff Development Coordinator indicated no root-cause analysis would be investigated for incidents that did not result in significant injury. The Interim DON/Staff Development Coordinator indicated that if the facility policy stated that two people should be used to operate the sit-to-stand lift, it was her expectation that the facility staff use two staff and follow the facility's policy. During an interview on 12/01/2022 at 12:18 PM, the Administrator indicated adverse event packets should be completed, to include a full investigation with root-cause analysis for incidents of abuse, falls/fall with major injury, or head injuries. The Administrator stated an adverse event packet should have been completed for the 12/09/2021 incident, due to the resident's injury, the staff involved, and the fact that a piece of equipment was involved. The Administrator indicated she was not employed at the facility at the time of the 12/09/2021 incident and could not answer why an adverse event packet was not completed. The Administrator indicated it was her expectation that the staff follow the facility's policy on mechanical lifts when transferring residents.

Based on record review and interviews, the facility failed to ensure residents received treatment and care which met professional standards of practice, was consistent with comprehensive assessments, and comprehensive care plans for one (#1) residents out of three sample residents. Specifically, the facility failed to prevent a fall out of the wheelchair for Resident #1 on 7/4/22. The resident was assessed by staff and noted to have suffered a skin tear to her left elbow and decreased range of motion and hand grasp strength to her left upper extremity. The staff informed the resident's physician and family of the fall and the skin tear. The resident experienced increased pain in her left wrist and elbow and x-rays were ordered on 7/5/22. The x-ray provider did not come to the facility until the afternoon of 7/6/22 and a radius fracture was discovered. The resident continued to experience increased pain and an order to send her to the emergency department was written on 7/6/22. The resident was not sent to the emergency department until 7/7/22 where additional x-rays revealed the radius (wrist) fracture as well as a proximal cortical femur (hip) fracture. Cross-reference F689 for accident/hazards related to fall prevention. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/20/22 and 9/21/22, resulting in the deficiency being cited as past noncompliance with a correction date of 8/13/22. I. Facility action The facility designed a performance improvement plan on 8/7/22 with the aim to complete a fall huddle and the interdisciplinary team ( IDT) to review of each fall to ensure all steps had been completed and falls were handled uniformly through the facility. This action was to minimize falls in the facility, be able to track falls and ensure everything was being done to prevent falls for residents. Nursing staff were educated on 8/12/22 and 8/13/22 related to assessments and documentation needed at the time of the fall and for the days following the fall. The education included fall risk assessments, pain evaluations, risk management documentation, nursing note documentation, implementing a new intervention that is different from previous interventions, communication to future shifts related to the fall and new intervention to ensure implementation was sustained. Fall huddles were occurring after each fall in the facility to review and ensure the fall protocols were followed. Monitoring in daily leadership meetings since 8/2/22 of all falls and weekly risk management meetings 8/12/22, 8/19/22, 8/26/22, 9/2/22, 9/9/22, and 9/16/22 to review each fall and ensure all protocols were followed, interventions were implemented, notifications were made and timely assessment and treatment were provided. II. Resident #1 A. Resident status Resident #1, age 87, was admitted on [DATE] and transferred to the hospital on 7/7/22. According to the July 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/8/22 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status(BIMS) score of 12 out of 15. She required extensive assistance of one staff member with mobility and activities of daily living (ADLs). B. Record review A nursing note on 7/4/22 at 6:17 p.m. revealed the resident was found on the floor next to her wheelchair and the call light was pushed by her roommate. The resident stated she was trying to pick something up off of the floor and slid out of her wheelchair. The resident's physician group was informed and her two sons were notified of the fall. The registered nurse assessed the resident and she was found to have a skin tear to her left elbow. The wound was cleansed and a dressing was applied. The resident was encouraged to use her call light every time she needed assistance. She was medicated for pain at 7:00 p.m. and neurological checks were in place. The resident received an as needed [MEDICATION(S)] (pain medication) on 7/4/22 at 6:39 p.m. A follow up pain scale at 9:35 p.m. revealed the resident's pain level at two (out of 10, with 10 being the worst on the scale). -There was no initial pain level indicated when the [MEDICATION(S)] was administered. A pain assessment on 7/4/22 at 6:59 p.m. revealed the resident had pain in her left elbow with pain worsening upon movement and pain better with medication. -There was no pain level indicated on the assessment. A fall risk assessment on 7/4/22 at 6:59 p.m. revealed the resident's fall score was 20, with a score of 10 or more indicating a high risk for falls. A nursing note on 7/4/22 at 10:22 p.m. revealed around 8:00 p.m. the floor nurse called the registered nurse (RN) writer to assess the resident who was on the floor. Upon arrival to the room, the resident was on the floor next to her wheelchair on her right side. The resident was alert, responded to verbal commands and stated she was trying to pick something up from the floor and slid out of her chair. A purple bruise was noted to the left side of her temporal area. A skin tear with mild bleeding was noted to her left elbow and left pinky finger. Range of motion to her left arm was weaker than her right arm. She complained of mild pain and her vital signs were at baseline. Her neurological checks were performed by the floor nurse. The resident received an as needed [MEDICATION(S)] at 2:45 a.m. for left wrist pain rated at a six. A follow up pain scale at 7:51 a.m. revealed a pain level of two. A nursing note on 7/5/22 at 5:54 a.m. revealed the resident was on observation related to an unwitnessed fall. She voiced complaints of pain to her left wrist. She received as needed pain medication. Her left hand grip was weak and she stated her wrist up to her elbow was painful when pressure was applied to stand and transfer as well as when asked to squeeze staff hands. The resident's physician group was called and orders were received for x-rays to the resident's left wrist and elbow. A nursing note on 7/5/22 at 10:34 p.m. revealed the x-ray provider company called to inform the facility that x-ray would not be taken that day and was delayed until the next day (7/6/22). A nursing note on 7/6/22 at 3:48 p.m. revealed the resident's left upper arm was observed to have swelling, redness, and was warm to the touch. The resident's physician group was called and the nurse was informed the resident's physician would be in the facility and would assess the resident. The resident received an as needed [MEDICATION(S)] at 7:50 p.m. for a pain level of eight. A follow up pain scale at 9:05 p.m. was zero. A nursing note on 7/6/22 at 9:26 p.m. revealed the resident was admitted to hospice. A nursing note on 7/6/22 at 9:29 p.m. revealed the radiology report revealed a distal radial fracture with malalignment, mild soft tissue swelling, and joint space narrowing. The resident's hospice provider nurse notified the physician and a new order was entered. An order was entered on 7/6/22 at 10:30 p.m. to send the resident to the emergency department. An order note on 7/7/22 at 12:56 a.m. revealed the family requested the resident go to the emergency department in the morning. The resident received an as needed [MEDICATION(S)] at 4:00 a.m. for a pain scale of six. The medication was ineffective and the resident received an as needed acetaminophen at 8:08 a.m. for a pain scale of six. -The facility failed to notify the physician when the [MEDICATION(S)] was ineffective in treating her pain. An additional order was entered on 7/7/22 (no time) to send the resident to the emergency department. A nursing note on 7/7/22 at 10:13 a.m. revealed the resident's son was called and informed she was being sent out to the emergency room to treat her wrist. A change of condition assessment dated [DATE] revealed the resident experienced a change of condition of an acute distal radial fracture which started on 7/5/22. She was noted to have an abrasion, skin tear, and acute pain in her left elbow. An x-ray was completed on 7/6/22. The resident was unable to move her left arm due to pain. The physician and the resident's son were informed on 7/7/22 at 8:00 a.m. Review of the resident's