Every finding on record at Lorien Bulle Rock

Based on review of facility reported incident details, resident medical records, facility staff personnel files, and interview with facility staff, it was determined that the facility failed to ensure a resident was free from abuse. This was evident for 1 (Resident #76) out of 35 residents reviewed during the annual survey. The findings include: The Office of Health Care Quality received a facility reported incident on 3/22/23, MD00190490, that alleged a facility staff, Registered Nurse, RN #12, verbally abused Resident #76 on 3/20/23 during the 3 pm to 11 pm shift. In the investigation, the facility substantiated through multiple witnesses (Staff # 13, GNA #14, Staff #15, and GNA #16) that RN #12 used verbally abusive and inappropriate language while rendering care to Resident #76. Resident #76 was was admitted to the facility on [DATE] for long term care services. At the time of the incident, Resident #76 was under hospice care with diagnoses including, Alzheimer's, Dementia, and Repeated Falls. Review of Resident #76's MDS assessment dated [DATE] showed the resident was dependent for all care, transfers with a mechanical lift, and his/her BIMS was 1/15. A review of the facility investigation file showed: Resident #76 does attempt to get out of bed on his/her own and requires frequent monitoring from staff to keep him/her safe. On the evening shift of 3/20/23, Resident #76 was brought into the hallway in a recliner to offer a change in environment and allow staff to monitor him/her more closely. The Resident was repeatedly attempting to climb out of her chair, putting himself/herself in danger of falling which required constant supervision and interaction with staff. Staff later reported that the assigned Nurse,RN #12, showed visible signs of stress secondary to the needs of the residents that were in her assignment. Staff report that RN #12 made comments loud enough to be heard by anyone in the area that were degrading . On 6/25/25 at 12:25 PM further review of the investigation file revealed a handwritten statement by Housekeeping Staff #13 that reported that RN #12 was yelling at Resident #76 and grabbing his/her pant leg, pulling his/her leg violently and RN #12 said infront of the resident, If I could open the stairwell door, I would push the resident in there. The file also revealed that another facility staff member, geriatric nursing assistant, GNA #14, wrote a statement that he/she witnessed RN #12 being verbally harsh to Resident #76 on 3/20/23 during the 3pm to 11pm shift. Statements from a Dietary Aide, Staff #15, revealed that he/she saw RN #12 pushing a Resident into a chair and telling him/her to sit down, then stating you know what, get up and fall down, I don't care and then walked away. An additional statement was reviewed which noted that GNA #16 wrote a statement that he/she saw with his/her own eyes on 3/20/23 RN #12 threaten to push Resident #76 down the back steps. Review of a documented interview held on 3/24/23 between the Director of Nursing (DON) and RN #12 showed that: RN #12 reported that this Resident (Resident #76) and one other were restless that evening and he/she did not respond appropriately. RN #12 stated that he/she had an Emotional breakdown and realized he/she needed to remove himself/herself from the unit. He/She reports that he/she used inappropriate language stating that I have to get the he!! out and that he/she can't stand this damn s*!t. He/She reports that her words were not directed towards anyone, it was just his/her response to the situation. On 6/25/25 at 1:09 PM the surveyor reviewed the facility's Abuse Prevention Policy which defined verbal abuse as: The use of oral, written or gestured language that willfully includes disparging and derogatory terms to residents {or their families}, or within their hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident On 6/25/25 at 1:18 PM a review of RN #12's personnel file, revealed a front page that stated Do not rehire, he/she would have been terminated for verbal abuse. Term date 4/1/23, last day worked 3/20/23. The surveyor reviewed this information with the DON who confirmed the findings in RN #12's personnel file. On 6/26/25 at 7:30 AM the surveyors held an interview with the DON. The surveyors reviewed the staff's witness statements and UM #12's statement with the DON. The DON confirmed that the allegation of verbal abuse was substantiated and even though UM #12 did not return to work since 3/20/23, the decision had been made to terminate UM #12's employment due to these findings.

