Every finding on record at Life Care Center Of Columbia

Based on observation, interview, and facility policy review, the facility failed to ensure foods that were are stored in the freezer, coolers, and dry food storage were appropriately sealed, labeled, dated, and/or discarded after the manufacturer's expiration date in 1 of 1 walk in freezer, 1 of 1 walk in cooler, and 1 of 1 dry storage room. This had the potential to affect all residents who received meals from the kitchen. Findings include: Review of the facility policy, revised on 04/26/23, titled, Food Safety, revealed, food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. Food Safety Policy Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. 2. Pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary (NSF) container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). 'Use by Date' is noted on the label or product when applicable. 3. The 'use by date' guide is easily accessible to all associates involved with resident for storage. 6. Dented, leaky, rusted and swelling cans that could affect food safety are returned to the vendor but stored in a designated area away from other food. These items will not be used. Dry Storage 2. Opened packages of food are resealed tightly to prevent contamination of the food item and 'use by date' will be used when applicable. Review of the facility policy, revised on 04/30/23, tiled Safe Food Handling revealed, all food purchased, stored and distributed is handled with accepted food-handling practice and per federal, state and local requirements. 5. Food that is not stored, prepared, handled and/or consumed in any area which food may be contaminated . Review of the facility undated policy, titled, Use by Date revealed, The following guide can be used to determine a use by date for labeling food (opened or unopened) that should be used within a certain time frame. All opened containers of food in the dry storage area should be placed in an enclosed container, labeled, and dated with the open date and the use by date. Any unopened cans/packages should be marked with the date received. After opening, the above guideline is followed regarding opened containers of food. During an initial observation on 06/17/25 at 9:30 AM, the Dry Storage Room revealed the following: 1 - 62 ounce (oz) can mushroom pieces and stems- dented on rack for use. 1 - gallon jug Worcestershire sauce was open with no open date or use by date. 1 - 10 pound (lb) bag rainbow sprinkles with no open date. 1 - 7.5 lb jug Old Bay seasoning with the top covered with white debris, labeled in 04/08/25 out 05/08/25, no clear expiration or best by date. At 9:56 AM the walk in cooler revealed the following: 1 - box of bacon strips open on top shelf, labeled shelf life 6/17 use by 6/24 and not properly sealed. 1 - gallon dill pickle chips with an open date of 05/03/25 and a use by date of 05/03/25. 1 - gallon jug sliced jalapeno peppers with no open or use by date. 1 - gallon jug container mayonnaise, marked R (received) 6/5 no open or used by date. 1 - gallon barbeque sauce, marked R date 6/5 no open or use by date. 1 - 8.44 lb container mild chunky salsa dates 4/24 use by 5/24. 1 - 5 lb container sour cream with a best by date of 06/04/2, no open or use by date. 1 - 5 lb container low fat cottage cheese with a best by date of 05/10/25, no open date. 1 - 48 oz block cream cheese with a best by date of 05/27/25. 1 - 5 lb container ricotta cheese with a best by date of 03/20/25. 2 - 5 lb container ricotta cheese with a best by date of 05/01/25; 1 - bag fresh cut vegetables/cabbage with no open or use by date. 1 - bag iceburg lettuce with a use by date of 06/14/25 with no open date. At 10:20 AM the freezer revealed the following: 1 - bag French fries was opened with no open date and not sealed properly. During an interview on 06/18/25 at 4:45 PM, the Dietitian revealed that she does a monthly walk through of the kitchen and once it's complete she provides a report to the Executive Director, the Dietary Manager and the Director of Nursing. The Dietitian stated that during her walk through she is looking for anything that may be expired, that the walk-in refrigerator and freezer temperature are at the right temperature, that the logs are properly completed, that items are properly dated with an open and use by date, check for the cleanliness of the floors, ceilings and that the staff are performing proper sink sanitation. The Dietitian further stated that she has provided a printout of a use by guide for staff to refer to for properly dating food items, and she advises them to memorize it because it is a daily task. The Dietitian further explains that for any food items in the area past its use by date it should be discarded, and if items are opened and dated and past the use by date, items should be discarded. The Dietitian concluded that her expectation is that any items open should be labeled with an open date and a use by date. During an interview on 06/18/25 at 5:06 PM, the Dietary Manager (DM) revealed that items are labeled with received date, when they are delivered to the facility, and then when an item is opened staff will put a tag on it marking it with a prep/open date and an expiration/use by date. That date will vary depending on the item. The DM stated that the use by date and expiration date are determined by a national data base, use by recommendation and the facility policy. The DM further stated that all items should be discarded if opened and not labeled with an open/use by label for dry storage, coolers and freezers, and any items beyond the use by date needs to be discarded immediately. The DM concluded that he does a daily walk through of the kitchen and if he is not here, the walk through should be done by his assistant or chef on duty. During an interview on 06/18/25 at 5:41 PM, the Administrator revealed that the DM oversees the kitchen, however he does walk through the kitchen once a week and sometimes more. The Administrator stated that during the walk through he checks the vents, the sprinklers to make sure there is no build up on them, checks the rinse area, temperature logs, makes sure there are no fall hazards, check the three compartment sink, the freezer and cooler to make sure everything is labeled properly, checks to ensure that there is nothing too close to the ceiling. The Administrator stated he walked through the kitchen about a week ago and did not notice anything in the walk-in cooler. The Administrator further revealed that his expectation is that if items are beyond the use by date they should be discarded and he expects that the kitchen is clean.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, interviews and review of facility policy, the facility failed to ensure comprehensive assessments were initiated, completed, submitted, or exported for 17 out of 17 residents reviewed for resident assessments, Resident (R)65, R28, R96, R46, R106, R91, R30, R31, R15, R88, R62, R75, R37, R9, R105, R50 and R55. Findings include: Review of the facility policy titled Resident Assessment Instrument and Care Plan Development, with a revision date of 09/05/24, documented, Policy: The facility will follow the procedures set forth in the Resident Assessment Instrument (RAI) Users Manual 3.0 when completing the MDS, Care Area Assessment, and Comprehensive Care Plan. Procedure: The Resident Assessment Instrument is composed of the MDS, Care Area Assessments, and Utilization Guidelines. 2. MDS assessments are completed at a minimum upon admission, quarterly, annually, and with a significant change in patient status. 3a. The instructions for completing the RAI are found in the Centers for Medicare & Medicaid Services Long - Term Care Facility Resident Assessment Instrument User's Manual 3.0. 8. The information identified using the MDS and Care Area Assessment process is used to develop an individualized person - centered Care Plan that includes the patient's voice, the patient's goals while residing in the facility and for discharge that assist the patient to attain and/or maintain their highest practicable level of well - being. 9. The RAI is not all inclusive therefore other sources of information are to be included when developing an individualized person - centered care plan for each patient that is reviewed by the interdisciplinary team with each assessment including the patient and other participants as the patient desires. Review of the RAI Version 2.0 Manual, Chapter 5: Submission and Correction of the MDS Assessments documented, MDS assessments are edited to verify that clinical responses are within valid ranges, dates are reasonable, and assessments are consistent with the previous assessments completed for the same resident. The facility is notified of the results of this evaluation on the Initial Feedback Report or the Final Validation Report. Timeliness Criteria: Assessment Transmission: Comprehensive assessments must be transmitted electronically within 31 days of the Care Plan Completion Date (VB4). All other MDS or MPAF assessments must be submitted within 31 days of the MDS Completion Date (R2b). Review of R65's Face Sheet revealed that R65 was admitted to the facility on [DATE], with diagnoses including but not limited to: traumatic hemorrage of cerebrum, occipital condyle fracture, dementia and type 2 diabetes mellitus. Review of R65's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/25, revealed the assessment was not initiated and was 25 days overdue. Review of R28's Face Sheet revealed that R28 was admitted to the facility on [DATE], with diagnoses including but not limited to: other complications of gastrostomy, type 2 diabetes mellitus with diabetic neuropathy, dementia and chronic lymphocytic leukemia of B-cell type. Review of R28's Quarterly MDS with an ARD of 05/08/25, revealed the assessment was still in progress, not submitted and 27 days overdue. Review of R96's Face Sheet revealed that R96 was admitted to the facility on [DATE], with diagnoses including but not limited to: Parkinson's Disease without dyskenesia without mentions of fluctuations, dementia, type 2 diabetes mellitus and bipolar disorder. Review of R96's Quarterly MDS with an ARD of 05/03/25, revealed the assessment was still in progress and not submitted. The assessment was 32 days overdue. Review of R46's Face Sheet revealed that R46 was admitted to the facility on [DATE], with diagnoses including but not limited to: nondisplaced fracture of seventh cervical vertebra, type 2 diabetes mellitus, late onset dementia and adjustment disorder with mixed disturbance of emotions and conduct. Review of R46's Quarterly MDS with an ARD of 05/14/25, revealed the assessment was still in progress and not submitted. The assessment was 21 days overdue. Review of R106's Face Sheet revealed that R106 was admitted to the facility on [DATE], with diagnoses including but not limited to: type 2 diabetes mellitus, schizophrenia, anxiety disorder and depression. Review of R106's Quarterly MDS with an ARD of 04/19/25, revealed the assessment was still in progress and was not submitted. The assessment was 46 days overdue. Review of R91's Face Sheet revealed that R91 was admitted to the facility on [DATE], with diagnoses including but not limited to: fracture of head and neck of right femur, nontramatic subarachnoid hemmorage, cerebral infarction due to embolism of left cerebral middle artery and type 2 diabetes mellitus. Review of R91's Quarterly MDS with an ARD of 05/04/25, revealed the assessment was still in progress and was not submitted. The assessment 31 days overdue. Review of R30's Face Sheet revealed that R30 was admitted to the facility on [DATE], with diagnoses including but not limited to: cerebral infarction, flaccid hemiplegia affecting right dominant side, aphasia and type 2 diabetes mellitus. Review of R30's Quarterly MDS with an ARD of 04/19/25, revealed the assessment was still in progress and was not submitted. The assessment 46 days overdue. Review of R31's Face Sheet revealed that R31 was admitted to the facility on [DATE], with diagnoses including but not limited to: sequelae of cerebral infarction, type 2 diabetes mellitus, hypovolemic shock and peripheral vascular disease. Review of R31's Quarterly MDS with an ARD of 05/05/25, revealed the assessment was still in progress and was not submitted. The assessment was 30 days overdue. Review of R15's Face Sheet revealed that R15 was admitted to the facility on [DATE], with diagnoses including but not limited to: lobar pneumonia, schizoaffective disorder, chronic viral hepatitis C and hypertension. Review of R15's admission MDS with an ARD of 12/11/23, revealed the assessment was not initiated and was 557 days overdue. Review of R88's Face Sheet revealed that R88 was admitted to the facility on [DATE], with diagnoses including but not limited to: severe protein-calorie malnutrition, dementia, major depressive disorder and latent tuberculosis. Review of R88's Quarterly MDS with an ARD of 04/06/25, revealed the assessment was still in progress and was not submitted. The assessment was 59 days overdue. Review of R62's Face Sheet revealed that R62 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute embolism and throbosis of left femoral vein, Alzheimer's disease, sick sinus syndrome and long QT syndrome. Review of R62's Annual MDS with an ARD of 03/31/25, revealed the assessment was completed but not exported. The assessment remained in the que and was ready for export on 03/31/25, however was not exported. Review of R75's Face Sheet revealed that R75 was admitted to the facility on [DATE], with diagnoses including but not limited to: non-ST, elevation myocardial infarction, type 2 diabetes mellitus, asthma and anxiety disorder. Review of R75's Quarterly MDS with an ARD of 04/14/25, revealed the assessment was still in progress and was not submitted. The assessment was 15 days overdue. Review of R37's Face Sheet revealed that R37 was admitted to the facility on [DATE], with diagnoses including but not limited to: atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive heart disease without heart failure, dysphagia and depression. Review of R37's Quarterly MDS with an Assessment Reference Date (ARD) of 04/17/25, was still in progress and was not submitted. The assessment was 48 days overdue. Review of R9's Face Sheet revealed that R9 was admitted to the facility on [DATE], with diagnoses including but not limited to: spinal stenosis, acute respiratory failure, paranoid schizophrenia and Alzheimer's disease early onset. Review of R9's Quarterly MDS with an ARD of 05/14/25, revealed the assessment was still in progress and was not submitted. The assessment was 14 days overdue. Review of R105's Face Sheet revealed that R105 was admitted to the facility on [DATE], with diagnoses including but not limited to: displaced intertrochanteric fracture of left femur, pulmonary fibrosis, emphysema, and type 2 diabetes. Review of R105's Quarterly MDS with an ARD of 05/14/25, revealed the assessment was still in progress and was not submitted. The assessment was 114 days overdue. Review of R50's Face Sheet revealed that R50 was admitted to the facility on [DATE], with diagnoses including but not limited to: cerebral infarction, vascular dementia, chronic kidney disease stage 3 and type 2 diabetes mellitus. Review of R50's Quarterly MDS with an ARD of 05/06/25, revealed the assessment was not started. The assessment was 43 days overdue. Review of R55's Face Sheet revealed that R55 was admitted to the facility on [DATE], with diagnoses including but not limited to: metabolic encephalopathy, Alzheimer's disease, depression, anxiety disorder and type 2 diabetes mellitus. Review of R55's Significant Change MDS with an ARD of 04/01/25, was still in progress and was not submitted. Further review of R55's Quarterly MDS with an ARD of 05/13/25, revealed the assessment was still in progress and was not submitted. The assessment was 44 days overdue. During an interview with the MDS Coordinator on 06/18/25 at 6:20 PM, revealed that the time frame for submission of a MDS assessment according to the RAI is 14 days, the facility's expectation is 5 days for a Medicare assessment and 14 days for all other assessments. There is no documentation of this expectation, I received that information from the previous regional. The MDS Coordinator stated the MDS schedule is reviewed every morning in stand up meeting at 9 AM. The clinical dashboard in PCC (electronic medical record) indicates when an assessment is due. Everyone has access, it is expected to be reviewed each morning. The Executive Director (ED) and DON are notified if a part of the MDS is not completed in a timely manner. This facility has a chronic or historic issue of submitting assessments late, the number is not an accurate representation of what is truly late, being that information was behind when I first took the position. I am currently not up to date. The MDS Coordinator further stated, there is someone that is overseeing the area until someone is hired. We are not able to complete and submit the MDS because we are restricted by other areas. If the MDS is ready for export and not exported, it means its just sitting in the que, but nothing should be sitting in the que since March. During an interview with the Director of Nursing (DON) and the Administrator on 06/19/25 at 9:16 AM, revealed, the Administrator was notified yesterday regarding MDS assessments that are late. The DON revealed that she was notified regarding the late MDS assessments this morning. The MDS department reports to the DON. The DON revealed that her expectations are for the late assessments to be completed. The MDS nurses should communicate with her the departments that are behind completing the MDS so that she can make sure those departments complete the assessments in a timely manner. The MDS nurses should be showing us the calendar so that we are aware of what assessments are due. The Administrator revealed his expectations are that we go over the MDS calendar in morning meeting and review each MDS that is due. Each MDS should be completed timely and verified with me daily. During an interview on 06/19/25 at 9:57 AM, the Activities Director revealed, I do complete the Activities portion of the MDS. The MDS woman [name] will tell me when an assessment is due. I have not received a calendar. I am behind on assessments. I got behind on the last couple of days since you all have been here. The MDS is for Medicaid clearance. My section is important to make sure we are doing what we should do for the residents. The admission MDS is due three days after the resident's admission. I don't know when the assessments are due after that. I'm just given a date that I need to complete it. During an interview on 06/19/25 at 10:59 AM, the Director of Social Work revealed, Yes, I complete part of the MDS. One way I know when an MDS is due is by the MDS print off. Another way is a calendar but that has not been distributed in 2 or 3 weeks. The calendar comes from MDS. I saw it in the morning meeting and I liked it and asked for a copy. I received it twice and then have not seen it again. I have gotten behind but we do try to catch up. I know when an MDS is due by the MDS nurse telling me, Point Click Care (electronic medical record) and by printing off the MDS list. I am sure that there are some sections that need to be caught up and we will catch them up. The MDS is submitted to whomever and that is how we get paid. The MDS is also how we look at the overall functioning of the residents and how to care for the residents. Assessments are important for the overall functioning of the resident as well as communicating the status of a resident. In the future, my assistant and I will complete the MDS by the end of the day. During an interview with MDS Registered Nurse (RN) on 06/19/25 at 2:54 PM, revealed we were waiting on section F which is the activities section. The MDS RN stated, I don't know how floor staff would know how to take care of resident if the MDS is not submitted and the care plan is not updated. The MDS RN revealed that the MDS team emails department heads about outstanding MDS assessments that need be completed. MDS assessments that are due are also gone over during morning meeting. The MDS team will also give department heads a list of patients with MDS assessments which needs to be completed by department heads and the dates that assessments are due and required dates that the assessments need to be submitted. The Certified Nursing Assistants on the floor would not know any new care plan interventions for a resident if the MDS is not completed and submitted because the care plan would not be updated and the kardex would then not be updated.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, interview and facility policy, the facility failed to complete and submit a significant change Minimum Data Set (MDS) within 14 days after the facility determined that there had been a significant change in Resident (R55)'s physical or mental condition for 1 of 17 residents reviewed for completion of comprehensive assessment after a significant change. Findings include: Review of the facility policy titled Resident Assessment Instrument and Care Plan Development, with a revision date of 09/05/24, documents, Policy: The facility will follow the procedures set forth in the Resident Assessment Instrument (RAI) Users Manual 3.0 when completing the MDS, Care Area Assessment, and Comprehensive Care Plan. Procedure: The Resident Assessment Instrument is composed of the MDS, Care Area Assessments, and Utilization Guidelines. 2. MDS assessments are completed at a minimum upon admission, quarterly, annually, and with a significant change in patient status. 3a. The instructions for completing the RAI are found in the Centers for Medicare & Medicaid Services Long - Term Care Facility Resident Assessment Instrument User's Manual 3.0. 8. The information identified using the MDS and Care Area Assessment process's is used to develop an individualized person - centered Care Plan that includes the patient's voice, the patient's goals while residing in the facility and for discharge that assist the patient to attain and/or maintain their highest practicable level of well - being. 9. The RAI is not all inclusive therefore other sources of information are to be included when developing an individualized person - centered care plan for each patient that is reviewed by the interdisciplinary team with each assessment including the patient and other participants as the patient desires. Review of R55's Face Sheet revealed that R55 was admitted to the facility on [DATE], with diagnoses including but not limited to: metabolic encephalopathy, Alzheimer's disease, depression, anxiety disorder and type 2 diabetes mellitus. Review of R55's Significant Change MDS with an Assessment Reference Date (ARD) of 04/01/25, revealed the assessment was still in progress and was not submitted. Review of R55's Quarterly MDS with an ARD of 05/13/25, revealed the assessment was still in progress and was not submitted. During an interview with MDS Coordinator 1 on 06/18/25 at 6:20 PM revealed that the time frame for submission of a MDS assessment according to the RAI is 14 days, the facility's expectation is 5 days for a Medicare assessment and 14 days for all other assessments. MDS Coordinator 1 stated there is no documentation of this expectation, I received that information from the previous regional. The MDS schedule is reviewed every morning in stand up meeting at 9 AM. The clinical dashboard in PCC (electronic medical record) indicates when an assessment is due. Everyone has access, it is expected to be reviewed each morning. This facility has a chronic or historic issue of submitting assessments late, the number is not an accurate representation of what is truly late, being that information was behind when I first took the position. I am currently not up to date. During an interview with the Director of Nursing (DON) and the Administrator on 06/19/25 at 9:16 AM, revealed, the Administrator was notified yesterday regarding MDS assessments that are late. The DON revealed that she was notified regarding the late MDS assessments this morning. The DON revealed that her expectations are for the late assessments to be completed. The MDS nurses should communicate with her the departments that are behind completing the MDS so that she can make sure those departments complete the assessments in a timely manner. The Administrator revealed his expectations are that we go over the MDS calendar in morning meeting and review each MDS that is due. Each MDS should be completed timely and verified with me daily. During an interview with MDS Registered Nurse (RN)2 on 06/19/25 at 2:54 PM revealed, the significant change MDS on 04/01/25 was due to a wound greater than a stage 2. We give the wound 14 days to heal if facility acquired. We were waiting on section F which is the activities section. MDS RN2 stated I don't know how floor staff would know how to take care of a resident if the MDS is not submitted and the care plan is not updated. MDS assessments that are due are also gone over during morning meeting. The MDS team will also give department heads a list of patients with MDS assessments which needs to be completed by department heads and the dates that assessments are due and required dates that the assessments need to be submitted. The CNAs on the floor would not know any new care plan interventions for a resident if the MDS is not completed and submitted because the care plan would not be updated and the kardex would then not be updated.