neurological checks revealed the checks started at 5:30 p.m. All areas of the exams were documented to be normal until the second two hour exam at 12:15 a.m. where the hand grasps were documented to be right hand strong and left hand weak. Neurological checks continued as scheduled until 7/7/22 at 4:15 a.m. for the fourth eight hour check. -The first nursing note related to the fall was documented at 6:17 p.m. and first pain medication was given at 6:39 p.m. The resident was not sent to the hospital after a fall with injury for over 72 hours after the fall. III. Facility investigation An undated facility investigation was provided and revealed a timeline, it read, in pertinent part: -7/5/22 at 5:54 a.m. the resident voiced complaints of pain in her left wrist. Left hand grip weak, she stated that it hurt from her wrist to her elbow when applied pressure to transfer and when asked to grip hand. -7/5/22 at 10:34 p.m. Several calls were made to obtain x-rays ordered, though the Xx-ray provider called and told the facility staff the x-rays would be delayed. -There was no documentation or record of multiple calls being made to obtain or rush x-rays. -There was also no evidence or documentation the family or physician were notified of the delay in obtaining x-rays. (see above). -7/6/22 at 9:29 p.m. x-rays were performed in the early afternoon and results showed a distal fracture with malalignment, soft tissue swelling and joint space narrowing. Family, physician and hospice were notified. Family requested to wait until the morning to send to the hospital for additional x-rays and treatment so they could be at the facility and go with her. Physician approved. -There was little to no documentation related to discussion of injuries and pain level for the resident at the time and no documentation of physician notification of the family request to delay transfer to the hospital or the physician approval to wait. -7/7/22 at 8:15 a.m. in the morning rounds the night shift stated her pain had increased and that the son stated he would be at the facility in the early afternoon. The DON (director of nursing) went to assess the resident and called the son at 10:00 a.m. and told him we needed to send the resident to the emergency room stat (immediately) and he said he would meet her there. A question on fall investigation read: Was the resident involved transported to the hospital? Yes, but not for several days post fall. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/2022 at 9:49 a.m. She stated if a resident was a fall risk, the facility would try to room them close to the nurses station, ensure the resident had a low bed and a call light always within reach. She stated after a resident fall, the registered nurse needed to assess the resident, the physician was called and the director of nursing (DON) was notified. She stated a new intervention needed to be added for each fall. LPN #2 was interviewed on 9/21/22 at 11:31 a.m. She stated an unwitnessed fall needed an RN to assess the resident and neurological checks needed to be completed to ensure there was no brain injury. She stated the RN assessment also included range of motion assessments and checks for any possible injuries. She stated if an issue with neurological checks, range of motion or any suspected injury from the fall, the nurse needed to call the physician immediately and explain the situation to get orders for x-rays or transfer to the hospital for further assessment and treatment. She stated if x-rays were delayed or could not be obtained in a reasonable amount of time, two to three hours, the physician needed to be called for further orders to transfer to the emergency room for x-rays. LPN #3 was interviewed on 9/21/22 at 11:38 a.m. He stated if a resident fell , he would call the RN to assess the resident for any possible injuries. He stated after the assessment, if there was no injury, the resident was assisted up to their chair or bed and the nurse completed a risk assessment and implemented a new intervention. He stated the physician and family should be called after the assessment so they could be notified of the fall and any possible injury. He stated if there was any bleeding, pain, or swelling, the physician should be called the resident sent out to the hospital for assessment. LPN #4 was interviewed on 9/21/22 at 11:45 a.m. She stated if a resident fell , the RN needed to be called to complete an assessment and the DON and nursing home administrator (NHA) needed to be informed. She stated additional action would be based on what the physician ordered. She stated if there was an injury, the resident would be sent out to the hospital. She stated if x-rays could not be done in the facility in a timely manner, the resident should be sent to the hospital for x-rays. RN #1 was interviewed on 9/21/22 at 11:50 a.m. He stated he was called to assess residents after falls when he was working. He stated he would do a skin assessment, neurological exam, range of motion and check for injuries per the facility protocol. He stated if there was a difference between hand grasps or range of motion changes, he would notify the physician immediately because it could indicate a serious injury. He stated the resident would most likely be transferred to the emergency department at the hospital. He stated if x-rays were delayed or could not be completed in the facility, the physician should be notified. The resident's physician was interviewed on 9/21/22 at 12:05 p.m. She stated she remembered the resident and that she had a fall and was transferred to the hospital. She stated after a resident fell in the facility, they should call and report on the resident's condition. She stated if the resident was in pain or any concerns with range of motion or hand grasps may indicate an injury and x-rays would be ordered or the resident should be sent out to the hospital. She stated she reviewed the call log related to the resident and revealed the office received a call on 7/4/22 around 6:00 p.m. to inform them about the fall with a skin tear. A second call on 7/5/22 at 12:21 in the afternoon where the on-call physician ordered x-rays. A third call on 7/6/22 at 10:16 p.m. with a request for hospital evaluation and an additional call on 7/7/22 in the morning for transfer to the hospital. Upon review of the call log, there was no evidence of the physician being notified of the unequal hand grips on 7/4/22, the delay of the x-rays on 7/5/22-7/6/22, or the request to delay hospitalization . She stated the resident would have been sent to the hospital on 7/5/22 for x-rays if the physician had known there was a delay in the x-ray completion. The DON was interviewed on 9/21/22 at 12:16 p.m. She stated when the resident was assessed and there was a difference in her hand grasps, the physician should have been notified of that immediately and x-rays may have been ordered sooner. She confirmed there were no documented attempts to contact the x-ray provider and she could not be sure if the staff called or how many times the staff called. She stated the resident's son wanted to wait for transfer to the hospital so he could be with her, though there was no documentation of conversations with the son to express the extent of the resident's pain or description of her injuries. She stated the resident had recently been admitted to hospice which she assumed the family may decide to not hospitalize the resident. She stated conversations with the resident's son should have been documented in more detail. She stated the facility did not act in a timely manner for this resident and believed she should have been sent to the hospital sooner. She stated since this incident, residents who fall and experience increased pain or have abnormal assessments were sent out to the hospital for further evaluation. She stated after the resident fell and the facility investigation was completed, new fall protocols were put into place in the facility for every fall. The new protocols were placed to include a checklist of all steps that needed to be taken after each fall, a fall huddle for staff, witness statements, and an incident report. She stated each fall was reviewed in the morning meeting each weekday and a weekly interdisciplinary team meeting was held related to falls and fall risks. The NHA was interviewed on 9/21/22 at 12:30 p.m. She stated she had been in the facility for 42 days and was not the NHA at the time of Resident #1's fall. She stated the facility had identified falls and fall protocols as an issue in the facility and had developed a performance improvement plan and fall protocols to ensure all falls were handled in the same way and to ensure timely and thorough assessments were completed as well as timely treatment. She stated if ordered x-rays were delayed or not completed timely, the facility needed to call the physician for orders to send the resident to the emergency department. She stated if families request transfer to a hospital be delayed, the staff should explain the situation, inform them and educate them that transfer would be in the resident's best interest to evaluate the pain and possible injury and the conversation should be documented.

Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#1) out of three sample residents. Resident #1 admitted to the facility on [DATE] and was at risk for falls due to weakness and impaired balance. The facility failed to implement effective interventions due to the resident's fall risk and after she had a fall on 6/10/22 when she fell out of her wheelchair. The facility implemented a big disc call light due to her poor vision and she was reminded to use the call light. Resident #1 had a fall out of her wheelchair on 7/4/22 in a similar manner, when she fell out of her wheelchair trying to pick something up off the floor. On both occasions when the resident fell , she did not activate her call light for assistance, her roommate activated it. The resident was assessed by staff and noted to have suffered a skin tear to her left elbow and decreased range of motion and hand grasp strength to her left upper extremity. The staff informed the resident's physician and family of the fall and the skin tear. The resident experienced increased pain in her left wrist and elbow and x-rays were ordered on 7/5/22. The x-ray provider did not come to the facility until the afternoon of 7/6/22 and a radius (wrist) fracture was discovered. The resident continued to experience increased pain and an order to send her to the emergency department was written on 7/6/22. The resident was not sent to the emergency department until 7/7/22 where additional x-rays revealed the radius fracture as well as a proximal cortical femur (hip) fracture. Cross-reference F684 for quality of care related to the facility's delay in treatment. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/20/22 and 9/21/22, resulting in the deficiency being cited as past noncompliance with a correction date of 8/13/22. I. Facility action The facility designed a performance improvement plan on 8/7/22 with the aim to complete a fall huddle and the interdisciplinary team (IDT) to review of each fall to ensure all steps had been completed and falls were handled uniformly through the facility. This actions was to minimize falls in the facility, be able to track falls and ensure everything was being done to prevent falls for residents. Nursing staff were educated on 8/12/22 and 8/13/22 related to assessments and documentation needed at the time of the fall and for the days following the fall. The education included fall risk assessments, pain evaluations, risk management documentation, nursing note documentation, implementing a new intervention that is different from previous interventions, communication to future shifts related to the fall and new intervention to ensure implementation was sustained. Fall huddles were occurring after each fall in the facility to review and ensure the fall protocols were followed. Monitoring in daily leadership meetings since 8/2/22 of all falls and weekly risk management meetings 8/12/22, 8/19/22, 8/26/22, 9/2/22, 9/9/22, and 9/16/22 to review each fall and ensure all protocols were followed, interventions were implemented, notifications were made and timely assessment and treatment were provided. II. Facility policy and procedure The Fall Management policy, revised 4/7/22, was provided electronically by the nursing home administrator (NHA) on 9/21/22. It read in pertinent part: The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Residents will be assessed for fall indicators upon admission, readmission, quarterly, change in condition and with any fall. During the admission and readmission process, a care plan will be developed and initiated by the admitting nurse on any residents assessed to be a risk for falls. Upon completion of the other interdisciplinary team's admission and readmission assessments, the interdisciplinary team will review any additional fall risk indicators and revise the resident's care plan as indicated. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS (minim data set assessment), upon a fall event and as needed thereafter. III. Resident #1 A. Resident status Resident #1, age 87, was admitted on [DATE] and transferred to the hospital on 7/7/22. According to the July 2022 computerized physician orders (CPO), the diagnoses included acute and chronic [CONDITION(S)] with [CONDITION(S)] (low oxygen), congenital hiatal hernia (a hole in the diaphragm), unspecified gait and mobility abnormalities, lack of coordination, chronic kidney disease, anxiety, depression, and [CONDITION(S)]. The 4/8/22 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She required extensive assistance of one staff member with mobility and activities of daily living (ADLs). B. Record review A fall care plan dated 4/1/22 revealed the resident was at risk for falls related to weakness and impaired balance. The goal of the care plan was The resident will not sustain serious injury requiring hospitalization through the next review. Interventions, dated 4/1/22 and 4/11/22 read: Assist resident with ADLs as needed; call light within reach; complete fall risk assessment; orient resident to room; provide appropriate footwear/non-skid socks when ambulating or mobilizing in wheelchair; and physical therapy evaluate and treat as ordered or as needed. A nursing note on 6/10/22 at 10:03 p.m. revealed the resident was found on the floor next to her wheelchair. Her roommate pushed the call light. The registered nurse was called to assess the resident. The resident suffered a skin tear to her left upper arm and was medicated for pain. The skin tear was cleaned and dressed. The resident was provided with a disc call light due to poor vision and was reminded to use her call light every time she needed assistance. Neurological checks were put in place. -No additional injuries or pain was identified during the assessment period. No additional updates or revisions were made to the resident's care plan. A nursing note on 7/4/22 at 6:17 p.m. revealed the resident was found on the floor next to her wheelchair and the call light was pushed by her roommate. The resident stated she was trying to pick something up off of the floor and slid out of her wheelchair. The resident's physician group was informed and her two sons were notified of the fall. The registered nurse assessed the resident and she was found to have a skin tear to her left elbow. The wound was cleansed and a dressing was applied. The resident was encouraged to use her call light every time she needed assistance. She was medicated for pain at 7:00 p.m. and neurological checks were in place. The resident received an as needed [MEDICATION(S)] (pain medication) on 7/4/22 at 6:39 p.m. A follow up pain scale at 9:35 p.m. revealed the resident's pain level at two (out of 10, with 10 being the worst on the scale). -There was no initial pain level indicated when the [MEDICATION(S)] was administered. A pain assessment on 7/4/22 at 6:59 p.m. revealed the resident had pain in her left elbow with pain worsening upon movement and pain better with medication. -There was no pain level indicated on the assessment. A fall risk assessment on 7/4/22 at 6:59 p.m. revealed the resident's fall score was 20, with a score of 10 or more indicating a high risk for falls. A nursing note on 7/4/22 at 10:22 p.m. revealed around 8:00 p.m. the floor nurse called the registered nurse (RN) writer to assess the resident who was on the floor. Upon arrival to the room, the resident was on the floor next to her wheelchair on her right side. The resident was alert, responded to verbal commands and stated she was trying to pick something up from the floor and slid out of her chair. A purple bruise was noted to the left side of her temporal area. A skin tear with mild bleeding was noted to her left elbow and left pinky finger. Range of motion to her left arm was weaker than her right arm. She complained of mild pain and her vital signs were at baseline. Her