Based on interviews and record review, it was determined that the facility failed to immediately report an allegation of abuse to the State Office of Health Care Quality within the allotted two-hour timeframe. This was found evident in 2 out of 4 (Resident #74 & 81) residents reviewed for abuse allegations during an annual and complaint survey.The findings include: 1a) On 6/30/25 at 9:15 AM, the surveyor reviewed the facility investigation into an allegation of abuse related to Resident #81. The investigation revealed that an allegation of abuse was reported to a staff member by Resident #81's family member on 4/12/25 in the afternoon, however, the date the allegation was reported to the Office of Health Care Quality (OHCQ) and the date the investigation was started was 4/13/25.On further review, a progress note written on 4/12/25 at 3:07 PM, by Licensed Practical Nurse (LPN) #10, stated that Resident #81's daughter reported that Resident #81 told her that someone working the night shift had been hurting him/her. On 6/3/25 at 10:58 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the NHA confirmed that the allegation was not reported to the OHCQ immediately (two hours after the allegation) and that the reason why the allegation was not reported or the investigation started, was due to the staff not notifying him until the following day.1b) On 06/25/25 at 11:20 am a review of the facility's investigation related to Resident #74 revealed Maintenance Tech #19 statement indicated the resident told them about the alleged incident on 10/11/22 10:30 am. EVS Director #18 reported on 10/11/22 at 2:30 PM that the resident reported being smacked by someone during the early hours on the 11 PM - 7 AM shift. At 12:02 PM further review of the investigation revealed the incident was reported to the state agency at 4:30 PM which was outside of the 2-hour allotted timeframe to report an allegation of abuse. On 06/25/25 at 2:02 PM during an interview with the Director of Nursing (DON) the surveyor asked what the expectation of the staff related to reporting allegations of abuse. The DON verbalized that the staff should report abuse immediately to the DON or Administrator. They are aware of the 2-hour window and there was no reason for the delay. They typically report allegations of abuse within 2 hours.

Based on record review and interviews it was determined that the facility staff failed to interview all the staff who worked on the unit during the investigative phase of an allegation of abuse. This deficient practice was evidenced in 1 (#74) of 10 facility reported incident investigation reviewed during the recertification and complaint survey. The findings include: On 6/25/25 at 11:20 AM a review of the facility's investigation of Resident #74 allegation of abuse, the surveyor noted all the staff who worked on the unit during the alleged incident, statements were not included in the investigation. On 6/26/25 at 2:02 PM during an interview with the Director of Nursing (DON) the surveyor asked what process they follow when completing an investigation. The surveyor asked if there were statements from two Geriatric Nursing Assistant's (GNA) and a nurse who also worked on the unit during the time of the alleged incident. The DON verbalized they are in the process of revamping the policy on how investigations will be done. There were only 2 GNA's working at that time. The other GNA came in at 3 AM. Usually they interview everyone who worked. Not sure why the interviews are not part of the investigation because they always do that.

Based on medical record review and an interview it was determined that the facility failed to hold care plan meetings with the interdisciplinary team for a resident at the time of the quarterly revision of their care plan. This was evident for 1 (Resident #24) of 35 residents reviewed during the annual recertification survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). On June 26, 2025, at 4:25 PM, the medical records for Resident #24 were reviewed. This review showed that Resident #24 had a quarterly MDS assessment on October 24, 2024, and an annual MDS assessment on April 22, 2025. Review of the progress notes in Point Click Care (PCC) indicated that no care plan meetings were held with the interdisciplinary team for Resident #24 in October 2024 and April 2025. On June 27, 2025, at 9:39 AM, Staff #4 was interviewed and asked if documentation could be provided for Resident #24's care plan meetings with the interdisciplinary team for October 2024 and April 2025. Staff #4 replied that they have documentation for January and June 2025 care plan meetings with the interdisciplinary team for Resident #24, but they do not have documentation for care plan meetings in October 2024 or April 2025 for Resident #24.

Based on record review and staff interview it was determined that the facility failed to reposition the resident, toilet or check the resident for being wet or being soiled for 4.5 hours. This was evident for 1 (Resident #80) of 1 residents reviewed for ADL's during an annual and complaint survey Findings include: On June 30, 2025 at 9:45 AM during a chart review, it was noted that the Physical Therapist/Occupational Therapist had documented that after therapy on 3/25/2025, the resident was returned to his/her room at 11:00 AM and instructed to sit in the chair for 1 hour. The resident was given the call bell and told to alert the staff when he/she was ready to go back to bed. The surveyor reviewed a complainant that stated that Resident #80's daughter called at 3:15 PM stating that he/she was left in the wheelchair since early that morning and that no one had responded to his/her call bell. At 9:15 AM on July 1, 2025, a further chart review noted that on 3/25/2025 at 3:41 PM, Registered Nurse (RN) #20 received a call from the resident's daughter stating his/her parent had been in the chair since 11 AM and needed to be put to bed. The nurse reported that the resident stated he/she had been in the chair for 6 hours. On July 1, 2025 at 9:49 AM the Director of Nursing (DON) was interviewed and stated that according to the documentation the resident was put back to bed at 3:21 PM on 3/25/2025. There was no documentation for the resident being re-positioned, toileted or checked for being wet or soiled.