Based on observation, interview, record review, and review of facility policy, the facility failed to accurately code the quarterly Minimum Data Set (MDS) assessment for Resident (R)105, specifically coding a glucagon-like peptide receptor agonist (GLP-1) as insulin for 1 out of 17 residents reviewed for resident assessments. Findings include: Review of the facility policy titled Certification of Accuracy of the MDS revised on 04/22/25, states, The assessment must represent an accurate picture of the resident's status during the observation period of the MDS. The Observation Period (also known as the Look-back period) is the time frame over which the resident's condition or status is captured by the MDS assessment and ends at 11:59 p.m. on the day of the Assessment Reference Date (ARD). Review of R105's Face Sheet revealed R105 was admitted to the facility on [DATE], with diagnoses including, but not limited to, type 2 diabetes mellitus. Review of R105's Quarterly MDS with an ARD of 02/24/25 and a completion date of 02/25/25, revealed a 1 coded for the number of days that insulin injections were received during the last seven days of the look back period. Review of R105's Quarterly MDS with an ARD of 05/27/25 and a completion date of 06/10/25, revealed a 1 coded for the number of days that insulin injections were received during the last seven days of the look back period. Review of R105's Orders with a start date of 12/25/24, revealed an order for, Trulicity Subcutaneous Solution Auto-injector 1.5 MG/0.5ML (Dulaglutide) Inject 1.5 mg subcutaneously one time a day every Wed for DM. Further review of the Orders did not reveal an order for insulin. Review of R105's Medication Administration Record (MAR) for 02/25 and 05/25, revealed no order for insulin and no administration of insulin. During an interview with MDS Coordinator 1 and MDS Coordinator 2 on 06/18/25 at 6:45 PM, MDS Coordinator 1 confirmed Trulicity is a GLP-1 medication and not insulin. MDS Coordinator 2 questioned whether Trulicity was insulin. MDS Coordinator 1 stated they were trained by the prior regional MDS Director, who is no longer with the company, to code Trulicity as insulin in the MDS. Both were unable to provide documentation to support this. During an interview with the Administrator on 06/19/25 at 5:33 PM, revealed he has begun to put a plan in place to correct the MDS errors. The Administrator stated the new Director of Nursing, who takes over Monday, has also begun putting controls in place regarding the MDS process.

Based on observation, interview and review of the facility policy, the facility failed to ensure that medication and biologicals that were outdated or without proper labeling were removed from the medication cart for 3 of 3 medication treatment carts. Findings include: Review of the facility policy dated October 2018, titled ID1: Storage of Medications states medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal (see Section IE: DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES), AND REORDERED FROM THE PHARMACY (See IC3: ORDERING AND RECEIVING NON-CONTROLLED MEDICATIONS FROM THE DISPENSING PHARMACY), if a current order exists. During an observation on 05/09/2024 at 07:40 AM, reviewed Unit 300 Treatment Cart with Licensed Practical Nurse (LPN)2 revealed the following biologicals: -Two tubes of Regenecare Wound Gel 3 oz, manufacturer MPM Medical and an expiration date of 02/29/2023. -Three Curity Idofoam Packing Strips (sterile container open) Manufacturer Covidien Ref # 7831, Lot # 22E066362, Expires 04/30/2024. -Two Bottles Packing Strip Plain 1/4' x 5 yards. No expiration date. Lot# E23309, Manufacturer 61-59120. -Statlock PICC Plus Expiration Date 12-28-2023, Lot# JUEZ0814, Reference # VPPCSP -Dressing change tray with Giva expiration date 02/09/2024, Lot # 222451393 During observation on 05/09/2024 at 08:00 AM, all expired treatment medication were validated by LPN2. During an observation on 05/09/2024 at 09:00 AM, reviewed Unit 200 treatment cart with Registered Nurse (RN)1 revealed the following biologicals: -Ammonium Lactate 12%, apply to face topically two times a day for rash for 7 days. Original date 09/26/2022. Dispense date 10/01/2022. Manufactured by [NAME]-[NAME]. -One dressing change tray with Giva Lot# 21255700, expired 01/31/2023. -Surgical lubricant sterile bacteriostatic, reference # 281020537, Manufacturer HR Pharmaceuticals, Inc, expired 09/30/2023. -Mupirocin Ointment USP 2% 22g, Manufacturer Taro Pharmaceuticals, Inc, Lot# AC82185, SN 1000112223491, expired 02/2024. -Promogran Prism Matrix Ag Count 10, Lot# 2009V001, Ref MA028, expired 01/31/2022. -Promogran Prism Matrix Ag Count 4, Lot# 2009V001, Ref MA028, expired 01/31/2022. -Ascend silver Sulfate Cream, Lot# X0141, manufacturer Ascend laboratories, expired 02/2023. All expiration medications verified at 09:17 AM by RN1 and removed from cart. On 05/09/2024 at 09:52 AM, an interview with LPN3 (unit manager) stated we need to educate our staff on not to open sterile dressing and use partial pieces. LPN3 stated the wound nurse change the dressings during the week. All the nurses are trained to change dressings, but it is usually changed by the wound nurse during the week. We have two wound nurses. RN2 and LPN6. On 05/09/2024 at 10:12 AM, during an interview with RN2 stated we will need to find a better way to deal with open sterile dressings. We train by implementing ongoing training for the nurses. I come occasionally on the weekend to manage a wound vac dressing. We teach the Certified Nursing Assistants (CNA)s on how to position to best help promote wound healing for the residents. During an observation on 05/09/2024 at 11:45 AM, reviewed with RN1 the Medication Cart II revealed: -Two Bottles-Enulose (Lactulose Solution) USP 10g/15ml expired 04/2024 Lot# 17221831, Manufactured Fresenius Kabi AustraGMbH. During an interview with RN1 at 11:46 AM on 05/09/2024, she stated All nurses should check for expired medications. During an observation on 05/09/2024 at 12:45 PM, reviewed with LPN4 the 100 Hall Medication Treatment Cart revealed: -Clobestasol Propionate Topical Solution USP 0.005% Manufacturer Glenmark Pharmaceutical, Lot# 05212310, expired 05/2023. -Tretinoin gel 0.05% Lot#8134394, Manufacturer Oceanside Pharmaceutical, expired 02/2024. -Three tubes of Clotimazole & Betamethasone Dipropionte Cream USP, 1% / 0.05% , Manufacturer Glenmark, Lot# 05211663, expired 08/2023. -Two tubes of Tretinoin Cream USP, 0.05%, Lot# A088800, Manufacturer Taro, expired 01/2023. -Clindamycin Phosphate Topical Lotion, Lot# AC 71471, manufacturer Taro Pharmaceutical, expired 11/2023. -Nystatin Ointment 100,000 units per gram, Lot# A111051, expired 10/2023. -Hypodermic Safety Needle 18G, 1 2/3 expired 04/30/2024. -Mupirocin Ointment USP 2% (no top) Lot # AC699985, Manufacturer Taro, expired 10/2023. -Neosporin, Lot# 0002LZ/2, Manufacturer Johnson & Johnson, expired 11/2023. -Hydrocortisone Ointment 1%, Lot# KY8483, Manufacturer Fougera Pharmaceuticals, SN 10000000127148, expired 01/2024. -Triamcinolone acetonide Cream USP 0.1%, Lot# 1MT0423, Manufacturer [NAME], expired 11/2023. LPN4 confirmed the findings.

Based on the facility policy titled, Utilities Management Program, and instructions/steps for lint removal, observations and interviews, the facility failed to ensure an excessive amount of lint was removed from 3 of 3 clothes dryers and from behind the clothes dryers. The facility further failed to ensure 2 of 2 sinks in the kitchen were working properly. Specifically, the 2 sinks were leaking water into containers placed on the floor below the sinks in 1 of 1 main kitchen. Findings include: Review of the facility policy, Utilities Management Program, Purpose: The maintenance department will design, implement, and maintain the Utilities Management Program. The program will help assure the operational reliability, assess the special risks, and respond to failures of the utility systems that support the resident care environment. Review of the instructions/steps for lint removal, Confirm that the list is removed from the stack and inside the dryer. It is a fire hazard and a code violation if this is not maintained. Inside and Behind Dryer and Drum -Be sure to blow/suck all of the lint away from the burners and motors. -Be sure all vents leading out of the dryer are clean. -Pull the front covers off of the dryers and clean around drums. -Pull the back cover off the dryers and clean entire area. -A shop vac or air compressor works best for this task. Lint Catch/Screens -Lint catchers should be cleaned AFTER EACH LOAD. -Every few months, remove the lint catch and with a bristle brush, wash the screen clean. -A fine layer of lint can from across the screen and the stop the flow of clean air out of the dryer, hampering the speed of drying items. An observation on 05/09/2024 at 08:10 AM revealed 3 of 3 clothes dryers with excessive lint build up on top of the lint baskets, on the wiring and on the 3 upper sides of the clothes dryers above the lint basket. During an interview on 05/09/2024 at 08:30 AM with the Housekeeping Supervisor confirmed the excessive lint in the clothes dryers. She stated that the laundry workers clean the floor of the dryers and the Maintenance Department cleans the lint baskets, the upper 3 sides and the backs of the dryers. No lint removal logs were provided. During an interview on 05/09/2024 at 08:35 AM with the Maintenance Director, he stated that the upper inside of the dryers and behind the dryers are cleaned weekly. This surveyor brought to his attention a red sign with white lettering outside the door that leads to the backs of the clothes dryers. The sign states, Clean the Dryers of Lint Daily. He was not aware of the sign on the door. 50087 Review of the policy titled, Sanitation and Maintenance with a complete revision date of 04/26/23, states: The director of Food and Nutrition Services is responsible for ensuring that the department is maintained according to the standards of sanitation and in compliance with federal, state, and local requirements. During observation on 05/07/24 at 2:02 PM revealed two sinks; one sink with hot water, constantly running and sink 2 had water dripping into a small silver pan on the floor that had black slime floating in the pan. During an interview on 05/09/24 at 2:23 PM, the Maintenance Director stated Usually, I get word of mouth or a work order form that has three copies attached, about the request and who is requesting the work order. We have three nursing stations that has a pouch with the work order forms and I check on them several times per day. I prioritize most important to something that can wait. Right now, I have a back order, which is not a lot. We try to take care of orders as soon as possible. I have a couple of work orders that are no more than a couple days old. With the freezer issue, I'm waiting on the compressor to replace the old one for the walk-in freezer. We have a leaking faucet that probably needs a washer. The Maintenance Director stated he was not aware of the water drainage issue. He took a walk to the kitchen to see the hot water running in the sink. The kitchen worker stated that the sink has been running for two months and the Maintenance Director stated he wasn't aware of it. He also acknowledged the leaking sink with the silver pan with black slime floating in it, on the floor.

Based on the facility policy titled, Therapeutic Activities Program, record reviews and interviews, the facility failed to provide an ongoing resident centered program for Resident (R)37 and R53 designed to meet the resident's interests, hobbies and cultural preferences to promote physical, mental and psychosocial well-being for 2 of 2 residents reviewed for activities. Findings include: Review of the facility policy titled, Therapeutic Activites Program, states: The facility should implement an ongoing resident centered program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and or improving a resident's physical, mental and psychosocial well-being and independence. To create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning). The facility admitted R37 on 09/29/2021 with diagnoses including, but not limited to, sepsis, cerebrovascular accident, major depressive disorder, and a neurogenic bladder. R37 is on contact isolation, is non verbal and is receiving tube feeding continuous. The facility admitted R53 on 04/13/2022 with diagnoses including, but not limited to, repeated falls, fracture of right tibia, dementia, depression and adult failure to thrive. R53 has a Brief Interview for Mental Status (BIMS) of 15 out of 15 on the quarterly Minimum Data Set (MDS) assessment dated [DATE], indicating that she is not cognitively impaired and is able to make her own decisions. R53 is understood and understands verbal content. Review of the medical record for R37 on 05/08/2024 at 12:38 PM revealed a form titled, Record of One-To-One Activities. After requesting 3 months of attendance sheets, the facility provided one sheet dated 03/20/2024 in which R37 was read to from the Bible for 20 minutes. No other documentation could be found to ensure R37 was receiving any type of activities. R37 is bed bound, on contact isolation, and receives a continuous tube feeding. Review of the medical record for R53 on 05/08/2024 at 03:52 PM revealed, no activity attendance sheets for one- to-one activities or any group activities documented for the last 3 months. During an interview on 05/08/2024 at 03:15 PM with Activity Director, she stated, that she has been going into the rooms to speak with the residents, but had not documented any of the time spent with them and had no records to ensure activities were offered to R37 and R53.

Based on review of the facility policy titled, Person Centered Care Planning, record reviews and interviews, the facility failed to ensure Resident (R)53 was afforded the right to participate in the development and implementation of her person-centered comprehensive plan of care for 1 of 1 residents that verbalized they were not included in the care planning process, but would like to be included. Findings include: Review of the facility policy titled, Person Centered Care Planning, Issued 08/16/2022 and Reviewed 08/22/2023 and states the, Person-centered care - means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. Number 4 under procedure states: The facility will include the resident and if applicable resident representative participation in developing the person-centered plan. a. Reflective of residents right to make informed choices regarding treatments and services, b. Reflective of the residents' cultural preferences, values and practices, and c. For those residents with a history of trauma, the care plan will include the interventions for care and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause additional trauma for the resident. Number 7 states, The care plan will be developed and implemented to ensure consistency with implementation across all shifts. The facility admitted R53 on 04/13/2022 with diagnoses including, but not limited to, repeated falls, fracture of right tibia, dementia, depression and adult failure to thrive. R53 has a BIMS (Brief Interview for Mental Status) of 15 out of 15 on the quarterly MDS (minimum data set) assessment dated [DATE], indicating that she is not cognitively impaired and is able to make her own decisions. R53 is understood and understands verbal content. During an interview on 05/07/2024 at 11:02 AM, R53 stated, I have not been invited to a careplan meeting since admission. R53 also stated, I do not know if my plan of care is being followed. Review of the medical record on 05/08/2024 at 2:26 PM revealed a form dated 03/12/2024. The form was notifying the personal representative of R53 of a care plan conference. No documentation could be found in the medical record for R53, electronically or the hard chart to indicate that R53 was invited and included in the care planning process or if a care plan conference had been conducted. During an interview with the Social Services Assistant on 05/08/2024 at 02:30 PM, she stated that the care plan invitation was sent to the personal representative for R53 on 03/12/2024, and that she had not heard back from them. She stated that when the form is mailed to the personal representative, a copy is hand delivered to the resident. She stated she has no documentation to ensure R53 received a copy of the invitation to attend the care plan conference. The Social Services Assistant could not verify a care plan conference was conducted for R53. Review on 05/08/2024 at 03:35 PM of the facility, Admission Packet, Section II: Resident Rights: #14. The resident has the right to be informed of, and participate in, his or her treatment, including the right to be fully informed in a language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition: the right to participate in the development and implementation of his or her person-centered plan of care. #15. The resident has the right to participate in the planning process, including the right to identify individuals or roles to be including in the care planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. #16. The resident has the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. #17. The resident has the right to be informed, in advance, of changes to the plan of care. #18. The resident has the right to receive the services and/or items included in the plan of care. #19. The resident has the right to see the care plan, including the right to sign after significant changes to the plan of care.