neurological checks were performed by the floor nurse. The resident received an as needed [MEDICATION(S)] at 2:45 a.m. for left wrist pain rated at a six. A follow up pain scale at 7:51 a.m. revealed a pain level of two. A nursing note on 7/5/22 at 5:54 a.m. revealed the resident was on observation related to an unwitnessed fall. She voiced complaints of pain to her left wrist. She received as needed pain medication. Her left hand grip was weak and she stated her wrist up to her elbow was painful when pressure was applied to stand and transfer as well as when asked to squeeze staff hands. The resident's physician group was called and orders were received for x-rays to the resident's left wrist and elbow. A nursing note on 7/5/22 at 10:34 p.m. revealed the x-ray provider company called to inform the facility that x-ray would not be taken that day and was delayed until the next day (7/6/22). A nursing note on 7/6/22 at 3:48 p.m. revealed the resident's left upper arm was observed to have swelling, redness, and was warm to the touch. The resident's physician group was called and the nurse was informed the resident's physician would be in the facility and would assess the resident. The resident received an as needed [MEDICATION(S)] at 7:50 p.m. for a pain level of eight. A follow up pain scale at 9:05 p.m. was zero. A nursing note on 7/6/22 at 9:26 p.m. revealed the resident was admitted to hospice. A nursing note on 7/6/22 at 9:29 p.m. revealed the radiology report revealed a distal radial fracture with malalignment, mild soft tissue swelling, and joint space narrowing. The resident's hospice provider nurse notified the physician and a new order was entered. An order was entered on 7/6/22 at 10:30 p.m. to send the resident to the emergency department. An order note on 7/7/22 at 12:56 a.m. revealed the family requested the resident go to the emergency department in the morning. The resident received an as needed [MEDICATION(S)] at 4:00 a.m. for a pain scale of six. The medication was ineffective and the resident received an as needed acetaminophen at 8:08 a.m. for a pain scale of six. -The facility failed to notify the physician when the [MEDICATION(S)] was ineffective in treating her pain. An additional order was entered on 7/7/22 (no time) to send the resident to the emergency department. A nursing note on 7/7/22 at 10:13 a.m. revealed the resident's son was called and informed she was being sent out to the emergency room to treat her wrist. A change of condition assessment dated [DATE] revealed the resident experienced a change of condition of an acute distal radial fracture which started on 7/5/22. She was noted to have an abrasion, skin tear, and acute pain in her left elbow. An x-ray was completed on 7/6/22. The resident was unable to move her left arm due to pain. The physician and the resident's son were informed on 7/7/22 at 8:00 a.m. Review of the resident's neurological checks revealed the checks started at 5:30 p.m. All areas of the exams were documented to be normal until the second two hour exam at 12:15 a.m. where the hand grasps were documented to be right hand strong and left hand weak. Neurological checks continued as scheduled until 7/7/22 at 4:15 a.m. for the fourth eight hour check. -The first nursing note related to the fall was documented at 6:17 p.m. and first medication was given at 6:39 p.m. The resident was not sent to the hospital after a fall with injury for over 72 hours after the fall. (cross-reference F684). IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/2022 at 9:49 a.m. She stated if a resident was a fall risk, the facility would try to room them close to the nurses station, ensure the resident had a low bed and a call light always within reach. She stated after a resident fall, the registered nurse needed to assess the resident, the physician was called and the director of nursing (DON) was notified. She stated new interventions should be added to the care plan to try to prevent future falls. LPN #2 was interviewed on 9/21/22 at 11:31 a.m. She stated an unwitnessed fall needed an RN to assess the resident and neurological checks needed to be completed to ensure there was no brain injury. She stated the RN assessment also included range of motion assessments and checks for any possible injuries. She stated if an issue with neurological checks, range of motion or any suspected injury from the fall, the nurse needed to call the physician immediately and explain the situation to get orders for x-rays or transfer to the hospital for further assessment and treatment. She stated new interventions should be added for each fall to try to prevent further falls. LPN #3 was interviewed on 9/21/22 at 11:38 a.m. He stated if a resident fell , he would call the RN to assess the resident for any possible injuries. He stated after the assessment, if there was no injury, the resident was assisted up to their chair or bed and the nurse completed a risk assessment and implemented a new intervention. He stated the physician and family should be called after the assessment so they can be notified of the fall and any possible injury. LPN #4 was interviewed on 9/21/22 at 11:45 a.m. She stated if a resident fell , the RN needed to be called to complete an assessment and the DON and NHA needed to be informed. She stated additional action would be based on what the physician ordered. She stated if there was an injury, the resident would be sent out to the hospital. She stated neurological checks would continue and the resident was monitored for 72 hours for pain or any other injuries. She stated a new intervention was implemented after each fall. RN #1 was interviewed on 9/21/22 at 11:50 a.m. He stated he was called to assess residents after falls when he was working. He stated he would do a skin assessment, neurological exam, range of motion and check for injuries per the facility protocol. He stated if there was a difference between hand grasps or range of motion changes, he would notify the physician immediately because it could indicate a serious injury. He stated the resident would most likely be transferred to the emergency department at the hospital. The resident's physician was interviewed on 9/21/22 at 12:05 p.m. She stated she remembered the resident and that she had a fall and was transferred to the hospital. She stated after a resident fell in the facility, the facility staff should call and report on the resident's condition. She stated if the resident was in pain or any concerns with range of motion or hand grasps may indicate an injury and x-rays would be ordered or the resident should be sent out to the hospital. The DON was interviewed on 9/21/22 at 12:16 p.m. She stated the resident should have had new interventions added after the fall on 6/10/22. She stated when the resident was assessed and there was a difference in her hand grasps, the physician should have been notified of that immediately and x-rays may have been ordered sooner. She stated after the resident fell and the facility investigation was completed, new fall protocols were put into place in the facility for every fall. The new protocols were placed to include a checklist of all steps that needed to be taken after each fall, a fall huddle for staff, witness statements, and an incident report. She stated each fall was reviewed in the morning meeting each weekday and a weekly interdisciplinary team meeting was held each week related to falls and fall risks. The NHA was interviewed on 9/21/22 at 12:30 p.m. She stated she had been in the facility for 42 days and was not the NHA at the time of Resident #1's fall. She stated the facility had identified falls and fall protocols as an issue in the facility and had developed a performance improvement plan, updated fall protocols, and monitoring to ensure all falls were handled in the same way.