Based on observation, interview and record review, it was determined that the facility failed to ensure proper medication storage according to professional standards of practice. This was found to be evident for 1 out of 3 medication carts observed during the recertification survey. The findings include: During an observation of a second-floor medication cart on [DATE] at 9:04 AM, a bottle of Acetaminophen was found with a manufacturers expiration date of 4/2025 and was labeled opened on [DATE]. LPN #7 stated that the Acetaminophen expired and needed to be discarded. No open date was found on a bottle of Milk of Magnesia and an open bottle of Active Critical Care liquid protein labeled as opened [DATE]. LPN #7 stated that both bottles should be discarded. On [DATE] at 10:22 AM the Director of Nursing was shown pictures of the bottles found in the medication cart. He acknowledged the concerns of unlabeled and expired bottles found in the medication cart.

1c) On 7/01/25 at 8:45 AM a review of Resident #225 printed medical record revealed there was no documentation to verify the resident was repositioned at least every two hours. In addition, the staff documented the type of assistance the resident needed to get dressed but the documentation did not specify whether the resident was dressed. On 7/01/25 at 9:45 AM during an interview with the Director of Nursing (DON), the surveyor verbalized there was no documentation to verify the resident was being turned and/or repositioned. The DON verbalized they recently started having the GNA's sign off in Tasks. The staff should make sure the residents are turned every 2 hours. Based on interviews, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete and accurate documentation. This was found evident in 3 (Resident #62, #28 & #225) out of 35 residents reviewed during the survey. The findings include: 1a) On 6/24/25 at 9:06 AM, the surveyor conducted an interview with Resident #62. During the interview Resident #62 stated that he/she had struggled with constipation at times but was also offered medications to help. On 6/25/25 at 11:58 AM, the surveyor reviewed Resident #62's medical record. The review revealed that the TASK documentation had an area to document Bowel Movement (BM) size and consistency as well as control as in continent/incontinent. The surveyor reviewed the June 2025 documentation for size and consistency and noted Resident #62 was documented as having no bowel movement from 6/9/25-6/17/25, (9 days). On review of the control of bowel movement for June 2025 Resident #62 was documented as having no bowel movement from 6/9/25-6/13/25 (5 days). On further review the surveyor noted a progress note written on 6/12/25 by Nurse Practitioner (NP) #11 that stated Resident #62 reported that he/she had to strain to have bowel movements. The note further addressed the concern with a medication adjustment. On 6/26/25 at 7:40 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor relayed the concern about prolonged days of no bowel movement for Resident #62. The DON stated he believed the documentation was inaccurate and that he would follow-up. The surveyor conducted a follow-up interview with the DON. During the interview the DON provided the surveyor with a routine skilled note dated 6/13/25 in which Resident #62's Date of Last BM was documented as 6/11/25. He further stated he agreed that there were inconsistencies and inaccuracies in the documentation and that the facility started re-education in regards to documenting expectations. 1b) On 6/25/25 at 8:55 AM, the surveyor reviewed Resident #28's medical record. The record reviewed documentation that a wander bracelet was on Resident #28's left ankle. On 6/27/25 at 10:47 AM, the surveyor reviewed Resident #28 Minimum Data Set (MDS) assessments. On the assessment dated [DATE] and 4/15/25 Resident #28 was documented as having no wandering behaviors in section E. Next the surveyor reviewed resident #28's care plan. A care plan was initiated on 3/10/25 that stated Resident #28 is at risk for elopement related to exit seeking behaviors. On 6/27/25 at 9:39 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked the DON why a care plan was initiated for elopement when there was not documentation in the medical record to indicate Resident #28 had exit seeking behaviors. The DON stated he would look into it and follow-up. He further stated he was not sure why the behaviors were not coded in the MDS assessment. On 6/27/25 at 10:12 AM, the surveyor conducted a follow-up interview with the DON and Minimum Data Set Coordinator Staff #5. The DON stated that he spoke to the unit manager and the day the care plan was created the unit manager observed the resident in the hallway by the door, and that the Resident stated that he/she was going to go home. He confirmed that there was no documentation in the medical record of this incident. Staff #5 confirmed that the elopement/wandering was not coded in the MDS assessment because the behavior was not documented in the medical record. The DON confirmed that this behavior should have been documented in the medical record.

