Every finding on record at Lorien Nursing & Rehab CTR - Elkridge

Based on administrative record review and staff interview, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received the required annual in-service training. This deficient practice was evident for 4 of 4 GNA employee files reviewed during the annual survey.The findings include:On 02/10/2026 at 10:45 AM, a review of GNA#17, GNA #15, GNA #14, and GNA #25 employee files failed to reveal evidence of annual in-service training. On 02/10/2026 during an interview, the Director of Nursing (DON) stated that the Assistant Director of Nursing (ADON) is responsible for conducting the annual GNA in-service training, however, the ADON was not available for an interview at the time of the annual survey. She further explained that GNA in-service training should be conducted annually. The surveyor informed the DON that annual in-service training documents were missing for four GNA's and requested evidence of completed in-service training for 2025.On 02/10/2026 at 2:43 PM, the DON informed the surveyor that facility failed to maintain documentation of annual in-service training for GNAs in 2025.

Based on observations and interviews, it was determined that the facility failed to maintain residents' dignity while dining as evidenced by 1) not serving meals at the same time to residents sitting together and 2) facility staff standing while assisting residents with feeding. This was found to be evident in 1) 6 of 10 residents observed while dining and 2) 2 (Residents #21 and #64) of 2 residents observed with feeding assistance.The findings include:1) On 2/6/2026 at 12:29 PM, during lunch service in the common dining room, 8 residents were observed sitting together at a table and 2 residents were observed sitting together at another table. 3 of the residents at the table of 8 residents were observed having meals in front of them. 1 resident at the table of 2 residents was observed having a meal in front of them. At 12:35 PM, the other resident at the table of 2 residents received their meal, 6 minutes after the other resident was observed eating. At 12:43 PM, it was observed that not all residents at the table of 8 residents had received their meals.On 2/6/2026 at 12:44 PM Geriatric Nursing Assistant (GNA) #8 was questioned why all residents sitting together had not received meals at the same time. GNA #8 stated that there was not a specific dining room food cart sent from the kitchen for residents who took their meals in the dining room. They stated that food carts from the kitchen were sent up to the floor and scheduled based on a resident's room number. If the resident was eating in the dining room but had a room number that received a later scheduled food cart, they would be getting their food later than residents with a room number that had an earlier cart delivery. On 2/6/2026, the last resident to be served a meal at the table of 8 residents was observed receiving their food at 12:52 PM, 23 minutes after the first 3 residents at the table were observed with meals.2) On 2/6/2026 at 12:47 PM, during lunch service in the dining room, Licensed Practical Nurse (LPN) #6 was observed standing while feeding Resident #64. LPN #6 was then observed to turn to Resident #21 while standing and picking up a cup and assisting the resident with drinking.On 2/6/2026 at 3:23 PM, surveyor addressed concerns with the Director of Nursing and Nursing Home Administrator.

Based on administrative record review and staff interviews, it was determined that facility staff failed to ensure that newly hired geriatric nursing assistants (GNA) have the knowledge necessary to provide resident care. This deficient practice was evident for 5 of 5 GNA training files reviewed during the annual survey.The findings include:On 02/10/2026 at 10:45AM, the surveyor requested to review five GNA employee files. Upon review, the surveyor identified that the recently hired employee GNA #16 file were missing the required training in resident abuse, neglect, exploitation, Quality Assurance and Performance Improvement (QAPI), infection control, compliance and ethics, and dementia.During an interview on 02/10/2026, the Director of Nursing (DON) stated that newly hired GNA's complete two days of office orientation followed by two to three days of training on the nursing unit. The surveyor informed the DON of the missing training documents for GNA #16. The DON acknowledged the missing documents and stated she would continue searching for the GNAs training documents.On 02/10/2026 at 2:43 PM, the DON informed the surveyor that she could not find the required training for GNA #16.During an interview with Human Resource (HR) Director on 02/12/2026 at 7:21 AM, he stated he was recently transferred to Lorien Elkridge in December 2025 and assists with the new hire onboarding process. He explained that newly hired GNA's complete two days of in-office orientation, which includes training modules on a platform called Health Academy. The remainder of the training is conducted on the nursing unit.On 02/12/2026 at 9:12 AM, the surveyor request to review training documents for GNA #26, GNA #27, GNA #29, GNA #30, GNA #31 who were hired between October 2025 and January 2026. Review of the training documents revealed the following:GNA #26-No evidence of infection control and compliance and ethics training.GNA #27-No evidence of QAPI, infection control, compliance and ethics, and dementia training.GNA #29-No evidence of QAPI and compliance and ethics training.GNA #30-No evidence of QAPI, infection control, and compliance and ethics training.GNA #31-No evidence of QAPI, infection control, compliance and ethics, and dementia training.According to the facility's assessment staff orientation training includes abuse, neglect, exploitation, dementia, and infection control.