Based on interviews, record reviews, and facility policy, the facility failed to report an allegation of abuse to the state agency in the required time frame, for 1 of 3 residents (R)101, reviewed for alleged abuse. Findings Include: Review of the facility policy, Incident and Reportable Event Management, with a revision date of 08/15/23 revealed, Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Review of R101's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia, hemiparesis, asthma, congestive heart failure, muscle weakness, chest pain on breathing, and end stage renal disease. Review of R101's Five - Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/24 revealed R101has a Brief Interview of Mental Status (BIMS) score of 15 of 15, indicating that he is cognitively intact. R101 requires substantial/maximal assistance for toileting, showering, and lower body dressing. Partial/moderate assistance is needed for upper body dressing and putting on and taking off footwear. Review of R101's Care Plan revealed that 04/15/24 a care plan was developed, indicating that R101 is at risk for falls and ADL assistance and therapy services are needed to maintain or attain the highest level of functions. Review of a Concern and Comment Form, dated 05/04/24 at 12:15 PM revealed that the Rehab Director submitted a concern on behalf of R101 that stated that nursing staff from the night was Snatching and pulling on him, when transferring him back in bed using a hoyer lift and nursing staff was rude when speaking to him. This was reported to the Administrator at 12:05 PM. There was no time or date provided for contact with R101. Review of the 2-hour Initial report to the State Agency revealed the incident was reported at 05/07/24, investigation initiated with 5-day to follow. During an interview with R101 on 05/07/24 at 12:45 PM revealed he was attempting to move from his bed and the overbed table got away from him and he fell to the floor. He positioned himself so that he could ring the call bell and receive assistance from the nurse. R101 states there were two nurses that came in and they began laughing at him and asking why he was on the floor. After 15 minutes of back-and-forth conversation about the incident, the nurses used the Hoyer lift to get him back in bed. During the positioning in the Hoyer lift, he states the nurses were talking rudely and were very rough handling him, pushing and shoving him in the sling. The nurse asked if he was alright and if he was hurting and he told them that he had a little pain and he may need to go to the emergency room . The lady nurse told him if he left to go to the hospital that they were going to give his room away and he would no longer have a private room to himself. He included that she went and called 911 and when she returned, he told her he didn't want to leave because he did not want to lose his room. The nurse stated they were coming anyway, from that point he began to cry and asked her to cancel the call for 911. When the Emergency Medical Service (EMS) arrived, R101, told them what was going on and stated they were aware of the conversation about him losing his room if he left with them. R101 refused to go with EMS and told the nurse he would go to dialysis instead so he would not lose his room. He stated that he reported this to the day shift nurse on Saturday morning when he returned from dialysis, but no one has come in and inquired about the situation since then. During an interview with the Social Services Director (SSD) on 05/08/24 at 3:29 PM revealed that she has been educated on the abuse procedures and she would immediately review the definition of abuse, make sure resident is in safe environment, if physical harm has taken place, then the proper protocol for vitals and such would occur if she was presented with an abuse situation. She includes on Monday, 05/06/24, R101 reported to another staff that the nurse had done him wrong. This information was provided on a blue card and presented in the departmental meeting, which are held every morning. The blue card is completed by whomever is provided the information that there is a concern. Monday morning discussion did not define any form of abuse, it was more of Were there any concerns that she [Administrator] was not aware of? During an interview with the Executive Directive (ED) on 05/08/24 at 3:42 PM revealed she was included in abuse training within the last six months and multiple times since she has been employed here. The ED stated her expectations of her staff in regard to abuse is reporting immediately. The ED is the coordinator, and staff should know they have to protect residents and all aspects of policy, investigation, and timelines. The ED includes that a blue card was presented concerning a night shift nurse relating to poor customer service for R101. R101 stated the nurse was jerking, pulling, and threatening him about him losing his room. The ED stated she thought this was reported to her yesterday by a male surveyor, and this was when she learned of this situation. The Monday meeting did not include any information about any residents being verbally abused and she did not speak with R101. During an interview with the Director of Nursing (DON) on 05/08/24 at 3:59 PM revealed that all staff are in-serviced on hire, annually, and as needed for abuse. If any form of abuse is detected, they should notify the DON or ED, whether it is verbal, physical or injury of unknown origin. She states her expectation is for staff to be educated enough to identify signs of abuse and report it immediately. The DON included she interviewed R101 yesterday, and that is when she learned of the situation, that was initially reported to the surveyor. She received a call on Saturday morning, 05/04/24, from the nurse on duty and stated that R101 had a disagreement with her, he had a fall and wanted to go to the hospital, when the Emergency Medical Services (EMS) arrived, he refused to go. The DON states she did not follow up with the resident to determine why he refused to go to the hospital, as other residents refuse all the time. During an interview with Licensed Practical Nurse (LPN)2 on 05/09/24 at 8:47 AM, revealed that he was made aware of the alleged abuse incident from R101 on Saturday morning, 05/04/24. LPN2 proceeded to get the manager on duty, Director of Rehab, and she went to the resident's room and took a statement from him. He includes that he has attended approximately 10-15 in-services about abuse within the last six months. He is required to report abuse to the abuse coordinator, which is the ED and then complete a report/statement and from there an investigation would pursue. During an interview with the Director of Rehab (DOR) on 05/09/24 at 9:48AM revealed she was the manager on duty and R101 had dialysis and had fallen, she asked him about the fall, and he went through the story. R101 stated when the nurse picked him up off the floor she was pulling and snatching on him, and he felt like he was abused. She informed R101 that was a strong word to use, so she called the ED and wrote the information on a blue card and slid the card under the SSD's door, Saturday around 12:40 PM, and she realized that they wouldn't get this until Monday, 05/06/24. She contacted the abuse coordinator, ED, and the ED thanked her and told her she would follow up on this incident. The DOR went back to speak with R101 to ensure he was comfortable and safe, and he stated that he was. DOR explained that a blue card is completed any time a resident has any problems or concerns. If someone reports abuse, they document it on a blue card, give to social services and then an investigation is started. She makes sure the resident is safe and then reaches out to the abuse coordinator, which is the ED. During an interview with the ED on 5/09/24 at 11:07 AM, revealed that she wanted to clarify that she was aware of the alleged abuse concern on Saturday. She had also received a previous concern earlier that week with the same nurse and resident, in reference to poor customer service. Based on that concern the DON should have had a consult with the nurse. The ED included she counseled the DON for not counseling the nurse prior to her returning to duty with the same resident. She explains that she started an investigation immediately after the DOR called her on Saturday and she had the nurse leave a statement with the DON. The accused nurse was suspended due to the nature of the concern on Saturday via telephone. The ED also includes that concerns don't have to be reported as abuse and that was viewed as a concern and that is why it was not reported to the State Agency.

Based on the facility policy titled, Notice of Transfers and Discharges, interviews and record reviews, the facility failed to ensure Resident (R)37 personal representative received notice of discharge to the hospital in writing and in a language they could understand of the reason for discharge to the hospital for 1 of 2 residents reviewed for hospitalization . Findings include: Review on 05/08/2024 at 12:38 PM of the facility policy titled, Notice of Transfers and Discharges, states as the policy: The facility will provide notice to the resident and/or representative in situations where the facility initiates a transfer or discharge, including discharges that occur while the resident remains in the hospital after emergency transfer. Before a facility transfers or discharges a resident, the facility must: 1) Notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. 2) Record the reasons for the transfer or discharge in the resident's medical record. Timing of Notice. 2) Notice must be made as soon as practicable before transfer or discharge. Contents of Notice. The written notice must include: 1) The reason for transfer or discharge. 2) The effective date of transfer or discharge. 3) The location to which the resident is transferred or discharged . The Procedure: 1) The facility ensures that systems are implemented to provide written notification to the resident and representatives prior to transfer. This written notification is provided on the,Notice of Resident or Transfer Form. The facility admitted R37 on 09/29/2021 with diagnoses including, but not limited to, sepsis, cerebrovascular accident, major depressive disorder, and a neurogenic bladder. Review of the medical record for R37 revealed a hospital stay starting 03/08/2024 and returning on 03/28/2024. A second hospital stay starting on 04/03/2024 and returning on 04/09/2024. No documentation in the electronic medical record or the hard chart to ensure the notice of transfer was completed and provided for R37 and her personal representative. During an interview on 05/08/2024 at 02:20 PM with the Social Services Assistant (SSA), confirmed that a Notice of Discharge or Transfer, was not completed and provided to the resident and the responsible party in a timely manner. The SSA stated, that when a resident is sent out to the hospital the facility will call the personal representative, but nothing is mailed out.

Based on the facility policy titled, Bed-Hold Policy, record reviews and interviews, the facility failed to ensure Resident (R)37 or her personal representative received written information on the duration of the bed hold, and the reserve bed payment in a timely manner for 1 of 2 residents reviewed for hospitalization . Findings include: Review of the facility policy titled, Bed-Hold Policy, states: The Bed-hold policy should be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident goes on therapeutic leave of absence. The facility will provide written information to the resident or resident representative the nursing facility policy on bed-hold periods and the residents return to the facility to ensure that residents are made aware of the facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking therapeutic leave of absence from the facility. The procedure states: 1) The facility is obligated to provide two notices related to bed-holds. a. The first notice is given on admission well in advance of any transfer. b. The second notice must be provided to the resident and if applicable the resident's representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility admitted R37 on 09/29/2021 with diagnoses including, but not limited to, sepsis, cerebrovascular accident, major depressive disorder, and a neurogenic bladder. Review of the medical record for R37 revealed a hospital stay starting 03/08/2024 and returning on 03/28/2024. A second hospital stay starting on 04/03/2024 and returning on 04/09/2024. No documentation in the electronic medical record or the hard chart to ensure the bed-hold notice was provided for R37 and/or her personal representative. During an interview on 05/08/2024 at 02:20 PM with the Social Services Assistant she stated, that there is no documentation in the medical record that the bed-hold policy was provided to R37, nor her personal representative. The Social Services Assistant states, the the personal representative is called the next day with the bed-hold payment amount, should the resident exhaust the 10 days. She also confirmed that there was no documentation for the phone call. During an interview on 05/08/2024 at 02:35 PM with the Admissions Coordinator (AC), she stated that the personal representative signed the bed-hold on admission and then when the resident goes to the hospital, we call the personal representative with the number of days the bed will be held and the amount for each day after the 10 days. The AC also stated that no documents were mailed out.

Based on interviews, record reviews, and facility policy, the facility failed to provide Activities of Daily Living (ADL) Care, specifically showers, for 1 of 1 resident (R) 104, reviewed for ADL care. Findings Include: Review of the facility policy, Activities of Daily Living, with a revision date of 02/12/24 revealed, The resident will receive assistance as needed to complete activities of daily living (ADLs). A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of R104's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, acute respiratory failure with hypoxia, hypertension, muscle weakness, need for assistance with personal care, and other lack of coordination. Review of R104's five-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/24 revealed R104 has a Brief Interview of Mental Status (BIMS) score of 15 of 15, indicating that he is cognitively intact. R104 is dependent for toileting, showering, upper body dressing, lower body dressing, and putting on and taking off footwear. Review of R104's Care Plan, with a revision date of 03/12/24, revealed that R104 is dependent on staff for meeting emotional, intellectual, physical, and social needs due to immobility, physical limitations. The Care Plan also states that R104 needs assistance with activities of daily living as required during the activity. Review of the Follow Up Question Report dated 05/09/24 revealed within a 30-day time frame from 04/09/24- 05/09/24, that R104 received a bed bath on two days, 04/18/24 and 04/24/24. Review of Shower Sheets dated 04/27/24, and 05/02/24 revealed that resident received a shower on those respective dates. There were not any other shower sheets that could be provided for R104. A review of a Witness Interview/Statement Form dated 05/09/24 revealed that Certified Nursing Assistant (CNA)2, verbally stated that he gives R104 showers on Tuesdays, Wednesdays, and Thursdays. During an interview with R104's family member on 05/07/24 at 11:21 AM revealed that R104 did not receive showers on the weekends, and it was hard to get staff to comply with that request. During an interview with Licensed Practical Nurse (LPN)2 on 05/09/24 at 8:58 AM, revealed that R104's family is very involved in his care. LPN2 stated showers are provided by room number. If a resident requests a shower, a shower is given. R104 gets majority of bed baths because transfers increase his pain level, and his pain is so bad. His shower days are Tuesdays, Thursdays and Saturdays from 7AM - 3PM. R104 doesn't want to be transferred in the Hoyer lift. LPN2 includes that the resident and representatives are aware of the schedules. An interview with CNA1 on 05/09/24 at 11:24 AM revealed based on the documentation for ADL tasks, if the not applicable column is checked, that indicates that a bath or shower was not provided, and the tasks on the electronic health record (EHR) indicate he was only bathed one day. CNA1 stated residents should receive bed baths every day, even if that is not their shower day.

Based on observation, interview, and record review, the facility failed to manage the resident's pain during a pressure ulcer treatment to support the highest practicable level of physical and mental well-being for one of six sampled residents (Resident (R)1) reviewed for pressure ulcers. This failure caused the resident to experience severe pain during a pressure ulcer treatment. Findings include: Review of R1's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/04/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated the resident had moderate cognitive impairment, required extensive assistance of two for bed mobility, and had a stage four pressure ulcer (The most severe category of pressure ulcers. It may involve muscles and ligaments. Generally large and deep, often exposing muscle and bone. Other common symptoms of a stage four pressure ulcer include extreme pain). Review of the Care Plan located in the EMR under the Care Plan tab revealed the resident had a pressure ulcer to the coccyx and buttock with potential for additional pressure ulcer development related to decreased mobility, weakness, incontinence, refusal to reposition frequently, and disease process. Further review of the care plan revealed the resident expressed pain/discomfort due to migraines and [CONDITION(S)]. Interventions included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain, observe for probable cause of each pain episode and remove/limit causes where possible, and give pain meds as ordered. Review of R1's Physician Orders located in the EMR under the Orders tab revealed an order dated 5/21/21 for [MEDICATION(S)] 50 milligram (mg) tablet give 1 tablet by mouth every 6 hours as needed for right shoulder pain. The Physician Orders dated 3/18/22 indicated to irrigate the wound on the coccyx with normal saline, apply gauze moistened with full strength Dakin's solution (a solution that fights bacteria and is used to treat or prevent infections caused by pressure ulcers), cover with gauze, ABD (abdominal dressing) pad, secure with tape two times a day. Continued review of R1's orders revealed no orders for pain assessment in conjunction with wound treatment, or the availability of as needed pain medications aside from the [MEDICATION(S)] ordered for shoulder pain. Review of R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Wound Consultant Evaluation dated 03/22/22 and provided by the Director of Nursing (DON), documented R1's coccyx pressure ulcer was a stage four wound with length of 7.5 centimeters (cm), width of 6.5 cm, and depth of 3.9 cm. Total undermining length was 105 cm and total undermining width was 135 cm. The wound bed had excessive necrotic (dead) and yellow tissue. Further review of the Wound Consultant Evaluation revealed no assessment of the R1's pain levels during wound care. An observation was conducted on 03/29/22 at 9:50 AM of R1's wound treatment with the Consultant wound Nurse Practitioner (NP) and the facility wound treatment Registered Nurse (RN)2. After RN2 set up the wound care supplies, the NP removed the old dressing, and the wound was exposed. The area had slough (necrotic tissue) in the wound bed and bone was visible. The NP confirmed the bone was exposed and stated that the resident had [CONDITION(S)] (an infection of the bone, with common symptoms of swelling or inflammation of the bone and pain). NP opened a package that contained a [MEDICATION(S)] tool and said she was going to debride the wound (a process to remove necrotic material from a wound that is not healing well on its own). NP told the resident she was going to spray a medicine to numb the area ([MEDICATION(S)] spray). Immediately after spraying the [MEDICATION(S)] to the wound, NP held the [MEDICATION(S)] tool (a sharp blade used to perform an invasive procedure to remove the necrotic tissue, known to cause severe pain) to the wound bed and exposed bone. Neither the NP nor RN2 assessed R1 for pain prior to placing the debridement tool to the wound bed. The surveyor stopped the NP and asked what the resident's pain level was, which prompted the NP to ask R1 if she was in pain, and R1 responded, yes. NP asked R1 the level of pain using the pain scale of one to ten, with ten being the most severe. R1 stated her pain was nine out of ten. RN2 rang R1's call bell and asked for the nurse to bring in pain medication for R1. NP told R1 she would wait until the next visit to debride the wound. RN2 continued the remainder of the wound treatment, which included cleaning the wound bed and tunneled areas normal saline. During the treatment, Licensed Practical Nurse (LPN)1 entered the room at 10:25 AM (35 minutes after the treatment began) and administered 50 mg of as needed [MEDICATION(S)] using the order for shoulder pain. Immediately after the pain medication was administered, RN2 packed the wound with Dakin's solution-soaked gauze, applied two ABD pads, and taped the pads in place. When RN2 finished the treatment, R1 was asked if she was in pain. R1 stated, yes. R1 stated her pain level was nine out of ten. The resident stated, I hurt. When asked where she hurt, the resident stated, my butt (buttocks). RN2, in an interview on 03/29/22 at 10:15 AM, stated that she did not obtain a pain assessment prior to conducting R1's pressure ulcer treatment. RN2 stated that she did not ask the charge nurse if R1 was pre-medicated with pain medication before going in to provide the pressure ulcer treatment. RN2 was unable to explain why, when she knew R1 was in severe pain, she did not wait for the administered pain medication to take effect before completing the pressure ulcer treatment. LPN1, in an interview on 3/29/22 at 10:25 AM, stated that she was not asked by NP or RN2 to administer the as needed pain medication to R1 prior to the pressure ulcer treatment. LPN1 stated RN2 asked her to bring in pain medication because R1 stated she was in pain because of the pressure ulcer treatment. The NP, in an interview on 3/29/22 at 10:30 AM, stated that with the type of pressure ulcer R1 has, pain medication should be administered 30 minutes prior to the treatment. NP could not explain why R1 did not have an order to administer pain medication prior to conducting the pressure ulcer treatment. Review of the Wound Observation Tool dated 03/29/22 located in the EMR under the Assessment tab documented a stage four pressure ulcer on the coccyx with length of 7.5 cm, width of 9.0 cm, and depth of 2.5 cm. Total undermining length of 101 cm and total undermining width of 130 cm. R1 voiced pain during the treatment. The resident was seen by the medical nurse practitioner for pain management and pain medication order was changed. Review of the facility policy titled, Pain Assessment and Management reviewed 05/05/20 and revised 07/17/21 documented, .Pain Management. The facility must ensure that pain management is provided to residents who require such services; consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences . Review of the facility policy titled, Documentation and Assessment of Wounds reviewed on 10/03/19 and revised on 08/23/21 documented, .Premedicate the resident for pain 30 minutes to 1 hour before the procedure, as needed and prescribed, to promote comfort during the procedure. Coordinate with the medication nurse, if needed.