Based on clinical record review, observation, resident interview, and staff interview it was determined that the facility staff failed to ensure residents' pain management programs were overseen in a consistent manner. This was evident for 2 (#13 and #20) out of 27 residents in the survey sample. The findings are: 1. Resident #20 was interviewed on 06/22/22 at 10:33 AM. The resident stated that he/she has chronic back pain that radiates throughout the body and gets creams to treat. The resident was not observed to be in pain. A review of Resident #20's clinical record on 6/24, 6/27, and 6/28 revealed that the resident was ordered [MEDICATION(S)] (pain medication) 5 mg every 6 hours as needed for moderate to severe pain to address the resident's chronic back pain. The nursing staff monitor the effectiveness of the pain medication by asking the resident to rate their pain level before and after the administration of the pain medication. The resident's plan of care includes interventions to: 1) Resident will experience relief or decrease in pain until score is met which allows for optimum and maximum functioning until next review. 2) Monitor for s/s of constipation related to use of pain medications and administer bowel medications as ordered. 3) Administer pain medication as per MD orders and note the effectiveness. 4) Give PRN meds for breakthrough as per MD orders and note the effectiveness. 5) Acknowledge presence of pains and discomfort. Listen to resident's concerns. 6) Document/Report complaints & non-verbal signs of pain. The following is a list of days where the resident's pain level was the same but there was no mention of an alternative pain relief strategy that was implemented nor was the physician contacted. It some cases there was also a long time gap between the times the pain level was checked. 4/2 15:01 10 16:59 10 4/2 21:28 10 4/3 00:37 0 4/4 16:21 10 17:02 10 20:53 6 22:17 10 23:45 1 4/6 05:51 8 06:39 1 07:36 0 4/13 15:35 10 16:34 10 4/14 15:39 10 16:10 10 4/15 16:01 10 18:03 10 4/15 22:34 10 Not checked again. 4/18 17:20 10 17:59 10 4/19 15:58 10 16:57 10 22:29 10 22:30 10 4/22 15:54 10 17:58 10 21:09 10 22:44 10 23:35 0 4/25 15:01 10 17:20 10 No Further checks 4/26 15:25 10 18:36 10 20:29 10 23:03 10 4/27 15:16 10 15:48 10 18:01 10 21:38 0 5/03 17:36 10 19:33 10 6/23 08:54 10 18:15 3 6/27 13:51 9 14:11 6 17:47 7 Pain level checked after 12 midnight 6/28 00:07 0 This surveyor did not observe the resident to be pain nor was it clear in the clinical record that the resident was in any unresolved pain for any extended period of time on a consistent basis. The Director of Nursing (DON) was interviewed on 6/28/22 at 8:42 AM. He was informed of the findings. Unit Manager (Staff #5) was interviewed on 6/28/22 at 10:02 AM. She said the physician was aware of the pain management issue. She said, and showed where the physician documented, that the physician suspects the pain is related to depression, so he decreased the [MEDICATION(S)] in December and increased the [MEDICATION(S)] (medication to treat depression) to 60 mg. The physician ordered in December 2021 Biofreeze (pain relieving spray) to be administered twice a day. The physician ordered a [MEDICATION(S)] (steroid) injection 40 mg to be administrated on 11/20/21 and 6/10/22. The physician also ordered acetaminophen 500 mg twice a day. Staff #5 stated that it is an education issue with the nurses. They should be addressing and/or documenting how they address when the resident states the pain level has not changed. She said the resident participates in all activities and has had no limitations related to pain. Staff #5 provided a copy of a physician's note from 12/27/21. The physician wrote: I suspect the patient has a component of depressive symptoms presenting as physiologic complaints. [He/She] is currently on [MEDICATION(S)] 60 mg daily. I will continue to monitor the patient with help from psychiatry. I will increase the patient's [MEDICATION(S)] [pain medication] to 600 mg every 8 hourly. I will monitor [him/her] for symptom relief. 2. A review of Resident #13's clinical record revealed that the resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that the physician was notified and/or that the nursing staff attempted an alternative intervention. The resident has a care plan that includes: 1. Administer pain medication as per MD orders and note the effectiveness. 2. Give PRN meds for breakthrough as per MD orders and note the effectiveness. 3. Acknowledge presence of pains and discomfort. Listen to resident's concerns. 4. Document/Report complaints & non-verbal signs of pain. The Director of Nursing (DON) was interviewed on 6/28/22 at 8:42 AM. He was informed of the findings. No further information to contradict the findings was presented prior to the team exiting the facility.