Based on administrative record review and staff interview, it was determined that the facility failed to ensure staff received Quality Assurance and Performance Improvement Training (QAPI) for new and existing staff. This deficient practice was evident for 6 of 10 employee files reviewed during the annual survey.The findings include:On 02/10/2026 at 10:45 AM, a review of Geriatric Nursing Assistant (GNA) #17, GNA #15, and GNA #25 employee file revealed that QAPI training was complete. Further review for GNA #14 and GNA #16 employee file failed to show evidence of QAPI training.During an interview with the Director of Nursing (DON) on 02/10/2026, she explained that newly hired GNA's complete two days in office onboarding orientation, followed by two to three days of training on nursing unit. The surveyor informed the DON that education was missing from GNA #14 and GNA #16 employee file and requested to review the training files.On 02/10/2026 at 2:43 PM, the DON informed the surveyor that the facility failed to maintain documentation of QAPI training for GNA #14 and GNA #16. In addition, the DON explained that the facility experienced staffing changes in 2025. She stated that the employee previously responsible for staff training is no longer employed at the facility.On 02/12/2026, the surveyor requested to review the training files for GNA #26, GNA #27, GNA #29, GNA #30, and GNA #31. Review of the training file revealed that all GNA's except for GNA #26, were missing documentation of QAPI training from the employee training file.The surveyor informed the Administrator of the findings on 02/12/2026.

Based on administrative record review and staff interview, it was determined that the facility failed to ensure staff received training on abuse, neglect, and exploitation training. This deficient practice was evident for 1 of 5 employee files reviewed during the annual survey.The findings include:On 02/10/2026 at 10:45 AM, a review of Geriatric Nursing Assistant (GNA) #16s employee file revealed a hired date of October 2025. Further review failed to show evidence of abuse training.During an interview with the Director of Nursing (DON) on 02/10/2026, she explained that newly hired GNA's complete two days in office orientation, followed by two to three days of training on nursing unit. The surveyor informed the DON that education was missing from GNA #16s employee file and request to review the training files.On 02/10/2026 at 2:43 PM, the DON informed the surveyor that the facility failed to maintain documentation of abuse training for GNA #16.On 02/11/2026 the Administrator was made aware of the finding.

Based on administrative record review and staff interview, it was determined that the facility failed to ensure staff received required compliance and ethics training. This deficient practice was evident for 3 of 5 employee files reviewed during the annual survey.The findings include:On 02/10/2026 at 10:45 AM, a review of Geriatric Nursing Assistant (GNA) #17's employee file revealed a hired date of March 2024. Further review of the file failed to show evidence of compliance and ethics training completed in 2025. The surveyor reviewed four additional employees files and identified that compliance and ethics training was missing for GNA # 14 and GNA #16.During an interview with the Director of Nursing (DON) on 02/10/2026, the surveyor informed the DON that documentation of 2025 compliance and ethics training was missing from three GNA employee files. The surveyor again requested evidence of completed compliance and ethics training for the three GNAs. On 02/10/2026 at 2:43 PM, the DON informed the surveyor that the facility failed to maintain documentation of compliance and ethics training for GNA #17, GNA #14 and GNA #16.