Based on observation, interview, record review, and review of facility policy, the facility failed to develop a person-centered baseline care plan within 48 hours of admission to ensure the resident's care needs would be met. This had the potential to affect one Resident (R) 230 of eighteen sampled residents. Findings include: Review of the facility's policy titled Baseline Car Plan revised 05/19/21 revealed that the purpose of the policy was, To develop a baseline care plan within 48 hours of admission to direct the care team while a comprehensive care plan is developed that incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being. The policy further provided that, A baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care of the resident that meet professional standards of care. Review of R230's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R230 was admitted to the facility on [DATE] under hospice care with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R230's orders located under the Orders tab in the EMR revealed medical doctor (MD) order dated 03/11/22 (admitted ) for, Catheter care every shift - Keep catheter bag placed below the level of the bladder. Review of nursing progress notes dated 03/12/22 at 6:55 AM, located in R230's EMR under the Progress Notes tab, revealed R230 was alert with some confusion and had pulled out her indwelling urinary catheter. Review of nursing progress note dated 03/22/22 revealed that R230's catheter had been replaced the previous day and had once again been pulled out by resident. Review of R128's initial baseline Care Plan, located on the Care Plan tab of the EMR initiated on 03/14/22, failed to reveal a focus area or intervention for R230's need for an indwelling urinary catheter, nor did the care plan address R230's confusion and removal of indwelling catheter. During an interview on 03/28/22 at 2:07 PM LPN3 stated that R230 was admitted with an indwelling urinary catheter but that she kept pulling it out. During an interview with the MDS coordinator (MDSC) on 03/30/22 at 10:48 AM, she confirmed R230 was admitted with a catheter and that nursing staff were responsible for developing the initial baseline care plan. MDSC further stated that nursing staff should be updating the resident's care plan with anything going on acutely on the nursing floor with the resident.

Based on interview and record review the facility failed to ensure that one resident of six Resident (R) R230) reviewed for unnecessary medications was free from as needed (PRN) [CONDITION(S)] medication. Specifically, R230 had an order for a PRN anxiolytic medication without a stop date. Findings include: Review of the facility's policy # 3.8 entitled [CONDITION(S)] Medication Use effective date 12/1/07, last review date 1/1/22 revealed, . A [CONDITION(S)] drug is any medication that affects brain activities associated with mental processes and behavior . PRN [CONDITION(S)] medications should be ordered for no more than 14 days. Each resident who is taking a PRN [CONDITION(S)] drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days and also by a pharmacist every month . For [CONDITION(S)] medications, excluding antipsychotics, that the attending physician believes a PRN order for longer than 14 days is appropriate, the attending physician can extend the prescription beyond 14 days for the resident by documenting their rationale in the resident's medical record . The facility should not extend PRN antipsychotic orders beyond 14 days . Facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacologic medications including gradual dose reductions . Review of the physician order dated 03/11/22 located on the Orders tab in the Electronic Medical Record (EMR) revealed an order for [MEDICATION(S)] Tablet (anxiolytic medication) one milligram (mg) tablet by mouth every 4 hours as needed for restlessness and agitation. Review of R230's Medication Administration Record (MAR) accessed through the EMR revealed R230 received [MEDICATION(S)] Tablet 1 MG on 3/11/22, 3/12/22, 3/13/22, 3/14/22, 3/15/22, 3/16/22, 3/17/22, 3/18/22, 3/19/22, 3/20/22, and two doses on 3/27/22. In an interview with the Regional Director of Clinical Services (RN3) on 03/30/22 at 11:04 AM, she stated the expectation is that nursing would review the resident's orders to determine if there are as needed psychotropics and notify the physician to clarify the order. She also stated the after 14 days the physician should reassess the resident for continued need for the as needed medication. RN3 stated that the as needed medication should not have gone beyond 14 days before being reviewed. RN3 further stated that as needed psychotropics and anxiolytics fall under the same rule.

Based on record review and staff interview, the facility failed to ensure the staff provided transfer care consistent with the resident's care plan. Resident #1 requires extensive assistance, with the use of a Hoyer-lift, and two staff to physically assist with the transfer. On March 6, 2021, Certified Nursing Assistant (CNA) #1 attempted to transfer Resident #1 by [his/her] self which resulted in a fall with fracture for one of one sampled residents reviewed for accidents. Findings Include: The facility admitted Resident #1 on 06/12/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum data set (MDS), quarterly assessment, dated 12/19/20 reviewed on 4/26/2021 at 9:30 AM revealed that Resident #1 scored a 15 during the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. For functional status with bed mobility, transfer, dressing, and toilet use, [s/he] requires extensive assistance with two+ persons' physical assist. The care plan reviewed on 4/26/2021 at 10:05 AM indicated that Resident #1 has a performance deficit and requires assistance for the completion for the activities of daily living (ADL) due to decreased mobility, weakness, and disease process. Resident #1 requires assistance by two (2) staff to move between surfaces. Progress notes reviewed on 4/26/2021 at 10:45 AM noted that Resident #1 suffered a fall on 3/6/21. S/he complained of knee pain. The Results of the X-ray indicated a fracture of the right leg. In an interview with CNA #1, via phone, on 4/26/21 at 11:16 AM [s/he] stated that [s/he] and CNA #2 transferred resident #1 from the bed into the shower chair. Resident #1 requested a shower that day. CNA #1 went on to care for other residents and CNA #1 proceeded to shower Resident #1. During the shower, Resident #1 started complaining about the chair. CNA #1 raised the resident's legs up, finished the shower, dried [him/her] off and put on a gown, and pushed the resident in the shower chair to [his/her] room. In the room, Resident #1 was still saying [s/he] was sliding out of the shower chair. CNA #1 stated [s/he] went outside the room to look for help but did not see anyone so [s/he] proceeded to transfer the resident from the shower chair to the bed. S/he said that [s/he] connected all the parts of the sling to the Hoyer lift and pushed the button. CNA #1 said that when Resident #1 was in the air, the Hoyer lift tilted and the resident went up flying in the air and back down to the shower chair. Once Resident #1 hit the shower chair, the shower chair broke, and Resident #1 hit the floor. Resident #1 complained of pain. CNA #1 then went outside and yelled for help. CNA #1 acknowledged [s/he] did not follow Resident #1's care plan related to transferring. In an interview with the Director of Nursing on 4/26/2021 at 11:20 AM [s/he] confirmed the above findings.

Based on observation, record review, and staff interview, the facility failed to ensure each resident receives adequate supervision to prevent accidents. Resident #1 requires extensive assistance, with the use of a Hoyer-lift, and two staff to physically assist with the transfer. On March 6, 2021, Certified Nursing Assistant (CNA) #1 attempted to transfer Resident #1 by [his/her] self which resulted in a fall with a fracture for one of one sampled residents reviewed for accidents. Findings: The facility admitted Resident #1 on 06/12/2019 with diagnoses including but not limited to [CONDITION(S)], [CONDITION(S)], dementia, anxiety, and depression, chronic obstructive pulmonary disease, type 2 diabetes, and [CONDITION(S)]. Minimum data set (MDS), quarterly assessment, dated 12/19/20 reviewed on 4/26/2021 at 9:30 AM revealed that Resident #1 scored a 15 during the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. For functional status with bed mobility, transfer, dressing, and toilet use, [s/he] requires extensive assistance with two+ persons' physical assist. The care plan reviewed on 4/26/2021 at 10:05 AM indicated that Resident #1 has a performance deficit and requires assistance for the completion for the activities of daily living (ADL) due to decreased mobility, weakness, and disease process. Resident #1 requires assistance by two (2) staff to move between surfaces. Progress notes reviewed on 4/26/2021 at 10:45 AM noted that Resident #1 suffered a fall on 3/6/21. S/he complained of knee pain. The Results of the X-ray indicated a fracture of the right leg. On 4/26/2021 at approximately 11:15 AM Resident #1 was observed lying in [his/her] bed watching television. S/he appears alert and oriented to person and place. The room appears clean and uncluttered. The resident well-groomed and the call light is within reach. In an interview with Resident #1 on 4/26/2021 at 11:16 AM [s/he] stated that during the shower [s/he] was sliding out of the shower chair. CNA #1 finished the shower, covered [hin/her] with a nightgown, and took [him/her] to the room. Once in the room, CNA #1 connected the Hoyer-lift sling and proceeded to transfer [him/her] to the bed. Resident #1 said, Something happened [s/he] wasn 't sure what, but [s/he] fell back down onto the shower chair and to the floor with excruciating pain. S/he stated that [s/he] was wet at the time [s/he] hit the floor. Resident #1 also said that since that fall [s/he] has only got out of bed twice and they must give [him/her] something to calm his/her nerves and that every time [s/he] thinks about it [s/he] gets nauseated and their stomach hurt. In an interview with CNA #1, via phone, on 4/26/21 at 11:16 AM [s/he] stated that [s/he] and CNA #2 transferred resident #1 from the bed into the shower chair. Resident #1 requested a shower that day. CNA #1 went on to care for other residents and CNA #1 proceeded to shower Resident #1. During the shower, Resident #1 started complaining about the chair. CNA #1 raised the resident's legs up, finished the shower, dried [him/her] off and put on a gown, and pushed the resident in the shower chair to [his/her] room. In the room, Resident #1 was still saying [s/he] was sliding out of the shower chair. CNA #1 stated [s/he] went outside the room to look for help but did not see anyone so [s/he] proceeded to transfer the resident from the shower chair to the bed. S/he said that [s/he] connected all the parts of the sling to the Hoyer lift and pushed the button. CNA #1 said that when Resident #1 was in the air, the Hoyer lift tilted and the resident went up flying in the air and back down to the shower chair. Once Resident #1 hit the shower chair, the shower chair broke, and Resident #1 hit the floor. Resident #1 complained of pain. CNA #1 then went outside and yelled for help. CNA #1 acknowledged [s/he] did not follow Resident #1's care plan related to transferring. In an interview with CNA #2 [s/he] stated that [s/he/] helped CNA #1 to transfer Resident #1 from the bed to the shower chair. S/he, then, went on to care for [his/her] assigned residents. In an interview with the Director of Nursing on 4/26/2021 at 11:20 AM [s/he] confirmed the above findings.

Based on record review and interview, the facility failed to ensure that a resident who wanted the pneumococcal vaccine was provided with the vaccine for 1 of 5 sampled residents reviewed. Resident #4 had a signed consent form for the Pneumococcal Vaccine, dated 10/07/20 in the medical record, and had no documentation that the pneumococcal vaccine was given. The findings included: The facility admitted Resident #4 on 5/08/18 with [DIAGNOSES REDACTED]. During an interview on 3/03/21 at approximately 1:59 PM with the Director of Nursing (DON), a list of five (5) residents were provided to the DON, and a request for written consent/education, as well as written documentation of which pneumococcal vaccine was provided for each resident. An interview on 3/03/21 at approximately 2:32 PM with the DON confirmed Resident #4 did sign a consent to get the pneumococcal vaccine on 10/07/20. The DON then stated, he/she could not locate documentation that the resident had the pneumococcal vaccine. An interview on 3/03/21 at approximately 2:45 PM with the DON revealed, Resident #4 had another consent form dated 11/17/21, and stated the resident got his/her pneumococcal vaccine in the hospital in November 2020. When asked if the facility requested copies of the medical record from the hospital back in November to ensure the resident got the pneumococcal vaccine; the DON stated no. Resident #4 was noted to be over age 65 and there was no documentation to indicate when the resident received his/her first pneumococcal vaccine of PCV13 or when the PPSV23 would be required.

This requirement was not met as evidenced by: Based on record review and interviews the facility failed to supervise Resident #297 whom was left in the bathroom, unsupervised, and had a fall with injury for one of 4 residents reviewed for accident. Findings include: Resident #297 was admitted to the facility 4/17/2019 with [DIAGNOSES REDACTED]. BIMS score of 9. Complaint SC 786 filed by family member and Complaint SC 507 filed by the family stated Resident 297 fell [DATE] while in the bathroom and fractured his/her left hip. The MDS was reviewed for Cognitive patterns, Mood, Behavior, Functional Status, Swallowing and Nutrition, Skin Assessment, Medications and Care areas and confirmed Resident #297 is confined to a wheelchair. The MDS 5/12/2020 (quarterly), stated Resident #297 required extensive assistance with mobility and was total dependence for toileting. Review of Fall Management policy confirmed residents will have a care plan developed for all residents assessed to be at risk of falls. The Fall risk evaluations dated 4/17/2020 (Quarterly) and 5/21/2020 (post event) confirmed the resident required assistance with elimination and was confined to wheelchair. The Clinical care plan dated 5/11/2020 stated toileting and transferring required assistance by one staff member. A review of the nursing/progress notes 9/21/2020 at 10:15 AM for the day of the incident, 5/21/2020, revealed conflicting information of the fall. CNA #7, (who has moved out of state, no contact information available), reported originally at 13:04 PM to RN #2 that Resident #297 transferred self to toilet, missed the toilet and fell to the floor. The nursing note documented at 13:34 PM stated CNA #7 took the resident to the bathroom, placed him/her on the toilet, gave privacy with door opened, instructed resident to use the call bell when finished. Then CNA #7 heard a loud noise and found the resident lying on the bathroom floor with his/her undergarments pulled up and yelling out loudly in pain. The nursing note at 14:05 by RN #2 stated the family had been contacted regarding the fall. The family member was confused about Resident #297's ability to ambulate and transfer him/herself. The family member was informed Resident #297's condition had improved. There was no incident report available for Resident #297, the Administrator states s/he is unable to find one but will continue looking through the files. No PT notes available and no notes from medical staff available, requested information from Administrator and Clinical Care Coordinator. The review of [MEDICATION NAME] Health Baptist Hospital discharge summary revealed Resident #297 sustained a left femoral neck fracture from a fall at the facility requiring surgical intervention. Review of Event Management System Policy 9/22/2020 at 3:30 PM revealed in part, under the heading, At the Time of Event .The licensed nurse will document an event note, update the care plan and provide any resident teaching as indicated. The licensed nurse will initiate the incident report in the electronic system and assign an event type and risk level. Also revealed under the heading, Notification and Reporting of an Event .Federal requirements mandate the facilities immediately report injuries of unknown source to officials in accordance with state law including state survey and certification agencies. Fall policy stated Avoidable Accident means the facility failed to .Implement interventions including adequate supervision . After multiple requests, the documentation not provided by the facility throughout the investigation (dates 9/21/2020 - 9/23/2020) included Physical Therapy notes, Medical staff notes, 24 hour and 5-day incident reports, facility investigation, written witness statements, and contact information for CNA #7. An Interview on 9/21/2020 at 10: 00 AM with the Administrator s/he stated s/he would search for the 24 hour and 5-day incident report and the facility investigation related to the resident fall. During an interview on 9/22/2020 at 4:00 PM with RN #2 s/he stated s/he was in charge on 5/21/2020 and remembered CNA #7 reported s/he was assisting the Resident #297 to the bathroom, decided s/he needed more help to transfer resident to bathroom, left resident at bathroom doorway and before s/he came back with the help, the resident was heard crying out in pain and found on the floor of the bathroom. (Unable to find statement in progress notes, requested RN #2 to provide a written statement of above. Also requested notes from Medical staff which were not located in paper chart or in electronic medical record.) Spoke to the Administrator (Regional Vice President), on 9/23/2020 at 8:30 AM and requested a copy of the 24 hour and 5 day Incident reports and facility Investigation into Resident #297's fall on 5/21/2020 and s/he stated s/he was unable to find any incident or investigation reports and the staff were working on creating one. We have to pull the information from the chart because we do not have anything. During an interview on 09/23/20 between 08:53 - 09:25 AM, with CNA #1, #2 and #3 it was requested to discuss facility protocol for assisting resident in a wheelchair, requiring extensive assistance, to the bathroom. All three CNA's stated the protocol is to assist the resident to the bathroom, help them onto the toilet, give them some privacy but not leave them alone. Once finished, assist the resident back to the wheelchair. They stated at no time are they to leave the resident alone. Also discussed the facility protocol when finding a resident who had an unwitnessed fall. All three stated the protocol is to provide first aid/assistance to the resident, notify nursing and assist nursing as needed. Once the resident is stable, all staff write a witness statement and the staff member who found the resident would be responsible for initiating the report. Interview on 09/23/20 at 9:30 AM with RN #2 to review protocol for falls. S/he stated all falls are reported immediately, to the DON, by phone if after hours. The nurse assigned to the resident writes the incident report and witness statements are obtained from all members of the staff on the wing. The Administrator is responsible for writing the Incident reports and conducting the investigation. S/he confirmed if a incident report was not completed or an investigation was not begun, then policy was not followed. S/he also confirmed residents who require assistance with toileting are not to be left alone. Multiple attempts to reach family for information or discussion of incident during survey were unsuccessful.