Based on medical record review, it was determined that facility staff failed to notify the physician of finger stick results below 100 as ordered by the physician for Resident #21. This was evident for 1 of 27 residents reviewed during the survey process. The findings include: Medical record review for Resident #21 on 6/24/22 at 10:00 AM revealed on 2/7/22 the physician ordered: Glucose Check (finger stick) before meals and bedtime; call physician if finger stick is <100 or >350. A fingerstick is a minimally invasive procedure using a lancet to draw a drop or two of capillary blood from a finger and is an easy way to measure the amount of a certain substances in your blood (glucose). Medical record review revealed the facility staff obtained and documented the resident's finger stick on: 3/2/22 at 4:31 PM as 91, 3/6/22 at 12:30 PM as 94, 3/8/22 at 11:30 AM as 80, 3/18/22 at 11:30 AM as 80, 3/21/22 at 11:42 AM as 91, 3/26/22 at 11:30 AM as 96, 4/10/22 at 11:30 AM as 84, 5/18/22 at 11:53 AM as 96, 5/22/22 at 6:22 AM as 71, 5/30/22 at 11:30 AM as 90, 6/2/22 at 12:09 PM as 83, and 6/8/22 at 11:30 AM as 97; however, there is no evidence the facility staff notified the physician of the finger stick below 100 per order. Interview with the Director of Nursing on 6/28/22 at 8:30 AM confirmed the facility staff failed to notify the physician when the finger stick was below 100 per order. Interview with the Nursing Home Administrator and Director of Nursing on 6/28/22 at 2:00 PM were notified of the concern of the facility staff failure to notify the physician of finger sticks below 100 for Resident #21 as ordered.

Based on medical record review it was determined the facility staff failed to perform a bladder scan as ordered for Resident #199 and failed to notify the physician of the results of a bladder scan for Resident #300 as ordered by the physician. This was evident for 2 of 27 residents selected for review during the annual survey process. The findings include: A bladder scan is a safe, painless, reliable procedure that allows the facility staff to assess the volume of urine retained within the bladder. The bladder scan measures ultrasonic (sound wave) reflections within the resident's body to differentiate the urinary bladder from the surrounding tissue. It is a noninvasive portable tool for diagnosing, managing, and treating urinary outflow dysfunction. Bladder scans determine the need for catheterization. 1. The facility staff failed to perform a bladder scan as ordered for Resident #199 as ordered by the physician. Medical record review on 6/23/22 at 12:00 PM for Resident #199 revealed on 6/22/22 at 3:00 PM the physician ordered: bladder scan x 1 and call physician with the results. Further record review revealed no evidence that the bladder scan was done. Interview with the Unit Manager #5 on 6/28/22 at 8:00 AM confirmed the facility staff failed to perform the bladder scan as ordered by the physician for Resident #199. Interview with the Nursing Home Administrator and Director of Nursing on 6/28/22 at 2:00 PM were notified of the facility staff failure to perform a bladder scan as ordered for Resident #199. 2. The facility staff failed to notify the physician of the results of a bladder scan as ordered for Resident #300. Medical record review for Resident #300 on 6/24/22 at 1:00 PM revealed on 12/22/21 the physician ordered: bladder scan x 1 related to bladder retention and call physician with results. Further record review revealed the facility staff performed the bladder scan on 12/22/22 as ordered; however, there is no evidence the facility staff notified the physician of the results as ordered. Interview with the Director of Nursing on 6/27/22 at 8:00 AM confirmed the notification of the results to the physician could not be obtained and assumed not done. Interview with the Nursing Home Administrator and Director of Nursing on 6/28/22 at 2:00 PM revealed the concern that the facility staff failed to notify the physician of the results of a bladder scan as ordered by the physician for Resident #300.

Based on observations and staff interviews it was determined the required staff posting information was not in prominent place readily accessible to residents and visitors. This was evident during the entire survey process. The finding includes: On 6/21/22, 6/22/22, 6/23/22, 6/24/22 and 6/27/22 the required nursing staffing information per this regulation the facility staffing posting was not posted visible upon entering the facility or readily accessible to residents, family members and legal representatives of residents. On 6/27/22 at 1:00 p.m. interview of Administrator and Director of Nursing verified the required staff posting was not available for resident or visitors during the survey process. The finding was discussed with the Administrator and Director of Nursing in detail of this concerns prior and during survey exit conference held on 6/28/22 at approximately 2:30 p.m.