Based on observations, interviews, and document review, it was determined the facility failed to implement interventions to eliminate or reduce the risk of an avoidable accident for one (#35) of 24 sampled residents (R), consistent with the resident's needs for supervision, goals, and care plan. This deficient practice resulted in an unsafe environment where R#35 fell sustaining an injury. Findings include: A. Observations Observations conducted of R#35, during the survey dates of 9/17/18 at 12:15 p.m. in the dining room, 9/18/18 in the one west hallway, sitting in the wheelchair, 9/19/18 at 4:14 p.m. at the resident's bedside and 9/20/18 at 8:30 a.m. in the dining room, indicated that R#35 was cognizant of their surroundings and had limited ability with wheelchair mobility. B. Document Review 1. R#35 was admitted on [DATE] with the admitting [DIAGNOSES REDACTED]. 2. A review of the quarterly Minimum Data Set (MDS), dated [DATE], the Brief Interview of Mental Score (BIMS) was 11 out of 15, which indicated the resident had minimal cognitive impairment and memory (recall) deficits. A review of R#35's functional status indicated the resident required extensive nursing care including a need for assistance for bed mobility (two or more persons) and activities of daily living (ADLs). 3. A review of R#35's care plan, dated 11/21/17, indicated Resident is here for rehabilitation due to fall prior to admission with compression fracture of lumbar vertebra, decreased mobility, weakness, [MEDICAL CONDITION] (stroke), [MEDICAL CONDITION] disorder, medication use and history of [MEDICAL CONDITION]. The care plan approaches included but not limited to: Ensure call light within reach, staff to assist as needed, bed in lowest position, and hi/low bed with mattress. 4. Further review of R#35's care plan, dated 11/21/17, indicated Resident has activities of daily living (ADL) deficits related to compression fracture of lumbar vertebra, decreased mobility, weakness, [MEDICAL CONDITIONS] disorder and history of [MEDICAL CONDITION]. The care plan approaches included but not limited to: Call light within reach, staff to assist as needed, staff to explain task at hand, staff to encourage independence/ participation with ADLs, resident relies on a wheelchair for mobility in room, and in corridors she propels self. Staff to assist as needed or as requested, staff may use mechanical device during transfer as needed on resident's strength tolerance and time of day as needed, one to two staff to assist resident as needed or requested with bed mobility, transfers, eating, personal hygiene, toileting, and bathing. 5. A review of the Nursing Progress Notes dated 7/20/18 at 7:02 a.m., Licensed Practical Nurse (LPN) EE documented, Resident was found per Certified Nurse Aide (CNA) on the floor on the left side of the bed. Resident says that she rolled out of the bed. Injuries present due to her hitting her head on the air conditioning unit. Resident has a hematoma on (sic) the center of her forehead with a pinpoint area center. Also has some bruising to her nose. A small pin point area above top lip. Blood pressure was elevated at 163/100. Assisted off floor by Hoyer lift and staff, range of motion (ROM) within normal limits (WNL), neurology checks started and WNL. Assessed per registered nurse (RN) in facility. Further review of LPN EE's documentation indicated a call was placed to R#35's on-call physician group and orders were received to send resident to the emergency room (ER) for an evaluation. Neurology checks were continued until resident exited the facility at approximately 1:40 a.m. Received call from hospital stating that resident would be returning. No abnormal findings were noted. 6. A review of the Nursing Progress Notes, dated 7/20/18 at 2:59 p.m., LPN II documented, Resident returned from hospital per ambulance. Communicated Topography (CT) of head, face and cervical spine is negative. Resident has abrasion to right knee, bruises to right upper leg, left posterior ankle, lower right arm, nose and left eye, scratch to right wrist, hematoma to right eye, scratch below nose, laceration at inside of bottom lip. Resident complained of nausea. A call was placed to physician for antiemetic (nausea) medication. The physician assistant called back, (the nurse) let him know left eye was not tracking and resident unable to see out of left eye. Received orders to send resident back to ER. 7. A review of the initial emergency department (ED) Provider Notes, dated 7/20/18 at 4:50 a.m., revealed the following information: History of present illness (HPI) indicated the resident has a past medical history notable for stroke with left sided deficits, who was brought in by ambulance from facility, after an unwitnessed fall off her bed, one to one and a half hours ago when she was calling for an aid. She hit her face on the wall and reports right forehead, right side of nose and right eye pain. She also reports generalized facial/frontal headache and nausea (no vomiting), which she did not have when she was calling for bathroom assist prior to falling. Further review of the ED providers physical examination revealed the resident was oriented to person, place, and situation. A CT scan of the head was completed on 7/20/18 at 3:50 a.m. The results indicated no injuries noted. The resident was discharged back to the facility. 8. A review of the hospital's Discharge Summary, dated 7/22/18 at 9:12 a.m., revealed, the resident has residual left-sided weakness due to prior [MEDICAL CONDITION]. The resident was being changed at the long-term care facility at about 1:00 a.m. on 7/20/18 and was rolled onto her left side, and unfortunately rolled off the bed. She fell about three feet to the floor, landing first on her face. Resident was taken to the ED for evaluation and underwent CT scans which did not show bleeding or fractures. The resident was discharged back to the facility. At the facility, the resident was thought to have difficulty tracking with the right eye, and was sent back to the ED. The resident developed multiple episodes of vomiting and was admitted for observation. The resident had a repeat CT scan that resulted in a small subarachnoid hemorrhage over the frontal area where the resident fell . Neurosurgery evaluated patient without further intervention. Resident was discharged back to long term care facility. C. Interviews 1. An interview was conducted with the Director of Nursing (DON) on 9/19/18 at 3:15 p.m. in the DON's office. The DON was asked for the investigative report concerning R#35's fall with injury. The DON provided the investigation report and the information required to report to the State for this surveyor to review. 