Multiple concerns in the kitchen FACILITY Kitchen 09/20/20 11:45 AM obs of no open date on pasta labella honey nut cherrios no sealed not dated not sealed rice crispy treats frosted flakes and cornflakes and raisin bran, ripple block and Barrell chips not dated interview with vera wilson, cook, [AGE] years, open date on outside of food item, should wrap with plastic, left overs last for 3 days per policy, everyone's resp to clean, vera's resp refrig, wakin frig 40 degrees obs of 9/12 soup tomato on shelf, freezer carrots and squash not dated freezer obser of refrigerator 2 [MEDICAL TREATMENT] snacks with no date in refrigerator no thermometer 09/20/20 12:16 PM sandwich grape juice teddy grahams oatmeal pie peanut butter and crackers 09/20/20 12:16 PM obs scoop in ice machine 09/20/20 12:22 PM quart sanitizer logged 300 on 9/20/2020 for dinner no 300 0n test strip supervisor antwinette martin, supervisor, 6 years, no cdm at this time, rd robbie dietitian oversees 09/20/20 12:27 PM roast 140, carrots 160, baked pot 140, pureed meat 160, mashed pot pureed 160, ground meat 140, broccoli 115, purred broccoli 145, yams 150, chicken 09/20/20 12:35 PM obs of salad bowls not inverted on 2nd tray on cart 09/20/20 12:37 PM obs of 5 inch serving plates 38 stacked on not inverted 09/20/20 12:39 PM obs of cook not wearing gloves touched ready to eat food 2 fruit cocktails and put on tray then did not wash hands, touching plates with bare hands 09/20/20 12:42 PM chicken temp 100 took off tray 09/20/20 12:59 PM int with ant revealed cook should wear gloves while she is plating food on the tray line 09/20/20 01:00 PM obs of cook not wearing hairnet angela bingo part time [AGE] years, came in front to be screened and got off track trained and have enough supplies. works every weekend and 2 to 3 days during week. did not remove gloves and wash hands after applying hair net. 09/20/20 12:49 PM mixed fruit not covered when put on trays 09/20/20 12:50 PM chicken 149 using digital thermometer 144 using 09/20/20 01:11 PM fruit cocktail did not have covering on tray shelves 09/20/20 02:36 PM obs of 3 4 inches pans with water and food on steel rack 09/21/20 11:28 AM interivew with robbie brady, dietician, 4 years, oversee operations and clinical documentation food brought in by visitors, bring it in for that day, place in nourishment rooms, discard after 4 hours, policy is to wear hair nets at all times, started inservice yesterday, monthly RD audit, have not found that they were not wearing hair nets. hairnets at both entries, food service director is responsible for ensuring they wear the hairnets. CDM resigned last monday. 3 CDMs in the past year. here part time 3 days a week. it depends on the need of the building covering 30 hours a week here which if full time. cooks dont have to wear gloves, they wash their hands prior to serving the food as long as the they do not touch the utensils where the food or mouth is placed per the safe food handling policy. when the package is opened should place an opened date on it then seal with plastic wrap or place in zip lock bag per policy per policy. don't want leftovers cool them down then stored in the frig and used in 72 hours per policy. ice scoop should be placed in holster after shift run it through the dish machine important for infection control hand touches the ice scoop then touches the ice. expect them to complete the concentration log one shift at a time, could have gotten a day a head. normal ppm is 200-400 per policy. that is wetnesting bacteria growth should have let the pans dry before storing them per policy. they need to stored to air dry before storing it's a challenge to store items because of space. use solipower xl wash 160 or above rinse 180 cycle. prepared evening prior to the date send to the unit or nurse will come pick it up and provide it to the resident for [MEDICAL TREATMENT]. should write date on it with a marker. don't have a policy specific to [MEDICAL TREATMENT] bag. guidance is that you date it so you know when prepared and can discard them using the leftover policy. food complaints doing temp how long does it take to get to the resident. diagram of the building. test trays and rely on resident council. any food related concerns with resident council. new admissions and annuals assessment which includes hieght, weight, kcal needs, weight loss, wounds. in the event that food complaints are made, if they can make it or have it will provide it. they are menu cycle, don't have a stable CDM to resolve all of the dietary issues. staff trained to look at food prior to serving and not serve burnt food. CDM will spot check food before it goes out to residents but this role is vacant at this time. no set temperature for food served to residents once on floor, must be palatable and the right temperature to their tasting. adm is the supervisor of the CDM, rd monthly presented to the ADM and CDM, admin respon for followup to ensure cdm performing job. he is involved in the interview process, adm and reg vice president too. 09/21/20 01:39 PM obs of temp log 36 degrees 38 thermometer, clean no issues 09/22/20 03:27 PM interview april lee, dietary aide, role help prepare the meals, snacks, you and another member. [AGE] years been here. place items in the ziplock bag, name on sandwich, date outside of the ziplock bag, date on know what date to discard item. place in the refrigerator. purpose of this is to prevent food borne illness.

Based on record review, interview, and review of the facility's policy entitled Abuse, Mistreatment, Neglect, or Misappropriation of Property Investigation (Revised 11/19/16) the facility failed to ensure that one of two sampled residents reviewed for abuse remained free of neglect. Following investigation of an injury of unknown origin, it was determined that 2 Certified Nursing Assistants (CNAs) transferred the resident manually instead of using a mechanical lift resulting in a comminuted mid [MEDICATION NAME] patellar fracture. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Review of the 6-24-17 Quarterly Minimum Data Set (MDS) assessment revealed that the resident required extensive assistance of 2 people with bed mobility and transfers. Record review on 1-5-18 at 4:18 PM revealed a 9-9-17 Nursing Note: 7:45 PM Called to room by (Certified Nursing Assistant), residents right knee observed to be red, swollen, warm to touch, painful to touch. The physician and family were notified and the resident was sent to the emergency room for evaluation. Review of hospital records revealed that the resident presented with a red hot inflamed right knee. Per the nursing home, this started earlier today and got worse throughout the day . Right knee with significant swelling and [DIAGNOSES REDACTED] . There are patchy petechial like [MEDICAL CONDITION] on the back of the leg extending to the calf. A computed tomography (CT) scan in the emergency room revealed that Resident #16 had a comminuted mid [MEDICATION NAME] patellar fracture with 10 millimeter diastases of the more proximal fragment. The resident was admitted to the hospital and treated conservatively with an immobilizer. A Doppler of the leg showed a common femoral [MEDICAL CONDITIONS]. Patient with IVC (inferior vens cava) filter. This is a new clot for her (him) .Patient is paralyzed and can only transfer via the staff. To the (family) this indicates that she (he) was dropped on the knee. During an interview on 1-5-18 at approximately 4:30 PM, the Administrator and Director of Nursing (DON) stated they were advised of the fracture on 9-10-17, immediately reported it and began an investigation. Incident reports since the previous recertification survey were provided and reviewed on 1-18-18 at 10:30 AM. No report was provided for the fractured patella. Review of the facility's investigation file on 1-4-18 at 3 PM revealed the contents as: face sheet, staff assignment sheets for 9-8-17 and 9-9-17, Care Directive, law enforcement notification/case number, 9-9-17 Nursing Note, written statements by one licensed nurse and four Certified Nursing Assistants (CNAs), 2 Suspension Pending Investigation Forms, reporting documents and verifications, orthopedic consult, and post-incident inservice records. There was no evidence of a thorough investigation. Of the six licensed nurses assigned to the 200 Hall for 9-8-17 and 9-9-17, there was only one written statement. Of the 14 Certified Nursing Assistants on duty, there were only 4 written statements. There was no evidence of interviews of the remaining nursing staff assigned to the 200 Unit. There were no statements/interviews of ancillary staff (therapy, maintenance, housekeeping) to determine when/how the fracture actually occurred. There were no interviews conducted with the resident's roommate or with the 2 families of residents residing in the room. During an interview on 1-3-18 at 9:45 AM, CNA #4 (Restorative Aide) stated that Resident #16 was on the get-up list for 11-7 shift and was always up when day shift arrived. The resident remained up in the chair until s/he was put back to bed after lunch. There was no evidence in the file that the 11-7 shift CNAs had been interviewed. Review of the Weekly Skin Integrity Data Collection form revealed that a body audit had been completed by Licensed Practical Nurse (LPN) #5 on Friday 9-8-17 at an undetermined time. The body audit noted no skin conditions on the lower extremities. According to the Director of Nursing at 11:37 AM on 1-5-18, this nurse worked from 7 PM on 9-8-17 to 7 AM on 9-9-17. S/he verified the date the body audit was completed and agreed that the audit had to have been done between 7 PM and 12 AM for it to be dated 9-8-17. There was no evidence in the investigation file that LPN #5 had been interviewed. When asked if the DON interviewed LPN #5, s/he stated, I remember talking to her (him) but it's not in the file. I talked with everyone on duty in the prior 24 hours. S/he stated there was no record of employees interviewed other than what is in the file. When asked about ancillary services, the DON stated that employees in housekeeping, therapy, maintenance, and restorative departments had not been interviewed, though they had been conducting their daily duties and responsibilities on the unit where the incident occurred. During an interview at 11:37 AM on 1-5-18, the Director of Nurses stated s/he determined how and when the incident occurred by when the symptoms were reported on 9-9-17 on the 7p-7a shift. The facility's investigation resulted in Certified Nursing Assistants #5 and #6 being suspended and terminated as a result of improperly transferring Resident #16. Review of Resident #16's Care Directive in effect at the time of incident revealed that staff were to use a mechanical lift with her/him. Statements obtained from the two CNAs indicated they transferred the resident via manual lift instead of using a mechanical lift. The facility policy entitled Abuse, Mistreatment, Neglect, or Misappropriation of Property Investigation (Revised 11/19/16)) provided by the administrator on 1-5-18 at 4 PM stated: All reports of abuse will be promptly and thoroughly investigated . 2. The representative will utilize the Incident Investigation Questionnaire to complete the investigation. 5. The investigation shall include a written summary of: A review of the Incident Report . Interviews with any witnesses to the incident . A review of the resident's medical record . A review of the employee's file, Interviews with staff members on all shifts contact with the resident at the time of the incident, Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident, An interview with other residents who received care or services from the alleged perpetrator, A review of all circumstances surrounding the incident 9. The results of the investigation will be recorded on the Incident Investigation Questionnaire. Any additional documents including interviews and record reviews will be attached to the Incident Report. No incident report was completed. There was no Incident Investigation Questionnaire or Investigation Summary available for review

Based on record review, interview, and review of the facility's policy entitled Abuse, Mistreatment, Neglect, or Misappropriation of Property Investigation (Revised 11/19/16) the facility failed to implement established policies and procedures for investigation of an injury of unknown origin for one of two sampled residents renewed for abuse. Resident #16 was diagnosed with [REDACTED]. Of the six licensed nurses assigned to the 200 Hall for the 24-48 hour period prior to the reported symptoms, there was only one written statement. Of the 14 Certified Nursing Assistants on duty, there were only 4 written statements. There was no evidence of interviews of the remaining nursing staff assigned to the 200 Unit. There were no statements/interviews of ancillary staff (therapy, maintenance, housekeeping) to determine when/how the fracture actually occurred. There were no interviews conducted with the resident's roommate or with the 2 families of residents residing in the room. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Review of the 6-24-17 Quarterly Minimum Data Set (MDS) assessment revealed that the resident required extensive assistance of 2 people with bed mobility and transfers. Record review on 1-5-18 at 4:18 PM revealed a 9-9-17 Nursing Note: 7:45 PM Called to room by (Certified Nursing Assistant), residents right knee observed to be red, swollen, warm to touch, painful to touch. The physician and family were notified and the resident was sent to the emergency room for evaluation. Review of hospital records revealed that the resident presented with a red hot inflamed right knee. Per the nursing home, this started earlier today and got worse throughout the day . Right knee with significant swelling and [DIAGNOSES REDACTED] . There are patchy petechial like [MEDICAL CONDITION] on the back of the leg extending to the calf. A computed tomography (CT) scan in the emergency room revealed that Resident #16 had a comminuted mid [MEDICATION NAME] patellar fracture with 10 millimeter diastases of the more proximal fragment. The resident was admitted to the hospital and treated conservatively with an immobilizer. A Doppler of the leg showed a common femoral [MEDICAL CONDITIONS]. Patient with IVC (inferior vens cava) filter. This is a new clot for her (him) .Patient is paralyzed and can only transfer via the staff. To the (family) this indicates that she (he) was dropped on the knee. During an interview on 1-5-18 at approximately 4:30 PM, the Administrator and Director of Nursing (DON) stated they were advised of the fracture on 9-10-17, immediately reported it and began an investigation. Incident reports since the previous recertification survey were provided and reviewed on 1-18-18 at 10:30 AM. No report was provided for the fractured patella. Review of the facility's investigation file on 1-4-18 at 3 PM revealed the contents as: face sheet, staff assignment sheets for 9-8-17 and 9-9-17, Care Directive, law enforcement notification/case number, 9-9-17 Nursing Note, written statements by one licensed nurse and four Certified Nursing Assistants (CNAs), 2 Suspension Pending Investigation Forms, reporting documents and verifications, orthopedic consult, and post-incident inservice records. There was no evidence of a thorough investigation. Of the six licensed nurses assigned to the 200 Hall for 9-8-17 and 9-9-17, there was only one written statement. Of the 14 Certified Nursing Assistants on duty, there were only 4 written statements. There was no evidence of interviews of the remaining nursing staff assigned to the 200 Unit. There were no statements/interviews of ancillary staff (therapy, maintenance, housekeeping) to determine when/how the fracture actually occurred. There were no interviews conducted with the resident's roommate or with the 2 families of residents residing in the room. During an interview on 1-3-18 at 9:45 AM, CNA #4 (Restorative Aide) stated that Resident #16 was on the get-up list for 11-7 shift and was always up when day shift arrived. The resident remained up in the chair until s/he was put back to bed after lunch. There was no evidence in the file that the 11-7 shift CNAs had been interviewed. Review of the Weekly Skin Integrity Data Collection form revealed that a body audit had been completed by Licensed Practical Nurse (LPN) #5 on Friday 9-8-17 at an undetermined time. The body audit noted no skin conditions on the lower extremities. According to the Director of Nursing at 11:37 AM on 1-5-18, this nurse worked from 7 PM on 9-8-17 to 7 AM on 9-9-17. S/he verified the date the body audit was completed and agreed that the audit had to have been done between 7 PM and 12 AM for it to be dated 9-8-17. There was no evidence in the investigation file that LPN #5 had been interviewed. When asked if the DON interviewed LPN #5, s/he stated, I remember talking to her (him) but it's not in the file. I talked with everyone on duty in the prior 24 hours. S/he stated there was no record of employees interviewed other than what is in the file. When asked about ancillary services, the DON stated that employees in housekeeping, therapy, maintenance, and restorative departments had not been interviewed, though they had been conducting their daily duties and responsibilities on the unit where the incident occurred. During an interview at 11:37 AM on 1-5-18, the Director of Nurses stated s/he determined how and when the incident occurred by when the symptoms were reported on 9-9-17 on the 7p-7a shift. The facility's investigation resulted in Certified Nursing Assistants #5 and #6 being suspended and terminated as a result of improperly transferring Resident #16. Review of Resident #16's Care Directive in effect at the time of incident revealed that staff were to use a mechanical lift with her/him. Statements obtained from the two CNAs indicated they transferred the resident via manual lift instead of using a mechanical lift. The facility policy entitled Abuse, Mistreatment, Neglect, or Misappropriation of Property Investigation (Revised 11/19/16)) provided by the administrator on 1-5-18 at 4 PM stated: All reports of abuse will be promptly and thoroughly investigated . 2. The representative will utilize the Incident Investigation Questionnaire to complete the investigation. 5. The investigation shall include a written summary of: A review of the Incident Report . Interviews with any witnesses to the incident . A review of the resident's medical record . A review of the employee's file, Interviews with staff members on all shifts contact with the resident at the time of the incident, Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident, An interview with other residents who received care or services from the alleged perpetrator, A review of all circumstances surrounding the incident 9. The results of the investigation will be recorded on the Incident Investigation Questionnaire. Any additional documents including interviews and record reviews will be attached to the Incident Report. No incident report was completed. There was no Incident Investigation Questionnaire or Investigation Summary available for review

Based on record review and interview, the facility failed to ensure services were provided to prevent decline in range of motion (ROM) and/or to maintain mobility for two of two sampled residents reviewed for restorative services. Resident #448 did not receive ROM five times per week as ordered. Services were not provided to prevent contracture development and palmar guards were not in place for Resident #16. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Observation on 1-2-18 at 10:32 AM revealed that the resident had contractures of both hands with no hand rolls or splints in place. Hands were both in the fisted position. During an interview on 1-2-18 at 2:07 PM, the family stated Resident #16 had developed the contractures in her/his hands in the last 6 months. Prior to the hospitalization for the fractured patella in 9-17, the resident had been able to feed his/herself, predominantly with finger foods. Review of the 8-10-17 Monthly Summary on 1-3-19 at 2 PM revealed no contractures of upper extremities. Record review on 1-19-18 at 3:40 PM revealed that Resident #16 was seen by Occupational Therapy from 9-13-17 through 9-25-17 because Patient noted to be at risk for further deterioration in PROM (passive range of motion) in B(ilateral) fingers . The resident presented with decreased AROM (active range of motion)/PROM of both hands, held in clenched position influencing ability to tolerate hygiene. Daily notes indicated that the resident was gradually adjusting to placement of palmar guards. A 9-21-17 note stated, Without palmar guards hands are clenched and nails dig into palm of hand. Upon discharge, staff were educated on the need for palmar guards. Further review revealed a 9-26-17 physician's orders [REDACTED]. Review of 9-17 through 12-17 Restorative Nursing Program Flow Records with the Director of Nursing (DON) on 1-19-18 at approximately 9 AM revealed that R0M was not initialed as having been completed as ordered. Services were provided seven times as ordered for only one of the 12 weeks reviewed. Splint/brace assistance was not signed as completed for the entire 3 month period. On 12-12-17, an order was written to discontinue restorative services. During an interview on 1-19-18, the DON and Staff Development Coordinator (SDC) stated that residents on the restorative program were turned over to nursing after 12 weeks and the Certified Nursing Assistant (CNA) was responsible to apply the splint. Review of the Care Directive (CNA Care Plan) revealed that there was no instruction for application of palmar guards. Record review on 1-19-18 at 2:17 PM with the Minimum Data Set (MDS) Coordinator revealed a Care Plan problem of contractures to bilateral upper and lower extremities with interventions including palm protectors to both hands. Subsequent observations on 1-2-18 at 11:44 AM, 12:44 PM, and 3:29 PM and on 1-18-18 at 9:15 AM revealed that the palmar guards were not in place as ordered and not visible anywhere in the resident's location. On 1-3-18 at 9:45 AM, the resident had 2 palmar guards in place but they were incorrectly applied. Hands were fisted and the splint was not placed in the palms of the hands. During an observation and interview on 1-19-18 at 10:45 AM, the Director of Nursing verified that palmar guards were not in place as ordered. During an interview on 1-3-18 at 11:01 AM, Certified Nursing Assistant (CNA) #4 stated, The CNA assigned to the resident is supposed the make sure splints are on at all times. Restorative goes around and checks to be sure they're on. Review of the 6-24-17 Quarterly MDS at 1:10 PM on 1-4-18 revealed that Resident #16 had no functional limitation in ROM. After review of this MDS, the 9-19-17 Significant Change in Status MDS, and the Quarterly MDS completed in 12-17, the MDS Coordinator stated the resident had developed contractures of both upper extremities between 9-17 and 12-2017. The MDS Coordinator stated that Resident #16 received Occupational Therapy after hospitalization in 9-17 and contractures were noted at the time the palm guards were ordered. The facility admitted Resident #448 with [DIAGNOSES REDACTED]. Record review on 1-5-18 at 11:02 AM revealed 7-17-17 Telephone Orders to DC (Discontinue) PT (Physical Therapy)/OT (Occupational Therapy). Pt (Patient) to receive restorative nursing 5 X/w(ee)k to address B(ilateral) UE (upper extremity)/LE (lower extremity) ROM and positioning in bed as tolerated. Review of Restorative Records on 1-18-18 at 3:45 PM revealed that the week of 7-16-17, restorative services were only provided twice. The week of 7-23-17 services were provided four times. It was also noted that ROM was documented as having been provided for 20 minutes on 7-31-17, after the resident was discharged . During an interview on 1-19-18 at 9:51 AM, the Director of Nursing verified that the documentation reflected that physician's orders [REDACTED].#448 was discharged .