Based on medical record review it was determined that the facility staff failed to ensure Residents #4 and #300 were free from un-necessary medications. This was evident for 2 of 5 residents selected for review of un-necessary medications and 2 of 27 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to ensure Resident #4 was free from un-necessary pain medication. Medical record review for Resident #4 on 6/22/22 at 11:30 AM revealed on 9/17/21 the physician ordered: [MEDICATION(S)] 5 milligrams (mgs.) by mouth every 6 hours as needed for severe pain. [MEDICATION(S)] belongs to a class of drugs known as opioid analgesics and is used to help relieve moderate to severe pain. It works in the brain to change how the body feels and responds to pain Medical record revealed the facility staff assessed and documented the resident's pain level as 0 on: 6/1/22 at 9:01 AM, 6/1/22 at 4:04 PM, 6/5/22 at 2:17 PM, 6/6/22 at 3:14 PM (1), 6/7/22 at 5:06 PM (1), 6/11/22 at 8:34 AM, 6/11/22 at 3:09 PM, 6/15/22 at 3:15 PM, 6/20/22 at 2:34 PM, 6/21/22 at 1:30 PM, 6/25/22 at 6:36 PM and 6/26/22 at 2:49 PM; however, documented the administration of the [MEDICATION(S)]. Interview with the Director of Nursing on 6/27/22 at 10:45 AM confirmed the facility staff failed to ensure Resident #4 was free from un-necessary medication with the administration of [MEDICATION(S)] with a documented pain of 0 and 1 on 2 occasions. Interview with the Nursing Home Administrator and Director of Nursing on 6/28/22 at 2:00 PM were notified on the concern of the facility staff documenting a pain level of 0 and 1 on 2 occasions; however, documented the administration of [MEDICATION(S)]. 2. The facility staff failed to ensure Resident #300 was free from unnecessary medication. Medical record review for Resident #300 on 6/24/22 at 10:30 AM revealed on: 12/29/21 the physician ordered: [MEDICATION(S)] 10 milligrams (mgs.) by mouth 3 times a day related to [CONDITION(S)], hold for systolic blood pressure (SBP- top number) (>) greater than 135. On 12/29/21 the physician also ordered: [MEDICATION(S)] .2 mgs by mouth 2 times a day related to [CONDITION(S)] and hold for SBP > (greater than) 135. [CONDITION(S)] - also called postural [CONDITION(S)] - is a form of low blood pressure that happens when standing after sitting or lying down. [MEDICATION(S)] is used to treat [CONDITION(S)]. Fludrocortisone is a medication that seems to help some types of low blood pressure. It works by promoting sodium retention in the kidney. It works by causing blood vessels to tighten, which increases blood pressure fluid retention and some swelling, which is necessary to improve blood pressure. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1/3/22 evening shift the facility staff documented the resident's blood pressure as 149/88 and 1/5/22 early shift documented the residents blood pressure as 180/80; however, documented the administration of the Fludrocortisone at that time. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 1/7/22- early shift 158/72, 1/8/22- early shift 159/75, 1/8/22- evening shift 153/74, 1/9/22- early shift 146/69, 1/10/22- early shift 150/74, 1/10/22- evening shift 157/74, 1/11/22- early shift 158/66, 1/11/22- evening shift 154/78, 1/12/22 evening shift 158/62 and 1/14/22 early shift 142/80; however, documented the administration of the [MEDICATION(S)] and Fludrocortisone when the SBP was above the set parameter of 135. Interview with the Director of Nursing on 6/27/22 at 9:30 AM confirmed the facility staff failed to hold [MEDICATION(S)] and Fludrocortisone as ordered when the documented SBP was above 135. Interview with the Nursing Home Administrator and Director of Nursing on 6/28/22 at 2:00 PM were notified that the facility staff failed to ensure Resident #300 was free from un-necessary medications by documenting the administration of blood pressure medications when the SBP was above the set parameter as ordered by the physician.

Based on medical record review and interview, the facility staff failed to notify a resident's representative when there was a medication change and change in condition (Resident #1). This was evident for 1 out of 4 residents reviewed during a complaint survey. The finding include: During interview with Resident #1's representative on 8/22/19 at 11:57 am, he/she stated the facility failed to notify him/her of a medication change of [MEDICATION NAME] being discontinued in (MONTH) 2019 and a transfer to the hospital on [DATE] until after the Resident was sent to hospital. Review of Resident #1's medical record revealed the Resident was admitted to the facility on [DATE]. On 11/21/18 the Resident was assessed by the physician to be capable to make his/her own decisions. During a hospitalization [DATE] until 1/29/19 Resident #1 was assessed by psychiatry and deemed incapable to make decisions. After readmission to the facility, 2 physicians also certified the Resident to unable to comprehend information and make decisions on 1/30/19 and 3/19/19. Further review of the medical record reviewed the Resident had selected the complainant to be her health care agent on 6/4/18. Further review of Resident #1's medical record revealed the Resident returned from the hospital on [DATE] and the Resident was no longer receiving [MEDICATION NAME]. The facility staff at that time failed to notify the Resident's representative of the discontinuation of [MEDICATION NAME]. During the interview with complainant on 8/22/19, he/she stated he/she advised the facility staff if the Resident needed to be sent to the emergency room to please notify him/her prior because when 911 is called the hospital the Resident would be sent to could not address changing her nephrostomy and then the Resident would either be later transferred to a different hospital or the representative would have to do a follow up appointment. A nephrostomy tube is a catheter that is put into your kidney to drain your urine. The Resident's representative stated on 6/26/19 he/she came to the facility at approximately at 6 PM because the Resident called him/her and stated he/she had blood in his/her nephrostomy bag. On arrival the Representative stated he/she spoke to RN #1 and RN#1 stated the facility was going to monitor the Resident and not send to hospital. The Resident's Representative stated he/she again told RN #1 to please call him/her if decided to send to the hospital so he/she can take the resident. The Representative stated he/she went home and was called later that evening and advised by RN #1 the Resident had already been sent to the hospital. Interview with the Director of Nursing on 8/22/19 at 2:00 PM confirmed the surveyor's findings.