2. A telephone interview was conducted on 9/19/18 at 4:04 p.m. with CNA AA. The CNA was asked to describe the event with R#35. The CNA stated, I was making rounds and peeked into the resident's room. The resident was lying on her left side with a pillow propped behind her. I told the resident I was going to change her and was going to get help. When I returned with the other CNA, the resident was lying on the floor between the bed and air conditioner. The CNA was asked if the bed was in a high position and she stated No. She was then asked if the bed was all the way lowered and she stated, No, it was raised up. The CNA was asked why she had not lowered the bed or repositioned the resident for safety and she stated, I had to get help, I couldn't turn her by myself. The DON, Administrator and Team Lead were in the room while CNA AA was interviewed. 3. An interview was conducted on 9/19/18 at 4:14 p.m. with the resident at her bedside. The resident was asked if she remembered falling out of the bed and she stated, Yes and pointed to the left side of the bed. The resident was asked if she rolls around in bed and she stated No. The resident was further asked if she had rolled herself out of bed and she stated, No. 4. An interview was conducted on 9/20/18 at 9:00 a.m. with the Medical Director (MD) in the DON's office. The MD was asked if he was familiar with the resident and the event in July. He stated, I am very familiar with the resident, she was my patient prior to admission to the facility. I am not aware of all the details involving her fall, but she has had several falls prior to being admitted to the facility. She doesn't like to be dependent on anyone and tries to do things on her own. She also has a [DIAGNOSES REDACTED]. The surveyor explained the circumstances of the resident's fall to the MD. He was asked what his expectations of the staff would have been. The MD stated, Based on my knowledge of the resident, the resident is cognitive enough to make her needs known. I would ask if she was aware she was on the edge of the bed and depending on the size of the nurse would attempt to reposition into a safer position. Otherwise, I would have them get assistance to reposition resident. The MD further added, In my opinion and knowledge of the resident I think that after the CNA told the resident she was going to get assistance to change her, the resident tried to reposition herself and fell off the bed because she doesn't like to be a burden to staff. 5. An interview with the DON in the DON's office was conducted on 9/20/18 at 9:20 a.m. The DON volunteered that she was able to contact CNA BB and obtained her statement concerning the event. She added that she couldn't do this before because the CNA was out of the country on vacation. I requested the DON try and reach the CNA again for an interview, but she was unsuccessful and left a message for her to call back. (CNA BB had not returned the call as of the survey exit). The DON gave the surveyor a copy of the CNA's statement. The DON was asked based on the interview with CNA AA on 9/18/18, what was her expectations of staff in the situation where the resident is on the edge of the bed propped up by a pillow, and the bed is in a mid-height position. She stated, I think the CNA felt confident to leave the resident in that position and retrieve assistance from the other CNA. If there were a concern, she would expect the bed to be lowered and the resident repositioned for safety. The CNA could put the call light on. 6. An interview was conducted on 9/20/18 at 9:46 a.m. with LPN FF at the one west nursing station. The LPN was asked if she was familiar with the resident and she stated Yes. The LPN was asked how much bed mobility the resident has. LPN FF stated, The resident can scoot to the right but hasn't seen her scoot to her left due to being [DIAGNOSES REDACTED] on left side. LPN FF was asked if she walked by a resident's room and saw the bed in a mid-level position and the resident was lying on their left side on the edge of the bed, what would be the LPN's actions. LPN FF stated, Call for assistance and go into the room to lower the bed and reposition the resident. The LPN added, The resident is a 2-person assist. LPN FF was asked what the process would be if the LPN found a resident on the floor. The LPN stated, I would do a quick assessment, get the RN, complete vital signs, and make sure the resident is stabilized. The RN will notify the family, and MD. 7. An interview was conducted with LPN GG on 9/20/18 at 9:55 a.m. at the one east nursing station. LPN GG was asked if a resident was observed in a bed that was raised mid-way and the resident was located on the edge of the bed what would she do. The LPN stated, I would make sure the resident was safe then go get a CNA to assist. LPN GG was asked what the process was when a resident has fallen? LPN GG stated, I would notify the RN, complete vital signs, complete an initial assessment, notify the physician, and the family. 8. An interview was conducted on 9/20/18 at 10:00 a.m. with CNA DD at the one east nursing station. CNA DD was asked how the CNA would known when the resident was last turned. CNA DD state, The CNAs report off to each other, so night shift would have told CNA DD, who was positioned when. But it is not documented anywhere. Explained the scenario of a resident's bed being in a heightened position and the resident was lying on the edge of the bed what actions would CNA DD do? CNA DD stated she would make sure the resident was safe, remove the pillow so the resident would fall back in the middle of the bed, lower the bed, and put call light on for assistance with the resident. 9. An interview was conducted on 9/20/18 at 10:10 a.m. with CNA CC at the one east nursing station. CNA CC was given the same scenario as the other interviewees and asked what actions should be taken. CNA CC stated, I would reposition resident and lower the bed, turn call light on if I need assistance. On 9/19/18 at 5:00 p.m. the DON and Administrator were asked to provide any training that CNA AA would have had prior to R#35's event on 7/20/18 related to fall preventions and repositioning. The facility provided training on Body Mechanics/Transfer Training dated 2/1/18 for CNA AA. Also, the training was signed by CNA AA on 7/7/18 with the signature of the trainer dated 8/7/18 for Repositioning Resident. The summary of the training included: 1. When a resident needs repositioning and is close to the edge a) do not leave alone to get help, B) pull the call-light for assistance if you cannot leave alone, and C) ensure bed in lowest position. Training for all staff was performed on 8/28/18 related to fall prevention, call lights, oxygen, and lifts. (CNA AA and CNA BB were not on the sign-off list). Fall Prevention training for all staff was conducted on 9/19/18. (CNA AA and CNA BB were not on the sign-off list) An interview was conducted with the DON on 9/19/18 at 3:15 p.m. in the DON's office. The DON was asked what preventative measures were put into place following R#35's fall. The DON stated, There was already a mattress on the right side of the resident's bed, so they added a second mattress to the left side of bed. Staff was trained on fall prevention on 8/28/18.