On the days of the survey, based on record review and interviews, the facility failed to provide the necessary care and services for one of 3 residents sampled related to anticoagulants Resident A was not monitored adequately for abdominal pain and a newly acquired "knot" in her/his abdomen; physician's orders [REDACTED]. Staff failed to monitor the blood pressure (BP) as ordered for Resident #120 who suffered two acute hypertensive episodes involving administration of emergency and initiation of routine antihypertensive medication with no previous [DIAGNOSES REDACTED]. The findings included: Review of the medical record indicated that Resident A was care planned for being at risk for bleeding related to the use of anticoagulants. S/he was admitted on [DATE] with prescribed [MEDICATION NAME] and was diagnosed with [REDACTED]. A nosebleed was noted on [DATE] and the nighttime [MEDICATION NAME] was held for [DATE]. On [DATE] Resident A developed a "knot" in her/his left lower abdomen and complained of pain s/he received as needed pain medication of [MEDICATION NAME] ,[DATE] at 4 PM with documented relief from the medication. Per the nurse's notes the physician was called sometime during this event but did not respond. At 9:00 PM s/he again received [MEDICATION NAME] ,[DATE] for back/abdominal pain, which, was documented, as ineffective the physician was again called without responding. The nurse's notes stated that at 11:35 PM Resident A vomited a medium-large to medium amount of brown colored emesis, the family was called and directed the facility to send the resident to the hospital. Resident A expired at the hospital several hours later. Review of the medical record revealed the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident A was alert and oriented and able to make decisions regarding her/his activities of daily living. S/he required extensive assistance with transfers, walking and hygiene, and total care with locomotion, dressing and bathing. Resident A was coded as frequently incontinent of bowels and had an indwelling catheter for her/his urine. Review of the resident's care plan dated [DATE] revealed a care plan for resident at risk for abnormal bleeding or hemorrhage because of anticoagulation usage receiving [MEDICATION NAME] and does have history of [MEDICAL CONDITIONS]. Approaches included to "administer medications, labs and treatments as ordered and to be sure to rotate injection sites. Observe for and report to nurse bleeding gums, nose bleeds, unusual bruising, tarry black stool, and pink or discolored urine. Report to the physician any s/s (signs/symptoms) abnormal bleeding or hemorrhage." Review of the Hospital Discharge Summary dated [DATE] revealed the resident admitted to the hospital on [DATE] for dehiscence and exposed hardware from a previous open reduction, internal fixation of her/his left intra-articular olecranon fracture. Her/his discharge medications included [MEDICATION NAME] 40 milligrams subcutaneous daily. Review of the Physician Cumulative admission orders [REDACTED]. There was also orders for weekly lab work including, weekly CBC (complete blood count) with differential, weekly CMP (complete metabolic panel). Review of the physician progress notes [REDACTED]. The physician's admission note of [DATE] documented at that time the resident's hemoglobin was 9.2. S/he spoke with the daughter in the resident's room. On [DATE] the resident was seen for hematuria. A urinalysis was ordered to determine if the resident had a urinary tract infection. [DATE] the resident was seen due to concerns of her/his left leg swollen. The daughter... told the doctor the resident had a clot in her/his leg in the hospital. The physician documented that the information had not been included in the discharge summary. "So will check for active [MEDICAL CONDITION] of left leg". The physician ordered a venous study to check for [MEDICAL CONDITION]. [DATE] "[MEDICAL CONDITION] of left lower extremity. [DATE], Blood in urine, awaiting (culture and sensitivity) C&S. Physician spoke with daughter... [DATE], (urinary tract infection) UTI, start Cipro. [DATE], "Pt seen c/o (complaint of) ?/voiding pain". Spoke to daughter, will d/c (discontinue) catheter. Review of Physician Telephone Orders from [DATE] though [DATE] revealed: [DATE]: U/A (urinalysis) for hematuria, [MEDICATION NAME] stop date [DATE] (sic 2014). [DATE] D/[MEDICATION NAME] mixed infection in urine, Recollect Urine for UA and C&S on Monday [DATE]. Doppler Venous, Blood for CBC [DATE]: order clarification: BLE (bilateral lower extremity) venous doppler studies r/t (related to) [MEDICAL CONDITION]. [DATE]: Change [MEDICATION NAME] to 65 mg sub q every 12 hours x 3 months. (Left Lower Extremity [MEDICAL CONDITION]). [DATE]: [MEDICATION NAME] mgm Bid (twice a day) x 10 days start tonight [MEDICAL CONDITION]. [DATE] Instill small amount of triple antibiotic ointment in both nostrils gently twice/day x 5 days then ask MD. Hold [MEDICATION NAME] this PM. [DATE]: D/C foley catheter. In and out catheter q (every) 12 hours x 2 for residual and record residual. If greater than 300 notify MD. Review of the resident's labs revealed: [DATE] Hgb (hemoglobin) 9.3 and platelet count was 358 [DATE] Hgb 9.6 [DATE] Hgb 9.0 and platelet count 297 [DATE] Hgb 9.3 and platelet count 376 [DATE] Hgb 8.7 [DATE] Hgb 8.4 and platelet count 325. Review of the resident's Nurse's Notes from [DATE] through [DATE] revealed the resident was alert and oriented. S/he required assistance with her/his activities of daily living (ADL's). S/he had a wound on her/his sacrum. On [DATE] blood was noted on the resident's sheets. The bandage was not in place on the left arm. [DATE] at 2:35 PM. Late entry for [DATE] 9 PM: Resident's daughter visiting and stated resident had a bloody sputum and nose bleed earlier. MD in the building and notified. Order to hold [MEDICATION NAME]. [DATE] Dressings to coccyx and spine removed. Scant amount of pink drainage noted on both. Went out at approximately 1315 to cardiologist. Patient returned at 14:30. No new orders. No complaints of pain or discomfort. No nose bleeds. [DATE] No nose bleeding reported. [DATE] In and out done after lunch obtained 100cc of cloudy urine. No nose bleeding noted. [DATE] 3:02 AM: In and out cath for 150 ml orange colored urine. (on [MEDICATION NAME]) No nosebleed noted. 7:01 PM In and out cath done obtained 100 ml orange colored urine. Complaint of abdominal pain, pain med given with some relief, check for impaction negative, left a message for Dr... no return call yet, report given to incoming nurse, will continue to monitor. [DATE] 8:34 AM: [DATE] 7p-7a late entry-...."also very painful had [MEDICATION NAME] 0.5 mg and [MEDICATION NAME] ,[DATE] at 9:00 PM. was given in report that patient has a knot in left lower area of abdomen which is very painful and pain med (medicine) has not been effective... dr... was called by dayshift nurse and not able to notify. night shift nurse left messages with dr... and it wasn't until after patient was sent to hospital that dr... was able to call back. 2235 vomited a medium-large amt (amount) of brown colored emesis: called daughter and made aware of situation of her/his mother and was told to send her/him to Providence downtown and that s/he would meet her/him there. 2245 called 911 and EMS (emergency medical service) at 2250 and departed to ... hospital downtown." Review of the Nursing Home to Hospital Transfer Form revealed the resident was "transferred for vomiting dark brown colored emesis; uncontrolled pain. vital signs ,[DATE], HR (heart rate) 108, R (respirations) 20 O2 (oxygen) Sat (saturation) 94 on [DATE]". Review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. At 9:00 PM s/he again received [MEDICATION NAME] ,[DATE] for back/abdominal pain. It was documented the medication was ineffective. Record review on [DATE] at 1:54 PM revealed that Resident #120 had been admitted for short- term rehabilitation and administration of intravenous antibiotic therapy following a wound debridement. Review of the [DATE] Admission Minimum Data Set (MDS) Assessment on [DATE] at 7:35 PM revealed that Hypertension was not listed as a [DIAGNOSES REDACTED]. Record review on [DATE] at 3:20 PM revealed that on [DATE] at 10 AM, the resident's blood pressure (BP) was noted at ,[DATE]. A physician's orders [REDACTED]. Recheck BP in one hour." The "Indication-Dx (Diagnosis)" for medication administration was noted as "elevated BP". The BP one hour later was recorded as ,[DATE]. At 7:30 PM on the same date, Progress Notes revealed a BP of ,[DATE]. The physician repeated the same orders. No record could be located for the repeat BP results. The physician wrote an order on [DATE] for "[MEDICATION NAME] 2.5 mg daily-start tonight if available. Monitor BP every 8 hours and give [MEDICATION NAME] 0.1 mg TID (three times daily) PRN (as needed) systolic > 170. Hold [MEDICATION NAME] if BP systolic <110." Review of the ,[DATE] and ,[DATE] Medication Administration Records (MAR) on [DATE] at 2:15 PM revealed [MEDICATION NAME] documented as given daily, but with no BPs documented on the record. Review of the ,[DATE] MAR indicated BP every 8 hours" had been transcribed onto the MAR indicated and noted to be done at ",[DATE] P", ",[DATE]", and ",[DATE]". From ,[DATE] through [DATE], the BP was only documented twice daily. The order for routine BP monitoring was not brought forward onto the ,[DATE] cumulative physician's orders [REDACTED]. Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 verified the physician's orders [REDACTED]. When asked to identify the times the BPs had been taken on the Vital Signs record, the nurses stated there was no way to know unless specifically documented because the times noted on the form were computer input times. They were unable to determine when the BPs were done or even if done in conjunction with the daily antihypertensive medication administration. When asked if the BP results could be documented elsewhere, the nurses referred the surveyor to the 24 Hour Reports and Nurses Notes. Review of the Report sheets for [DATE] through the dates of the survey provided by LPN #1 on [DATE] revealed no BPs recorded for Resident #120. Following review of all documentation, the nurses verified that the BPs were not consistently monitored per physician's orders [REDACTED]. [DATE] = ,[DATE], ,[DATE] [DATE] = ,[DATE] [DATE] = ,[DATE] [DATE] = ,[DATE],,[DATE] [DATE] = ,[DATE], ,[DATE], ,[DATE]l [DATE] = ,[DATE] [DATE] = ,[DATE] [DATE] = ,[DATE], ,[DATE] [DATE] = ,[DATE] [DATE] = ,[DATE], ,[DATE]. [DATE] = ,[DATE] [DATE] = ,[DATE], ,[DATE] Further record review on [DATE] at 2:40 PM revealed that no Care Plan had been developed with measurable goals/objectives, and specific interventions related to Hypertension. During an interview on [DATE] at approximately 3 PM, RN #5 and RN #6 reviewed the Care Plan dated I[DATE] and verified that it did not address Hypertension, a new [DIAGNOSES REDACTED].

On the days of the complaint and extended survey, based on record review, interviews and information provided by the facility, the facility failed to provide the necessary goods and services to prevent harm to Resident #1, 1 of 2 residents with an acute changes in condition. Licensed Practical Nurse (LPN) #1 was told several times by the staff of Resident #1's complaints of pain and shortness of breath. Emergency medical services (EMS) telephoned the facility after receiving calls directly from Resident #1 and was told that the resident did not need to be hospitalization . There was no evidence even tho the (certified nurse aides) CNA's told her of the resident's continued pain and shortness of breath that LPN #1 addressed Resident #1's concerns after s/he medicated the resident at approximately 10:45 PM. There was no evidence that LPN #1 or the licensed staff addressed Resident #1 calls to 911. The findings included: Cross refers to F-157 as it relates to the failure of the facility to notify the physician/family of an acute change in Resident #1's condition. Cross refers to F-281 as it relates to the failure of the facility to meet professional standards of quality. Resident #1, 1 of 2 residents with an acute changes in condition was not adequately assessed or monitored after complaints of pain and shortness of breath. Resident #1 was not assessed after multiple calls to the facility from 911 in response to the resident's calls asking for assistance. Cross refers to F-309 as it relates to the failure of the facility to provide adequate care and services to Resident #1's whose complaints of pain and shortness of breath were not addressed. Cross refers to F-490 as sit relates to the failure of the facility Administration to effectively use its resources to provide the necessary care and services to 1 of 2 residents with acute changes in condition. Resident #1 was not provided the necessary care and services regarding complaints of pain and shortness of breath. Resident #1 sampled as a result of a complaint and a facility reported incident received by the State Agency. The information provided to the State Agency indicated that on Friday evening, [DATE], Resident #1 was yelling for assistance around 8:30 PM due to pain. Licensed Practical Nurse (LPN) #1 gave the resident Tylenol. S/he continued to have pain and called 911 first at 11:22 PM, then at 11:36 PM and again at 11:39 PM. Emergency Medical Services (EMS) called the facility after the calls at 11:22 PM and 11:35 PM to see if their services were needed and were told by the facility that the resident did not need to be hospitalized . Following the last call at 11:39 PM EMS went to the facility. On arrival EMS began CPR (cardiopulmonary resuscitation) on Resident #1 and s/he was transferred to the hospital. Review of the Hospital Discharge Summary dated [DATE] stated, "...S/he according to the daughter, apparently had been calling out since about 8:30 this evening callout out (sic) for help and then apparently called emergency medical services herself from her room. She finally tried to receive assistance. S/he was found unresponsive, pulseless... S/he was admitted to the Intensive Care Unit... Overnight, unfortunately, the patient showed no sign of any meaningful recovery. Now at noon, her pupils are still fixed and dilated with no corneal response... no response to pain... no respirations over the ventilator... The patient was extubated... s/he expired at 13:30 (1:20 p.m.)..." Review of the Resident Progress Note/nursing notes dated [DATE] at 1:25 AM stated, "Patient alert and oriented. C/O (complained of) left hip pain. Pain reliever given as prescribed by physician. At approx. (approximately) 10:50 pm, patient had c/o difficulty breathing. VS (vital signs) checked, BP (blood pressure) ,[DATE]; Pulse 100; Pulse OX 90%; Resp (respirations) 20; Temp (temperature) 97.2. At approx. 11:30 pm, patient called 911 with c/o resp distress. 911 arrived at approx 11:37 pm. Within minutes, resident was unresponsive, and CPR (cardiopulmonary resuscitation) was immediately initiated. MD, family, and DON (director of nurses) were immediately notified of resident's status, and orders were given to transport to... Report given to ER nurse." This Resident Progress Note was the first note written after a note written on [DATE] at 05:08 PM that stated, "...was able to successfully complete interview for care plan assessment on this date... She also signed advanced directives for full code on this date." Review of the facility investigation of the incident revealed an email statement sent to the facility, by LPN #1 dated [DATE] at 11:10 AM in the statement LPN #1 confirmed Resident #1 asked for medications at approximately 7:45 PM on [DATE] and the medication was not available, s/he informed the resident the medications had not arrived. At that time LPN #1 stated the resident do not report pain or being short of breath. LPN #1 stated that s/he was caring for another resident who s/he had called 911 for and requested transport. S/he wrote, "... During the whole process, my (certified nurse aids) CNAs kept telling me that (Resident #1) was c/o (complaining of) pain. I repeatedly told them to let (Resident #1) know that I was in the middle of sending a patient to the ER and that I would be with her/him as soon as I could get to her/him. After (the other resident ) was taken to the hospital, I then went to the MAR and looked to see of (sic) (Resident #1) had any medications ordered for pain. This was around 10:30 PM. I noticed (Resident #1) had Tylenol ordered for pain and had a 9 pm order for ASA (Aspirin). I prepared both, along with her insulin, and took the medication to her/his room. ...(Resident #1) then refused her/his insulin, ... was alert and oriented, without any s/s or respiratory distress or shortness of breath... At about 10:50pm, one of my CNAs informed me (resident #1) was c/o difficulty breathing... While I was in the room with a patient from room... the third shift nurse came on the hall, and answered the phone. It was 911 wanting to know if a call had been made to 911 stating we had a patient in respiratory distress. I told the nurse we had just sent a patient out about an hour before. 911 then stated that a patient in room ___ (Resident #1) had called 911 around 11:30 and stated to them s/he was in respiratory distress. 911 showed up at the back door and were let in by one of the CNAs and led to (Resident #1's) room. Resident #1 then coded. CPR was immediately initiated. I went to the desk and immediately notified the doctor and DON (director of nurses) of the situation, while another nurse notified the family ... The third shift nurse reported off to the ___ (hospital)." On [DATE] at 3:05 PM the Administrator, and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy were identified at F-224 at a scope and severity of"J". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE] related to the failure of the facility to provide the necessary care and services to 1 of 2 residents with an acute changes in condition. Resident #1 was not thoroughly assessed regarding complaints of pain and shortness of breath. Observations, interviews, and review of policy revealed the AOC submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the facility policies and procedures regarding reporting of resident changes in condition, physicians order clarification, ordering medications from the pharmacy and physical assessments. The Administrator was informed of this on [DATE] at 3:15 PM. The Substandard Quality of Care and Immediate Jeopardy at F-224 was removed but the citation at F-224 remained at a lower scope and severity of "E".