Based on medical record review, observation, and interview, it was determined that the facility failed to maintain a medical record in the most accurate form. The was found to be evident for 1 (Resident #33) of 35 residents reviewed during the investigation phase of the survey.The findings include:MOLST (Medical Orders for Life-Sustaining Treatment) is a medical order form that translates a patient's preferences for end-of-life care into actionable instructions for healthcare providers. Unlike a living will or healthcare proxy, which are legal documents for future use, a MOLST form consists of actual medical orders that must be followed immediately by all health professionals, including emergency medical services (EMS).A hard chart (or paper chart) is the physical, tangible medical record for a resident. Resident #33's electronic medical record (EHR) was reviewed on [DATE] at 1:54 PM. Resident #33 had an active order that was placed on [DATE] that read, NO CPR (Cardiopulmonary Resuscitation) OPTION A-2, DO NOT INTUBATE (DNI). A social work progress note dated [DATE] at 2:43 PM in Resident #33's EHR stated, Resident has MOLST code status of NO CPR A2. Another social work progress note dated [DATE] at 1:55 PM stated, The Resident has a MOLST on file indication NO CPR/DNI. 2 copies of voided MOLSTS were uploaded into Resident #33's EHR, no active MOLST was identified in the EHR.On [DATE] at 2:30 PM, Resident #33's hard chart was reviewed and disclosed a MOLST form dated [DATE] that attempt CPR was selected under CPR (Resuscitation) Status.Geriatric Nursing Assistant (GNA) #8 was interviewed on [DATE] at 2:35 PM and stated that copies of residents' up-to-date MOLST forms are kept in their hard charts.On [DATE] at 3:02 PM, the Director of Nursing (DON) and Social Services Director (SSD) were interviewed and made aware of the concern that Resident #33's MOLST information in their EHR and MOLST form in their hard chart did not match. The DON stated that they would figure out what happened and make sure to correct any discrepancies.On [DATE] at 11:05 AM, Resident 33's hard chart was reviewed and an updated MOLST form dated [DATE] was observed filled out by the facility's Medical Director.On [DATE] at 12:51 PM, the DON was interviewed and stated they did not know why Resident #33 did not have an updated MOLST form in their hard chart to match information in their EHR. The DON stated that the issue had been corrected with an updated MOLST form.

Based on observation, clinical record review, and interview, it was determined that the facility failed to ensure that enteral nutrition (tube feeding) and hydration canisters were labeled and dated to ensure safety and sanitation. This deficient practice was evident for 1 (Resident #7) out of 1 resident reviewed for tube feedings.Findings include:Enteral tube feeding (tube feeding) is a method of delivering nutritionally complete liquid formula directly into the stomach or small intestine via a tube. It is used when a person cannot eat enough by mouth to meet their nutritional needs but has a functioning gastrointestinal tract.mL/hr (milliliters per hour) in enteral feeding defines the speed at which liquid formula is delivered through a feeding tube over one hour, usually regulated by a pump. It determines the flow rate needed to deliver a specific total volume of nutrition (dose) over a set time or period. On 02/05/2026 at 12:47 PM, an initial observation of Resident #7's room was conducted. The resident was observed receiving a tube feeding infusion at a rate of 60 mL/hr. The tube feeding container and the attached tubing were not labeled with the resident's name, the date, or the start time. A manufacturer's label was present on the container for this purpose but remained blank. Additionally, the water canister used for flushes was not labeled or dated.On 02/05/2026 at 2:58 PM, a clinical record review for Resident #7 was conducted. The record identified that the resident received nutritional support via a feeding tube with Nothing by Mouth (NPO) status. Physician orders indicated: Diabetasource AC via feeding pump at 60 mL/hr for 20 hours per day (10:00 AM to 6:00 AM). Total nutrient 1200 mL. Orders also specified water flushes of 240 mL every 4 hours for hydration.On 02/09/2026 at 12:44 PM, a follow-up observation of Resident #7's room revealed the tube feeding was running at 60 mL/hr. The feeding container, tubing, and water flush canister remained unlabeled and undated. A syringe for water flushes was not observed at the bedside.On 02/10/2026 at 12:41 PM, a third observation of Resident #7's room was conducted. The tube feeding continued to run at 60 mL/hr. The feed and water canisters remained without identifying information (name, date, or start time). A syringe for flushes was not observed in the resident's room.On 02/10/2026 at 12:46 PM, an interview was conducted with Licensed Practical Nurse (LPN) Staff #6 regarding the expectation for dating tube feedings. LPN #6 stated that the feed and water flushes are required to be labeled and dated with the resident's name and the time it was initiated. LPN #6 confirmed that Resident #7's current feeding setup lacked this information and stated she would label and date it immediately.On 02/10/2026 at 1:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that enteral containers should be labeled with the date and the shift they are changed. She further stated that a syringe for flushing the tube should be maintained at the patient's side and changed with every feeding.On 02/10/2026 at 1:59 PM, the observations and lack of labeling were discussed with the DON. The DON acknowledged the concern and identified it as a problem.