Based on record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for one of six sample residents (#1). Specifically, the facility failed to collect and submit a stool sample for testing in accordance with the physician's orders in a timely manner. The findings include: Resident #1 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses, according to the face sheet, included a fractured left hip, rehabilitation, muscle weakness, hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITIONS] without urinary obstruction. a. Assessments The nursing admission assessment, dated [DATE], revealed the resident was alert and oriented, was able to communicate needs and understood others. The [DATE], [DATE] and [DATE] practitioner/physician's notes documented the resident was alert and oriented. The [DATE] bowel and bladder assessment showed the resident was always continent of bowel. b. Care Plans The interim care plan, dated [DATE], identified in part, the left [MEDICAL CONDITION], at risk for falls and a surgical wound following surgery to repair the fracture. The comprehensive care plan, dated [DATE], identified pain, risk for falls, nutrition and hydration, ADL (activities of daily living) deficit, at risk for skin breakdown, [MEDICATION NAME] use, Foley catheter in place, [MEDICAL CONDITIONS],[MEDICAL CONDITIONS]. c. Nurses' Notes The nurses' notes from when the resident was admitted on [DATE] through [DATE] were reviewed. Entries from [DATE] through [DATE], documented the resident was continent of bowel. However, on [DATE] at 12:00 p.m., a note documented the resident complained of abdominal pain and had two bowel movements with incontinent episodes. Further pertinent nursing entries included: -On [DATE]: "loose stools" -On [DATE]: "complained of nausea" -On [DATE]: at 11:00 p.m.,, "nervous, incontinent of bowel" -On [DATE]: at 7:00 a.m., "complained of not feeling well, lethargic." d. Physician's Progress Notes/Orders Physician's progress notes, dated [DATE], documented the resident had a fracture, post surgical repair and his pain was managed. He was experiencing anxiety and [MEDICAL CONDITION]; treated with medication. Nausea and vomiting were highlighted on the form, although no narrative documentation was found to explain the nausea and vomiting. No documentation was found to indicate the practitioner was aware of the resident's diarrhea. Two days after the first documented episodes of incontinent diarrhea stools, the progress notes, dated [DATE], documented the resident was having diarrhea: "diarrhea per pt (patient), will order stool [MEDICAL CONDITION]. (an intestinal infection). Coughing and congestion will order CXR 2 view (chest Xray) to rule out pneumonia, urinalysis with culture and sensitivity. Has ORIF (open reduction internal fixation) left femur and has decreased mobility." Physician's orders, dated [DATE] at 5:30 p.m., documented the orders for the above tests. e. Lab Test Reports On [DATE] at 10:41 p.m., the facility was notified the results of one of the blood tests (a CBC - for which there was no physician's order for - cross reference F281 Professional Standards). The results of this test showed the resident had an elevated white blood cell count (WBC) of 15.4, with normal ranges between 4.00 - 11.5. (WBC are a part of the body's immune system and will become elevated to help fight infections.) f. Bowel Record Review The stool sample was not collected and sent for testing until the morning of [DATE]. More specifically: The [DATE] Monthly Flow Report, Bowel - Observance Report, listed the names of the various certified nurse aides (CNAs) that recorded bowel movements for the resident during each day, evening and night shifts. According to this report, CNA #1 recorded the resident had a bowel movement during the evening shift on [DATE]; and CNA #2 documented a bowel movement during the night shift. Review of the [DATE] Monthly Flow Report - Bowel (a different sheet), also showed CNA #2 documented the resident was continent of a large stool during the night shift on [DATE]. On [DATE], according to the Monthly Flow Report, Bowel - Observance Report, CNA #4 documented the resident had a bowel movement during the day shift; CNA #3 documented the resident had a bowel movement during the evening shift, and CNA #5 documented the resident had a bowel movement during the night shift. On [DATE], according to the Monthly Flow Report - Bowel, zeros were documented in the corresponding boxes for day shift, evening shift and night shift. On [DATE], according to the Monthly Flow Report, Bowel - Observance Report, CNA #6 documented the resident had a bowel movement during the day shift. The Monthly Flow Report - Bowel for [DATE] documented the resident had a large continent stool. Review of the nurses' notes revealed a stool sample was collected and sent to the lab on [DATE] at 9:00 a.m. g. Additional Record Review On [DATE], the lab notified the facility the stool sample was positive for [MEDICAL CONDITION]. The nurse practitioner (NP) was contacted and antibiotic therapy was ordered, and started at 6:00 p.m., for treatment of [REDACTED]. Review of the [DATE] medication administration records (MARs) revealed the order for the antibiotic, [MEDICATION NAME] 500 mg 1 tablet by mouth three times daily for 10 days. According to nurse initials, the resident received five doses and then was transferred out to the emergency roiagnom on [DATE]. The [DATE] weekly care management review regarding "current status and barriers to achieving goals" was reviewed. The documentation showed [DATE] was the resident's 14th day at the facility following a left femur fracture. He had a left heel wound/blister, oxygen, steri strips to his hip incision, was 69 inches tall and weighed 175 lbs. He was weight bearing as tolerated, had the Foley catheter discontinued on ,[DATE], and then reinserted for inability to void. The discharge plans were for the resident to return home with his wife. The form was signed by six staff members including the nursing home administrator, therapy, social services and nursing staff. There was no documentation found regarding the incontinent loose stools on [DATE]. h. Interviews The family was interviewed on [DATE] at 3:45 p.m. The family said the resident fell , broke his hip and had been hospitalized for [REDACTED]. He was admitted to the facility for rehabilitation with the plan for him to return home with his spouse. The family stated during a visit with the resident on [DATE], the resident reported, "I sh** myself, and vomited," and he continued to have loose bowels. The family said then on [DATE], a call was received from the physician's assistant (PA) at the facility informing the family that 911 had been contacted and the resident was sent to the emergency room . When the family arrived at the hospital, the ER doctor said, 'I don't think so,' in reference to the resident's condition improving. The family said an abdominal scan was performed and showed the resident's whole large intestine was inflamed. The family was informed on [DATE] the resident had bacteria in his blood and there was nothing that could be done for him. Palliative care with pain medication was initiated and on [DATE] and around 7:00 p.m., the resident passed away. "He died in the hospital [MEDICAL CONDITION]." On [DATE] at 3:45 p.m., the director of nursing (DON) was interviewed and asked about the resident's elevated WBC. She stated she would research and respond back to the surveyor. She reported back that the elevated WBC was due to the positive [MEDICAL CONDITION]. On [DATE] at 10:44 a.m., (name - of director of the laboratory company that performed lab testing for the facility) was interviewed. He stated the lab staff traveled to multiple facilities for pick up services in the