On the days of the complaint and extended survey, based on record review, interviews and review of the facility investigation file, the facility failed to provide the necessary care and services to 1 of 2 residents with acute changes in condition. Resident #1 was not thoroughly assessed or treated timely regarding complaints of pain and shortness of breath. The findings included: Cross refers to F-157 as it relates to the failure of the facility to notify the physician/family of an acute change in Resident #1's condition. Cross refers to F-224 as it relates to the failure of the facility to provide the necessary goods and services to prevent harm to Resident #1, 1 of 2 residents with an acute changes in condition. Cross refers to F-281 as it relates to the failure of the facility to meet professional standards of quality. Resident #1, 1 of 2 residents with an acute changes in condition was not adequately assessed or monitored after complaints of pain and shortness of breath. Resident #1 was not assessed after multiple calls to the facility from 911 in response to the resident's calls asking for assistance. Cross refers to F-490 as sit relates to the failure of the facility Administration to effectively use its resources to provide the necessary care and services to 1 of 2 residents with acute changes in condition. Resident #1 was not provided the necessary care and services regarding complaints of pain and shortness of breath. Resident #1 sampled as a result of a complaint and a facility reported incident received by the State Agency. The information provided to the State Agency indicated that on Friday evening, [DATE], Resident #1 was yelling for assistance around 8:30 PM due to pain. Licensed Practical Nurse (LPN) #1 gave the resident Tylenol. Resident #1 continued to have pain and called 911 first at 11:22 PM, then at 11:36 PM and again at 11:39 PM. Emergency Medical Services (EMS) called the facility after the calls at 11:22 PM and 11:35 PM to see if their services were needed and were told by the facility that the resident did not need to be hospitalized . Following the last call at 11:39 PM EMS went to the facility. On arrival EMS began CPR (cardiopulmonary resuscitation) on Resident #1 and s/he was transferred to the hospital. Review of the Hospital Discharge Summary dated [DATE] stated, "...S/he according to the daughter, apparently had been calling out since about 8:30 this evening callout out (sic) for help and then apparently called emergency medical services herself from her room. She finally tried to receive assistance. S/he was found unresponsive, pulseless... S/he was admitted to the Intensive Care Unit... Overnight, unfortunately, the patient showed no sign of any meaningful recovery. Now at noon, her pupils are still fixed and dilated with no corneal response... no response to pain... no respirations over the ventilator... The patient was extubated... s/he expired at 13:30 (1:20 p.m.)..." Review of the Resident Progress Note/nursing notes dated [DATE] at 1:25 AM stated, "Patient alert and oriented. C/O (complained of) left hip pain. Pain reliever given as prescribed by physician. At approx. (approximately) 10:50 pm, patient had c/o difficulty breathing. VS (vital signs) checked, BP (blood pressure) ,[DATE]; Pulse 100; Pulse OX 90%; Resp (respirations) 20; Temp (temperature) 97.2. At approx. 11:30 pm, patient called 911 with c/o resp distress. 911 arrived at approx 11:37 pm. Within minutes, resident was unresponsive, and CPR (cardiopulmonary resuscitation) was immediately initiated. MD, family, and DON (director of nurses) were immediately notified of resident's status, and orders were given to transport to... Report given to ER nurse." This Resident Progress Note was the first note written after a note written on [DATE] at 05:08 PM that stated, "...was able to successfully complete interview for care plan assessment on this date... S/he also signed advanced directives for full code on this date." Review of the Medication Administration Record (MAR) dated [DATE] revealed Resident #1 had an admission order for [MEDICATION NAME] ,[DATE], give ,[DATE] a tab every 4 hours prn (as needed) pain. [MEDICATION NAME] was not signed as given during the residents stay at the facility. Tylenol 650 milligrams by mouth every 4 hours as needed was also ordered for pain. On [DATE] Tylenol was signed as given at 10:45 PM. The resident's 4:30 PM Humalog Mix Insulin, 9:00 PM [MEDICATION NAME] and 9:00 PM [MEDICATION NAME] were circled as not given. There was no documentation to explain why the evening medications were not given. Review of the facility investigation of the incident revealed an email statement sent to the facility, by LPN #1 dated [DATE] at 11:10 AM in the statement LPN #1 confirmed Resident #1 asked for medications at approximately 7:45 PM on [DATE] and the medication was not available, s/he informed the resident the medications had not arrived. At that time LPN #1 stated the resident did not report pain or being short of breath. LPN #1 stated that s/he was caring for another resident who s/he had called 911 for and requested transport. S/he wrote, "... During the whole process, my (certified nurse aids) CNAs kept telling me that (Resident #1) was c/o (complaining of) pain. I repeatedly told them to let (Resident #1) know that I was in the middle of sending a patient to the ER and that I would be with her/him as soon as I could get to her/him. After (the other resident ) was taken to the hospital, I then went to the MAR and looked to see of (sic) (Resident #1) had any medications ordered for pain. This was around 10:30 PM. I noticed (Resident #1) had Tylenol ordered for pain and had a 9 pm order for ASA (Aspirin). I prepared both, along with her/her insulin, and took the medication to her/his room. ...(Resident #1) then refused her/his insulin, ... was alert and oriented, without any s/s (signs/symptoms) or respiratory distress or shortness of breath... At about 10:50 pm, one of my CNAs informed me (resident #1) was c/o difficulty breathing... While I was in the room with a patient from room... the third shift nurse came on the hall, and answered the phone. It was 911 wanting to know if a call had been made to 911 stating we had a patient in respiratory distress. I told the nurse we had just sent a patient out about an hour before. 911 then stated that a patient in room ___ (Resident #1) had called 911 around 11:30 and stated to them s/he was in respiratory distress. 911 showed up at the back door and were let in by one of the CNAs and led to (Resident #1's) room. Resident #1 then coded. CPR (cardiopulmonary resuscitation) was immediately initiated. I went to the desk and immediately notified the doctor and DON (director of nurses) of the situation, while another nurse notified the family... The third shift nurse reported off to the ___ (hospital)." In an interview with the surveyor on [DATE] at 10:25 AM CNA#1 stated that s/he was working on the unit where Resident #1 lived the night the s/he went to the hospital. "Between 7:30 to 8:00 PM s/he turned on his/her light and said her/his lower back was hurting and s/he needed some pain medication. I immediately told the nurse... S/he stated s/he was doing her/his med pass and said s/he would get to her/him as soon as s/he can. I notified the patient the nurse said s/he was passing her medication and would be there as soon as s/he could. The patient said s/he needed the pain medicine real bad because her/his back was hurting real bad. I went and told the nurse the patient said her/his back was hurting real bad and needed the medication. The nurse just looked at me and went on passing medication; 10 minutes later s/he was on the light again and... (CNA #2) answered it. I don't know what happened with that situation. S/he (Resident #1) was on the light again and I answered. S/he asked me to tell the nurse please, please s/he needed the medication... s/he was rocking, complaining lower back hurting real bad. I notified the nurse and told her/him the resident was in excruciating pain and needed the medicine. It was sometime between 7:30 PM and 10:30 PM. The nurse said s/he was not on that cart right now... When I get to that cart I will give her/him something. I went back in to tell the patient. I told her the nurse said s/he would be in as soon as s/he could. The patient asked me to rub her back. I asked her to point to where it hurt and I rubbed her back. I left the room and another light came on. CNA #2 answered Resident #1's light. I answered the other light and there was another resident in distress." CNA #1 stated s/he went to tell the nurse the other resident needed her "real bad. While I was telling him/her about the resident s/he said s/he was going to take a break. I went to --- (another hall) and got the nurse to check on the other resident." CNA #1 stated that another nurse came from another hall and asked Resident #1 what was needed. "I heard the nurse from the other unit tell LPN #1 that Resident #1 needed pain medication. LPN #1 went to the other patients room and checked his blood pressure and called EMS. I was getting the other resident ready. I was still hearing Resident #1. I went in to check on Resident #1 and s/he said the nurse did give pain medication but s/he was having shortness of breath. I observed him/her with shortness of breath. (CNA demonstrated the shortness of breath by panting). The resident said to tell the nurse s/he was short of breath. The CNA stated the resident grabbed an inhaler and the CNA went to tell the nurse. "When I told the nurse s/he said okay. The CNA stated I took it upon myself to check the resident's O2 sats (oxygen saturation) and B/P (blood pressure). O2 Sat was 91% . The B/P was good ,[DATE] (? not sure exactly)." The CNA stated the nurse was notified and stated that it was good. "S/he did not go down and check on the patient." CNA #1 stated the resident called again and the s/he answered the call. The resident stated if the nurse did not come the resident was going to call 911. "Between 11:25 and 11:30 PM we heard the ambulance. The nurse on (another hall) called and said the ambulance called and were on their way here. The third shift nurse came on and asked if someone had called an ambulance. The CNA reported (to the third shift nurse) the patient had called the ambulance herself." In an interview with the surveyor on [DATE] at approximately 3:00 PM Registered Nurse (RN) #1 stated, "I arrived on the unit at approximately 11:30 PM. I passed by the nurse (LPN #1) s/he was still passing 9 (PM) meds and appeared to be over whelmed. As I was passing by s/he was venting that s/he was still passing 9 PM meds at 11:30 PM. I went to the nurse's station to put my bags down, the phone was ringing. ...I answered a call from (nurse on other unit). The nurse stated s/he had received a call from EMS and they were on route to facility as patient in (Resident #1's room number) had called EMS herself/himself, and stated s/he had breathing problems and couldn't get help from the facility. I am on the phone with the nurse and calling out to LPN #1 asking if s/he knew about the call to 911 for the resident in room___. LPN #1 said it had already been handled. I hang up and EMS is at the back door. I went down there." When the RN went to the room EMS was rescue breathing the resident with an ambu bag. One of the EMTs told the nurse to get help. RN #1 called a code and directed the staff. "I told LPN #1 to call the doctor, another LPN to call the daughter. I called the ER and gave them report. I told them the patient had called EMS and gave them information, history and physical, allergies and diagnoses. This was the first time I had ever met LPN #1. S/he did not come down to the room during the code. I don't know how much training she had on emergency situations... RN #1 stated the supplies needed for the wall suctioning and oxygen were not on the crash cart." In an interview with the surveyor on [DATE] at approximately 9:40 AM LPN #2 stated s/he worked the night shift on the night of the event and overheard the conversation with the nurse on the other unit (who took the calls from 911) and 911. LPN #2 stated the call was put on the speaker phone. "I heard phone call on speaker, EMS asking someone to go check on patient, 's/he called in respiratory distress and no one was coming'. The nurse that took the phone call called over to ___ (Resident #1's hall). S/he talked to LPN #1. LPN #1 responded that the patient was fine, 'I sent them out to hospital.' Then I heard the phone ring again from EMS. The nurse called back down to the hall and the response was, 'I checked on her she is fine.' I went to make rounds on my patients and I heard 'Code Blue' I went running... EMS was in the room working with the patient when I arrived. I am at the crash cart trying to get O2 together, the O2 didn't work, the seal didn't work. EMT called for suction, it wasn't working. It wasn't set up right. Those rooms have suction in the walls in the room. The suction machine that was suppose to be on the crash cart was in another resident's room. EMS called for thumper and back up..." In an interview with the surveyor on [DATE] at approximately 12:45 PM the Director of Nurses (DON) stated that LPN #1 had not worked the 300 hall before. S/he worked 4 shifts orienting with another nurse. S/he worked 2 shifts on a hall with two nurses. S/he did not orient on the 300 hall. Hall 300 was more short term rehab, more medically complicated hall, trachs, increased acuity. Oxygen and suction are on the walls on that hall. That night there was six (6) tube feedings. The census was 21 on the night of the occurrence." The DON did not know why the resident's medications were not available. "The day shift gave medications. I would expect a phone call if the medications were not available." The DON confirmed at the time of the interview that the facility did not have a Staff Development Coordinator; a supervisor on the ,[DATE] PM shift. On [DATE] at 3:05 PM the Administrator, and the Director of Nurses were notified that Substandard Quality of Care and Immediate Jeopardy were identified at F-309 at a scope and severity of"J". The Substandard Quality of Care and Immediate Jeopardy existed in the facility on [DATE] related to the failure of the facility to provide the necessary care and services to 1 of 2 residents with an acute changes in condition. Resident #1 was not thoroughly assessed regarding complaints of pain and shortness of breath. Observations, interviews, and review of policy revealed the AOC submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the facility policies and procedures regarding reporting of resident changes in condition, physicians order clarification, ordering medications from the pharmacy and physical assessments. The Administrator was informed of this on [DATE] at 3:15 PM. The Substandard Quality of Care and Immediate Jeopardy at F-309 was removed but the citation at F-309 remained at a lower scope and severity of "E".

On the days of the complaint and extended survey, based on record review, interviews and information provided by the facility, the facility failed to notify the physician and family of a change in the condition of Resident #1, 1 of 2 residents with an acute change in condition. Licensed Practical Nurse (LPN) #1 was told several times by the staff of Resident #1's complaints of pain and shortness of breath. Emergency medical services (EMS) telephoned the facility after receiving calls directly from Resident #1 and was told by the staff that the resident did not need to be hospitalized . There was no documentation that the staff notified Resident #1's physician or family regarding her/his concerns of pain, the calls to EMS or that the resident's medication was not available. The findings included: Cross refers to F-224 as it relates to the failure of the facility to provide the necessary goods and services to prevent harm to Resident #1, 1 of 2 residents with an acute changes in condition Cross refers to F-281 as it relates to the failure of the facility to meet professional standards of quality. Resident #1, 1 of 2 residents with an acute changes in condition was not adequately assessed or monitored after complaints of pain and shortness of breath. Resident #1 was not assessed after multiple calls to the facility from 911 in response to the resident's calls asking for assistance. Cross refers to F-309 as it relates to the failure of the facility to provide adequate care and services to Resident #1 whose complaints of pain and shortness of breath were not addressed. Cross refers to F-490 as it relates to the failure of the facility Administration to effectively use its resources to provide the necessary care and services to 1 of 2 residents with acute changes in condition. Resident #1 was not provided the necessary care and services regarding complaints of pain and shortness of breath. Resident #1 sampled as a result of a complaint and a facility reported incident received by the State Agency. The information provided to the State Agency indicated that on Friday evening, [DATE], Resident #1 was yelling for assistance around 8:30 PM due to pain. Licensed Practical Nurse (LPN) #1 gave the resident Tylenol. S/he continued to have pain and called 911 first at 11:22 PM, then at 11:36 PM and again at 11:39 PM. Emergency Medical Services (EMS) called the facility after the calls at 11:22 PM and 11:35 PM to see if their services were needed and were told by the facility that the resident did not need to be hospitalized . Following the last call at 11:39 PM EMS went to the facility. On arrival EMS began CPR (cardiopulmonary resuscitation) on Resident #1 and the resident was transferred to the hospital. Review of the admission History and Physical dated [DATE] stated, "...The patient... recently had open reduction and internal fixation of her hip about a week ago... was transferred to... for rehabilitation. The patient suddenly became unresponsive and 911 was called. She lost pulse and basic life support and advanced cardiac life support protocol were initiated... She is now admitted to intensive care unit and is being mechanically ventilated." Review of the Hospital Discharge Summary dated [DATE] stated, "...S/he according to the daughter, apparently had been calling out since about 8:30 this evening callout out (sic) for help and then apparently called emergency medical services herself from her room. She finally tried to receive assistance. S/he was found unresponsive, pulseless and had a rhyme consistent with pulseless electrical activity (PEA) on the monitor. S/he was emergently intubated at the scene and cardiopulmonary resuscitation was initiated and continued on arrival in the emergency room . Pulse and blood pressure were restored after multiple rounds of [MEDICATION NAME]. S/he was admitted to the Intensive Care Unit... Overnight, unfortunately, the patient showed no sign of any meaningful recovery. Now at noon, her pupils are still fixed and dilated with no corneal response... no response to pain... no respirations over the ventilator... The patient was extubated... s/he expired at 13:30 (1:20 p.m.)..." Review of the Resident Progress Note/nursing notes dated [DATE] at 1:25 AM stated, "Patient alert and oriented. C/O (complained of) left hip pain. Pain reliever given as prescribed by physician. At approx. (approximately) 10:50 pm, patient had c/o difficulty breathing. VS (vital signs) checked, BP (blood pressure) ,[DATE]; Pulse 100; Pulse OX 90%; Resp (respirations) 20; Temp (temperature) 97.2. At approx. 11:30 pm, patient called 911 with c/o resp distress. 911 arrived at approx 11:37 pm. Within minutes, resident was unresponsive, and CPR (cardiopulmonary resuscitation) was immediately initiated. MD, family, and DON (director of nurses) were immediately notified of resident's status, and orders were given to transport to... Report given to ER nurse." Review of the facility investigation of the incident revealed an email statement sent to the facility, by LPN #1 dated [DATE] at 11:10 AM in the statement LPN #1 confirmed Resident #1 asked for medications at approximately 7:45 PM on [DATE] and the medication was not available, s/he informed the resident the medications had not arrived. At that time LPN #1 stated the resident do not report pain or being short of breath. LPN #1 stated that s/he was caring for another resident who s/he had called 911 for and requested transport. S/he wrote, "... During the whole process, my (certified nurse aids) CNAs kept telling me that (Resident #1) was c/o (complaining of) pain. I repeatedly told them to let (Resident #1) know that I was in the middle of sending a patient to the ER and that I would be with her/him as soon as I could get to her/him. After (the other resident ) was taken to the hospital, I then went to the MAR and looked to see of (sic) (Resident #1) had any medications ordered for pain. This was around 10:30 PM. I noticed (Resident #1) had Tylenol ordered for pain and had a 9 pm order for ASA (Aspirin). I prepared both, along with her/his insulin, and took the medication to her/his room. ...(Resident #1) then refused her/his insulin, ... was alert and oriented, without any s/s or respiratory distress or shortness of breath... At about 10:50pm, one of my CNAs informed me (resident #1) was c/o difficulty breathing..." On [DATE] at 3:05 PM the Administrator, and the Director of Nurses were notified that Immediate Jeopardy was identified at F-157 at a scope and severity of"J". The Immediate Jeopardy existed in the facility on [DATE] related to the failure of the facility to provide the necessary care and services to 1 of 2 residents with an acute changes in condition. Resident #1 was not thoroughly assessed or treated timely regarding complaints of pain and shortness of breath. Observations, interviews, and review of policy revealed the Allegation of Compliance (AOC) submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of the facility policies and procedures regarding reporting of resident changes in condition, physicians order clarification, ordering medications from the pharmacy and physical assessments. The Administrator was informed of this on [DATE] at 3:15 PM. The Immediate Jeopardy at F-157 was removed but the citation at F-157 remained at a lower scope and severity of "E".