Based on record review and interviews it was determined the facility staff failed to provide showers to Residents (#20, #23, #35 and #21). This was evident for 4 of 39 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to provide showers to Resident #20. Medical record review for Resident #20 revealed the resident was to have showers on 3-11 shift on Wednesday and Saturday. Review of staff documentation revealed the facility staff documented showers for Resident #20 on 8/29/18, 9/7/18, 9/15/18 and 9/22/18 (4 showers in 2 months). Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to provide Resident #20 showers at least 2 times a week. 2. The facility staff failed to provide showers to Resident #23. Interview with Resident #23 on 10/2/18 at 12:00 PM revealed Resident #23 revealed he/she did not get 2 showers a week. The resident also indicated she/he would like to have a shower on 10/2/18. Facility staff documentation revealed Resident #23 is to have showers Monday/Wednesday/ Thursday/ Friday and Saturday. Review of facility staff documentation revealed the facility staff documented the resident received showers on 9/12/18, 9/19/18, 9/21/18 and 9/30/18 (4 showers, although showers are ordered 5 days a week). Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to provide Resident #23 showers at least 4 times a week as ordered by the physician. 3. The facility staff failed to provide showers to Resident #35. Interview with Resident #35 on 10/2/18 at 12:30 PM revealed the resident stated he/she did not receive 2 showers a week and has not had a shower for a while. Medical record review for Resident #35 revealed the resident was to receive showers at a minimum on Thursday 3-11 shift. Further review of staff documentation from 8/21/18 to 10/2/18 revealed the facility staff documented Resident #35 received a shower on 8/30/18 and 9/13/18 (2 showers in 2 months). Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to provide Resident #35 showers at least 2 times a week. 4. The facility staff failed to ensure Resident #21 received showers. Resident #21 was interviewed on 10/2/18 at 10:30 AM. The resident stated that he/she had only received showers half of the time. Medical record review for Resident #21 revealed the resident was to have showers on Mondays and Thursdays on day shift. The resident's clinical record revealed the resident received a shower on 9/3/18 and 9/28/18 in the months of September. Interview with the Director of Nursing on 10/4/18 at 2:00 PM confirmed the facility staff failed to administer showers to Resident #21.

Based on observation and staff interview it was determined the facility staff failed to provide Resident #35 with the most dignified existence. This was evident for 1 of 39 residents selected for review during the survey process. The findings include: During initial surveyor interview with Resident #35 on 10/2/18 at 10:00 AM facility staff nurse #1 and Geriatric Nursing Assistant (GNA) #1 entered the room without knocking and proceeded to attend to Resident #35's roommate. Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff nurse #1 and GNA #1 failed to knock on the door of Resident #35's room and wait for permission to enter prior to entering the room.

Based on record review, it was determined that the facility staff failed to properly void an old MOLST form when a new one is created. This was evident for 1 (Residents #62) of 9 residents reviewed for advance directives during an annual recertification survey. The findings include: A [NAME]land MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. Instructions for completing a [NAME]land MOLST include: A Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) must be accurately and legibly complete the form and then sign and date it. Voiding the Form: to void this medical order form, a physician or nurse practitioner shall draw a line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician or nurse practitioner to void the MOLST order f orm. Keep the voided order form in the patient's active or archived medical record. Review of Resident #62's medical record on [DATE] revealed Resident #62 had 2 active MOLST forms in his/her medical record that were incongruent. The first MOLST form was dated [DATE] and indicated Resident #62's had completed the MOLST form and wanted to be a Full Code/Attempt CPR. The second MOLST was dated [DATE] and was also created by Resident #62. The second MOLST form indicated Resident #62 want to be a No CPR, Option B, Palliative and Supportive Care, (MONTH) use only [MEDICAL CONDITION] or [MEDICAL CONDITION] for artificial ventilation, as medically indicated, (MONTH) give blood products, (MONTH) transfer to the hospital for any situation requiring hospital-level care, (MONTH) perform any medical tests to diagnose and/or treat a medical condition, (MONTH) use antibiotics, may give fluids for artificial hydration as a therapeutic trial, but do not give artificial nutrition. The facility staff must take steps to properly void an older MOLST form as this may lead the nursing staff to perform or not perform a Resident's correct end of life wishes.