p.m. hours, generally taking between five to eight hours depending on the number of facility stops needed. He said the expectation in processing and reporting of lab tests had to be completed within 72 hours of receipt of the specimen; within five hours if the test was ordered STAT (immediately). He said depending on the number of specimens they had to process, it could take up to 24 hours for the results. He further stated, though stool samples are good for 24 hours, a stool can be processed STAT if it is ordered that way. The tests for resident #1 were not ordered STAT. On [DATE] at 11:25 a.m., nurse (RN) #7 was interviewed. She stated she had worked at the facility for two years and had cared for resident #1 a couple of times while he was at the facility. She said he was alert and pleasant. When asked about collecting the stool sample, she said generally, when there were orders, a collection device (hat) would be placed inside the toilet so a sample could be collected as soon as possible. She reported she did not recall the resident having orders for a stool sample. She was, however, caring for the resident the day he was sent out to the hospital. She said after the start of her shift around 7:00 a.m., the resident was okay. However, when she returned two hours later, he was lethargic and unable to swallow. She notified the physician at the time, and said the physician's assistant (PA) for the resident was in the facility, so he responded and assessed the resident and said he needed to go out to the hospital right away. At 11:50 a.m., CNA #8 was interviewed. He stated he never cared for the resident. Although he stated all CNA cares provided included showers, mobility, ADLs, if the resident was incontinent and provision of incontinence care. At 12:15 p.m., a call was placed to the nurse practitioner (NP) who assessed the resident on [DATE], with a message requesting a call back. At 12:30 p.m., the PA that assessed the resident prior to ordering the resident be transferred to the hospital on [DATE] was interviewed. He stated his expectation regarding turn around time for stool sample collection should be with in 24 hours, and results from the lab within 12 hours. On [DATE] at 12:40 p.m., the director of nursing (DON) was interviewed. She stated the facility expectation time for obtaining and sending a stool sample for [MEDICAL CONDITION] should be as quick as possible, within 24 hours. She stated the facility standard was to place a "hat" in the toilet for collection as soon as possible. At 12:45 p.m., nurse #9, who cared for the resident back on [DATE], was interviewed. She reported the resident experienced urgency incontinence with diarrhea, though she did not recall if he had it every day. She said the standard expectation was to contact the physician if a resident had two diarrhea stools. However, nurse #9 stated for her, if a resident had a third diarrhea episode she would collect a stool sample, then call the doctor for orders. She said stool collection occurred either by scooping a sample from an incontinent brief or from a "hat" directly placed in the toilet. At 1:00 p.m., the night shift nurse (#10), who cared for the resident on [DATE], stated the resident had been complaining of abdominal pain. He said it would have been the CNA's responsibility to collect the sample after a "hat" was given to the CNA for placement in the toilet. He said he did not recall the resident having a BM during the night; and had not witnessed much diarrhea during the night. However, he said it was frequently reported to him the resident was having diarrhea. "We are big on reporting diarrhea here." On [DATE] at 1:15 p.m., a call was placed to CNA #2, who worked during the night shift and documented the resident had a large BM during the night of [DATE], after the order was received to collect the stool sample. Message was left for return call. At 1:40 p.m., a call was placed to CNA #6, who also cared for the resident and documented the resident had a BM on ,[DATE], ,[DATE], and [DATE]. Message left for return call. On [DATE] at 2:15 p.m., nurse #11 was interviewed. She stated she cared for resident #1 and said the resident had been having diarrhea stools, "I do remember him having loose stools, and antibiotics were ordered." She repeated she remembered the resident having loose stools during the shifts she cared for him. On [DATE] at 2:43 p.m., CNA #3 was interviewed. CNA #3 documented the resident had BMs on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE], and he had one small BM on ,[DATE] and one medium on ,[DATE] and ,[DATE]. She reported the resident had frequent incontinent loose stools and he wore briefs due to frequency and urgency. She said, regarding bowel documentation on the forms, the program did not allow individual entries for "medium, small, liquid, etc" each time the resident had a BM. So, on her shift, she said, "If the resident had 2 or 3 BMs on my shift, I just combine it and enter one large." On [DATE] at 3:00 p.m., CNA #1 was interviewed. She stated the individual check marks entered in the bowel records meant the resident had a BM. She said whenever a checkmark was entered, "You have to enter details or the program won't allow you to move forward." She said she remembered resident #1 had a lot of loose stools and thought he was on an antibiotic, "a lot of diarrhea." She said she helped with him and he seemed to have stress/urge incontinence. She was then asked about the inconsistent documentation between the two bowel record forms. After her review of the BM documentation, she said she could not understand how that was possible. On [DATE] at 3:15 p.m., a telephone interview was conducted with the NP from [DATE]. She said she recalled seeing the resident back on [DATE], and he told her he had been having diarrhea. She asked him how many and he said twice that same day. The NP said she thought the resident did not look good at the time so she ordered various tests including a stool sample to check for [MEDICAL CONDITION]. She said she did not know the stool sample was not collected and sent until [DATE] and said she did not understand why staff had not collected the sample and sent it that same day. On [DATE] at 9:50 a.m., a return call was received from CNA #2, who had documented the resident had a large BM the night of [DATE]. He apologized and said he did not remember the resident, that "a lot of them that come and go, I'm so sorry." The resident experienced ongoing loose/diarrhea stools, starting [DATE]. There was no evidence found to show physician services was notified at that time. Although there were orders for a stool sample to be tested for [MEDICAL CONDITION] written two days later, on [DATE], the collection was not completed until [DATE]. The result was positive. However, as a result of the delay in obtaining the stool sample, the diarrhea was not treated until five days after it was documented to have started. Review of the [DATE] hospital admission records showed the resident was admitted with altered mental status and low blood pressure. The resident was diagnosed with [REDACTED]." Review of the [DATE] hospital lab reports showed at the time of admission, the resident's WBC count was severely elevated at 57.7. The [DATE] hospital physician's notes documented the resident was highly complex with "sepsis secondary to [DIAGNOSES REDACTED], catheter associated UTI (urinary tract infection)/urosepsis. "In addition, the assessment showed the resident was in [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]. The resident subsequently passed away on [DATE] at 7:15 p.m. Review of the death certificate revealed the resident's cause of death [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and UTI and oliguric (no urine output) [MEDICAL CONDITION].