On the days of the complaint and extended survey the facility Administration failed to effectively use its resources to provide the necessary care and services to 1 of 2 residents with acute changes in condition. Resident #1 was not provided the necessary care and services regarding complaints of pain and shortness of breath. The findings included: Cross refers to F-157 as it relates to the failure of the facility to notify the physician/family of an acute change in Resident #1's condition. Cross refers to F-224 as it relates to the failure of the facility to provide the necessary goods and services to prevent harm to Resident #1, 1 of 2 residents with an acute changes in condition. Cross refers to F-281 as it relates to the failure of the facility to meet professional standards of quality. Resident #1, 1 of 2 residents with an acute changes in condition was not adequately assessed or monitored after complaints of pain and shortness of breath. Resident #1 was not assessed after multiple calls to the facility from 911 in response to the resident's calls asking for assistance. Cross refers to F-309 as it related to the failure of the facility to provide adequate care and services to Resident #1's whose complaints of pain and shortness of breath were not addressed. Resident #1 sampled as a result of a complaint and a facility reported incident received by the State Agency. The information provided to the State Agency indicated that on Friday evening, [DATE], Resident #1 was yelling for assistance around 8:30 PM due to pain. Licensed Practical Nurse (LPN) #1 gave the resident Tylenol. Resident #1 continued to have pain and called 911 first at 11:22 PM, then at 11:36 PM and again at 11:39 PM. Emergency Medical Services (EMS) called the facility after the calls at 11:22 PM and 11:35 PM to see if their services were needed and were told by the facility that the resident did not need to be hospitalized . Following the last call at 11:39 PM EMS went to the facility. On arrival EMS began CPR (cardiopulmonary resuscitation) on Resident #1 and s/he was transferred to the hospital. In an interview with the surveyor on [DATE] at approximately 12:45 PM the Director of Nurses (DON) stated that LPN #1 had not worked the 300 hall before. S/he worked 4 shifts orienting with another nurse. S/he worked 2 shifts on a hall with two nurses. She did not orient on the 300 hall. Hall 300 was more short term rehab, more medically complicated hall, trachs, increased acuity. Oxygen and suction are on the walls on that hall. That night there was six (6) tube feedings. The census was 21 on the night of the occurrence." The DON did not know why the resident's medications were not available. "The day shift gave medications. I would expect a phone call if the medications were not available." The DON confirmed at the time of the interview that the facility did not have a Staff Development Coordinator; a supervisor on the ,[DATE] PM shift. On [DATE] at 3:05 PM the Administrator, and the Director of Nurses were notified that Immediate Jeopardy was identified at F-490 at a scope and severity of"J". The Immediate Jeopardy existed in the facility on [DATE] related to the failure of the facility to provide the necessary care and services to 1 of 2 residents with an acute changes in condition. Resident #1 was not thoroughly assessed regarding complaints of pain and shortness of breath. Observations, interviews, and review of policy revealed the AOC submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the facility policies and procedures regarding reporting of resident changes in condition, physicians order clarification, ordering medications from the pharmacy and physical assessments. The Administrator was informed of this on [DATE] at 3:15 PM . The Immediate Jeopardy at F-490 was removed but the citation at F-490 remained at a lower scope and severity of "E".

On the days of the complaint and extended survey, based on observations, record review, interviews and review of the facility investigation, the facility failed to meet professional standards of quality. Resident #1, 1 of 2 residents with an acute changes in condition was not provided necessary care. Licensed Practical Nurse (LPN) #1 was told several times by the staff of Resident #1's complaints of pain and shortness of breath. Emergency medical services (EMS) telephoned the facility after receiving calls directly from Resident #1 and was told by the staff that the resident did not need to be hospitalization . There was no evidence of a comprehensive assessment, no monitoring and no response by the staff to Resident #1's calls to 911. The findings included: Cross refers to F-157 as it relates to the failure of the facility to notify the physician/family of an acute change in Resident #1's condition. Cross refers to F-224 as it relates to the failure of the facility to provide the necessary goods and services to prevent harm to Resident #1, 1 of 2 residents with an acute changes in condition. Cross refers to F-309 as it relates to the failure of the facility to provide adequate care and services to Resident #1's whose complaints of pain and shortness of breath were not addressed. Cross refers to F-490 as sit relates to the failure of the facility Administration to effectively use its resources to provide the necessary care and services to 1 of 2 residents with acute changes in condition. Resident #1 was not provided the necessary care and services regarding complaints of pain and shortness of breath. Resident #1 sampled as a result of a complaint and a facility reported incident received by the State Agency. The information provided to the State Agency indicated that on Friday evening, [DATE], Resident #1 was yelling for assistance around 8:30 PM due to pain. Licensed Practical Nurse (LPN) #1 gave the resident Tylenol. S/he continued to have pain and called 911 first at 11:22 PM, then at 11:36 PM and again at 11:39 PM. Emergency Medical Services (EMS) called the facility after the calls at 11:22 PM and 11:35 PM to see if their services were needed and were told by the facility that the resident did not need to be hospitalized . Following the last call at 11:39 PM EMS went to the facility. On arrival EMS began CPR (cardiopulmonary resuscitation) on Resident #1 and s/he was transferred to the hospital. Review of the Hospital Discharge Summary dated [DATE] stated, "...S/he according to the daughter, apparently had been calling out since about 8:30 this evening callout out (sic) for help and then apparently called emergency medical services herself from her room. She finally tried to receive assistance. S/he was found unresponsive, pulseless and had a rhyme consistent with pulseless electrical activity (PEA) on the monitor. S/he was emergently intubated at the scene and cardiopulmonary resuscitation was initiated and continued on arrival in the emergency room . Pulse and blood pressure were restored after multiple rounds of [MEDICATION NAME]. S/he was admitted to the Intensive Care Unit... Overnight, unfortunately, the patient showed no sign of any meaningful recovery. Now at noon, her pupils are still fixed and dilated with no corneal response... no response to pain... no respirations over the ventilator... The patient was extubated... s/he expired at 13:30 (1:20 p.m.)..." Review of the Resident Progress Note/nursing notes dated [DATE] at 1:25 AM stated, "Patient alert and oriented. C/O (complained of) left hip pain. Pain reliever given as prescribed by physician. At approx. (approximately) 10:50 pm, patient had c/o difficulty breathing. VS (vital signs) checked, BP (blood pressure) ,[DATE]; Pulse 100; Pulse OX 90%; Resp (respirations) 20; Temp (temperature) 97.2. At approx. 11:30 pm, patient called 911 with c/o resp distress. 911 arrived at approx 11:37 pm. Within minutes, resident was unresponsive, and CPR (cardiopulmonary resuscitation) was immediately initiated. MD, family, and DON (director of nurses) were immediately notified of resident's status, and orders were given to transport to... Report given to ER nurse." The Resident Progress Note/nursing note dated [DATE] provides not evidence that Resident #1 was assessed and monitored in response to her/his continued complaint of pain and shortness of breath or assessed after 911's calls to the facility in response to the resident. Review of the facility investigation of the incident revealed an email statement sent sent to the facility, by LPN #1 dated [DATE] at 11:10 AM in the statement LPN #1 confirmed Resident #1 asked for medications at approximately 7:45 PM on [DATE] and the medication was not available, s/he informed the resident the medications had not arrived. At that time LPN #1 stated the resident do not report pain or being short of breath. LPN #1 stated that s/he was caring for another resident who s/he had called 911 for and requested transport. S/he wrote, "... During the whole process, my (certified nurse aids) CNAs kept telling me that (Resident #1) was c/o (complaining of) pain. I repeatedly told them to let (Resident #1) know that I was in the middle of sending a patient to the ER and that I would be with her/him as soon as I could get to her/him. After (the other resident ) was taken to the hospital, I then went to the MAR and looked to see of (sic) (Resident #1) had any medications ordered for pain. This was around 10:30 PM. I noticed (Resident #1) had Tylenol ordered for pain and had a 9 pm order for ASA (Aspirin). I prepared both, along with her/his insulin, and took the medication to her/his room. ...(Resident #1) then refused her/his insulin, ... was alert and oriented, without any s/s (signs/symptoms) or respiratory distress or shortness of breath... At about 10:50pm, one of my CNAs informed me (resident #1) was c/o difficulty breathing... While I was in the room with a patient from room... the third shift nurse came on the hall, and answered the phone. It was 911 wanting to know if a call had been made to 911 stating we had a patient in respiratory distress. I told the nurse we had just sent a patient out about an hour before. 911 then stated that a patient in room ___ (Resident #1) had called 911 around 11:30 and stated to them s/he was in respiratory distress. 911 showed up at the back door and were let in by one of the CNAs and led to (Resident #1's) room. Resident #1 then coded. CPR was immediately initiated. I went to the desk and immediately notified the doctor and DON (director of nurses) of the situation, while another nurse notified the family ... The third shift nurse reported off to the ___ (hospital)." On [DATE] at 3:05 PM the Administrator, and the Director of Nurses were notified that Immediate Jeopardy was identified at F-281 at a scope and severity of"J". The Immediate Jeopardy existed in the facility on [DATE] related to the failure of the facility to provide the necessary care and services to 1 of 2 residents with an acute changes in condition. Resident #1 was not thoroughly assessed regarding complaints of pain and shortness of breath. Observations, interviews, and review of policy revealed the AOC submitted by the facility on [DATE] had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the facility policies and procedures regarding reporting of resident changes in condition, physicians order clarification, ordering medications from the pharmacy and physical assessments. The Administrator was informed of this on [DATE] at 3:15 PM . The Immediate Jeopardy at F-281 was removed but the citation at F-281 remained at a lower scope and severity of "E".

On the days of the survey, based on record review and interviews, the facility failed to provide necessary care and services for one of two sampled residents reviewed. Resident #1 failed to have adequate follow up and assessment after a head injury on 07/13/2012. The findings included: Resident #1 was sent out to the emergency roiagnom on [DATE] at 3:15 AM following a fall with a head injury. He returned to the facility on [DATE] at 1:40 PM with an order to hold his [MEDICATION NAME] x 1 dose due to an INR (international normalizing ratio) of 3.7. On 07/14/2012 at 8:00 AM the resident complained of a headache and was medicated, the physician was not notified. Documentation revealed neurological check were performed only twice at 9:00 AM and 10:00 PM on 07/14/2012, after the resident returned from the emergency room . Sometime after 10:00 PM on 07/14/2012, the resident became stuporous, his blood pressure was 98/58 and he developed a temperature of 100.2 degrees, at which time the physician was called. The resident was sent to the emergency at approximately 12:10 AM on 07/15/2012. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the closed medical record for Resident #1 revealed Nurse's Notes for the month of July 2012 that stated the following: "7/13/12 4 AM Walked into resident's room at 3:15 AM after hearing a bed alarm. Observed resident standing up with blood on his face with assigned CNA (certified nurse aide) attempting to help him sit on his wheelchair when he slid and sat on the floor. On observation noted a laceration to right side of his forehead and a bruise to right hip. Not able to tell how resident got the injuries... laceration measures 3 cm (centimeters) long. Call placed to MD, send resident out to ER (emergency room )... 7:30 AM Call received from ...hospital and given report... resident on the way back to facility... 1:40 P (M) Resident returned from ER this am with new orders to hold [MEDICATION NAME] x 1 dose tonight. Restart [MEDICATION NAME] 5.5 mg (milligrams) on 7/14/12. [MEDICATION NAME] 5/323 mg 1 po (by mouth) q (every) 6 hours prn (as needed) pain... New orders to clean area with NS (normal saline) and apply [MEDICATION NAME] or [MEDICATION NAME] and wrap with kling. Resident sedated this am from hospital. Able to arouse to give am meds. [MEDICATION NAME] and Risperadol held due to sedation... VS (vital signs) WNL (within normal limits) 96.3 (temperature) (T) 18 (respirations) (R) 73 (pulse) (P) 140/89 (bloodpressure) (BP). PERRL (pupils equal reactive to light). No s/s (signs/symptoms) of pain or discomfort at this time. 7/14/12 12:10 A (M) Resident alert with confusion noted. Continues to be noncompliant with bed alarm. Resident removes his gown and tries to get out of bed x 2 this evening. Resident was redirected and cont (continue) [MEDICATION NAME] 0.5 mg. i po given agitation with effective results... 9 AM [MEDICATION NAME] 5/325 mg at 8 AM for c/o (complaint of) headache good effect noted... Attempts to get our of bed. Res (resident) OOB (out of bed) to chair, fall asleep. 6 PM ...back to bed after lunch. Sleeping with no s/s (signs/symptoms) of distress. Son and wife were here visiting. 11:30 PM ...resident very stuporous. Neuro status altered - unable to follow commands, pupil response sluggish. low BP with low grade fever (100.2) Recent fall 7/13/12 ... contacted... Dr... updated him on resident's status/change from established baseline. Ordered resident sent to hospital... Shift supervisor notified... 11:40 PM This nurse went in to resident's room and noted resident sitting up in bed with eyes closed. Resident unable to be aroused verbally or with sternal rub. Unable to follow commands. Pupils sluggish with excessive tearing noted. Drooling noted and faint gurgle noted on expiration audibly... Floor nurse made aware and MD/RP/Ambulance service notified." Review of the CT (computerized tomography) dated 7/13/2012 stated, "Reason for Exam fall, [MEDICATION NAME] pt (patient). Finding: CT HEAD WITHOUT CONTRAST - 07/13/12 05:32 AM. CLINICAL HISTORY: [AGE] year old-male with fall. The patient is on [MEDICATION NAME] FINDINGS: ...There is no midline shift... No [MEDICAL CONDITION] is seen. There is some mild prominence of the extra-axial spaces along the frontal convexities, bilaterally. There is some mild periventricular white matter low attenuation which is similar to the prior study. No definite new areas of low attenuation are seen. The osseous structures appear unremarkable... IMPRESSION: 1. No acute [MEDICAL CONDITION]. 2. There is some mild increased prominence of the extra-axial spaces along the frontal convexities possibly due to some mild increase in atrophy or small subdural hygromas or old hematomas." Review of the emergency room laboratory result dated 07/13/12 at 04:40 showed and INR (international normalizing ratio) of 3.7. Review of the emergency room Patient Visit Summary stated, "...[DIAGNOSES REDACTED]. Review of the Vital Sign Flow Sheet for July 2012 documented the following: 07/13/2012 at 1:40 P (M) 140/80 (BP) 96.7 (T) 78 (P) 18 (R) 07/14/2012 at 7 A (M) - 7 P 118/78 (BP) 98 (T) 72 (P) 18 (R) 07/14/2012 at 10 PM 130/77 (BP) 98.5 (T) 78 (P) 20 (R) 07/14/2012 at 11:20 PM 98/58 (BP) 100.2 (T) 70 (P) 17 (R) Review of Resident #1's NEUROLOGICAL ASSESSMENT FLOW SHEET for the facility reported head injury that occurred on 07/13/2012 at 3:15 AM showed the assessments were performed at 3:15 AM, 3:30 AM, and 3:45 AM at which time the resident was transported to the emergency room . Two additional neurological assessments were documented on 07/14/2012 at 9:00 AM and 10:00 PM, prior to the resident's transport to the hospital due to a change in mental status. Review of the closed medical record indicated an Emergency Dept visit dated 07/14/2012 at 11:03 PM that stated, "...CHIEF COMPLAINT: Altered mental status. HISTORY OF PRESENT ILLNESS: This is an [AGE] year-old white male who was seen here yesterday after a fall at the nursing home. He suffered a right parietal frontal laceration that was repaired... CT scan at that time, I believe on preliminary read, showed no acute abnormality. Retrospectively, there was a read of a possible small subdural hematoma. Patient returns tonight from the nursing home for mental status change, minimally response to painful stimuli... MEDICAL DECISION MAKING: The patient presents with altered mental status after being seen here yesterday for a fall. He is on [MEDICATION NAME], increased risk of bleeding. We are going to repeat the CT scan of the head... RADIOLOGY RESULTS: CT scan of the head does show right side [MEDICATION NAME] hematoma as well as what appears to be a subdural hematoma, possibly some extensive subarachnoid, ventricular peritoneal shunt is also noted along with chronic changes..." Review of the facility policy and procedure manual included a Neurological Assessment policy that stated, "Flow sheet and Assessments: The Neurological Assessment Flow Sheet shall be initiated by a written physician's order for neurological checks or when indicated by a resident assessment... Neurological assessments shall be performed at least every four hours for the first 24 hours and then at least every eight hours, unless ordered more or less frequently by the physician or when the resident is determined to be at risk for neurological decompensation. In a telephone interview with Licensed Practical Nurse (LPN) #1 on 08/08/2012 at 9:00 AM she confirmed that she did neurological checks on Resident #1 at 10:00 PM on 07/14/2012 and that he became stuporous sometime after 10:00 PM, at which time she called the Nursing Supervisor to assess the resident. LPN #1 stated that after the fall he had been cleared by the emergency room .