Based on complaint, reviews of a closed record, and staff interview, it was determined that the facility staff failed to notify residents and/or representative and the Ombudsman of transfer and reason for transfer to the hospital in writing. This was evident for 2 (Resident #216 and #66) of 2 residents reviewed for hospitalization during an annual recertification survey. The findings include: 1. Review of complaint MD 182 on 10/3/18 revealed an allegation that Resident #216 was not allowed to return to the facility after a brief hospitalization . Review of the medical record for Resident #216 revealed the resident was transferred to an acute care facility on 4/29/18. There was no documentation found in the medical record that the resident, the resident's responsible party, or the Ombudsman was given written notice of Resident #216 being transferred to the hospital and the reason for the transfer to the hospital. On 10/5/18 at 9:15 AM, the facility Administrator stated that Resident #216 and the Resident's responsible party did not receive written notice as to why Resident #216 was being transferred to the hospital and the reason for the transfer to the hospital 2. Review of the medical record for Resident #66 revealed the resident was transferred to an acute care facility on 8/3/18 and returned to the facility on [DATE]. There was no documentation found in the medical record that the resident or the resident's responsible party was given written notice of Resident #66 being transferred to the hospital and the reason for the transfer to the hospital. On 10/5/18 at 11:06 AM, the Director of Nurses confirmed that Resident #66 and the Resident's responsible party did not receive written notice as to why Resident #66 being transferred to the hospital and the reason for the transfer to the hospital.

Based on review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, at the time of the resident transfer for hospitalization . This was evident for 1 (Resident #66) of 5 residents reviewed for hospitalization during an annual recertification survey. The findings include: Review of the medical record for Resident #66 revealed the resident was transferred to an acute care facility on 8/3/18 and returned to the facility on [DATE]. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. On 10/5/18 at 11:06 AM, the Director of Nurses confirmed that Resident #66 and the Resident's responsible party did not receive the facility bed hold policy when Resident #66 was transferred to the hospital on [DATE].

Based on medical record review, observation and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for residents (#30 and #35). This was evident for 2 of 39 residents selected for investigation during the survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of [DIAGNOSES REDACTED]. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. 1. The facility staff failed to update and revise care plan for Resident #30 to reveal an accurate assessment and interventions. Medical record review for Resident #30 revealed on 5/13/16 the facility staff initiated a care plan for Resident #30 addressing: Resident has exit seeking behavior related to impaired cognition and wandering behavior. Surveyor observation of Resident #30 during the survey process revealed Resident #30 no longer has exit seeking behavior related to decline in physical mobility and cognition. Further record review revealed the facility staff assessed the resident on 8/17/17, 11/17/17, 2/17/18, 5/31/18 and 8/3/18; however; failed to update the care plans to reflect accurate assessments and interventions. Interview with the Director of Nursing (DON) on 10/5/18 at 2:00 PM confirmed the facility staff failed to review and revise care plans for Resident # 30 to reflect current and appropriate interventions related to exit seeking behavior. The DON confirmed Resident #30 is not exit seeking related to declined physical mobility and decline in cognition. 2. The facility staff failed to conduct a care plan meeting for Resident #35. Medical record review revealed the facility staff assessed Resident #35 on 3/9/18, 3/19/18 and 5/10/18. Further record review revealed the facility conducted a care plan meeting on 3/9/18; however, there is no evidence the facility staff conducted a care plan meeting to address the MDS assessments and ensure accurate interventions were noted on care plans for assessments done on 3/19/18 and 5/10/18. Interview with the Director of Nursing (DON) on 10/5/18 at 2:00 PM confirmed the facility staff failed to conduct a care plan meeting for Resident #35 for each MDS completed.

Based on medical record review, observation and interview, it was determined the facility staff failed to apply ace wraps to Resident #35 according to the standard of practice. This was evident for 1 of 39 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #35 revealed on 5/12/18 the physician ordered: ace bandage to bilateral lower extremities, apply in morning and remove at bedtime. Typically, legs swell during the day because of dependent [MEDICAL CONDITION], meaning because a resident is up (even in a chair) fluid settles in feet, ankles and lower legs. This swelling should disappear at night when laying down. Typically, health care providers recommend wrapping legs or support stockings when the resident is up and then nothing during the night to give them a break and let the skin breath. It is the standard of practice to apply the ace bandage to the knee (unless thigh high is ordered). Surveyor observation of the resident on 10/4/18 at 12:30 PM revealed the facility staff applied an ace wrap; however, the ace wrap only encompassed the lower portion of the resident's leg, just above the resident's ankle. The ace wrap failed to extend to the resident's knee. Interview with the Director of Nursing on 10/4/18 at 2:00 PM confirmed the standard of practice is to apply an ace wrap to the knee (unless thigh high is ordered). Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to apply ace bandages to Resident #35 according to the standard of practice.