Based on observation, interview, and record review, the facility failed to provide and document individualized activities in accordance with the resident's assessed preferences for 1 of 1 resident (Resident #9) reviewed for activities.The Findings include:On 02/05/2026 at 10:37 AM, a telephone interview was conducted with Resident #9's relative. The relative informed the surveyor that Resident #9 is not involved in any activities.On 02/05/2026 at 1:47 PM, Surveyor visited Resident #9's room, she was seen in bed and there was no music on or any activity going on with the resident.On 02/06/2026 at 12:45 PM, a clinical record review was conducted of Resident #9's most current Minimum Data Set (MDS) and associated Care Area Assessments (CAAs), dated 11/20/2025. Sections C (Cognitive Patterns), F (Preferences for Customary Routine and Activities), and GG (Functional Abilities and Goals) were reviewed to determine cognitive and functional status relevant to activity participation.On 02/09/2026 at 7:29 AM, a follow-up observation was conducted in Resident #9's room. The resident was observed in bed. No music was playing at that time.On 02/09/2026 at 8:20 AM, review of Resident #9's MDS Section F (Preferences for Customary Routine and Activities), dated 09/18/2025, revealed the resident responded, very important to the question, How important is it to you to listen to music you like? The resident also responded, very important to the question, How important is it to you to participate in religious services or practices?On 02/09/2026 at 8:43 AM, an interview was conducted with the Activities Director (Staff #5). When asked about Resident #9's activity program, Staff #5 stated the resident received room visits because the resident did not come out of the room. Staff #5 stated she offered the resident the Daily Chronicle and asked whether he/she wanted to attend activities. Staff #5 further stated that staff would make him/her comfortable in bed, play continuous music, and perform nail care.On 02/09/2026 at 8:52 AM, Staff #5 was asked how frequently Resident #9 received music. She stated the resident was supposed to listen to music three or more times per week. When asked about religious activities, Staff #5 stated religious activities were provided at bedside. When asked to provide documentation or an activity log reflecting the provision of music and religious activities to Resident #9, Staff #5 stated there was no documentation or activity log available. When asked how activities were tracked for residents in the facility, Staff #5 stated there was currently no documentation system in place to track activity provision. When asked whether documentation or an activity log should have been maintained, Staff #5 stated that there should have been documentation.On 02/09/2026 at 9:35 AM, the concern regarding the lack of documentation of individualized activities for Resident #9 was discussed with the Nursing Home Administrator (NHA). The NHA acknowledged the absence of documentation and activity tracking as a concern.

Based on interviews and record reviews, it was determined that the facility failed to ensure a resident who required assistance with activities of daily living (ADLs) received assistance in a timely manner. This deficient practice was evident for one resident (#14) reviewed for ADL care during the annual survey.The findings include:During an interview on 02/05/2026 at 11:13 AM, Resident #14 reported long wait times for staff to respond to call bell for assistance to the restroom. The resident stated that they attempted to use the restroom without assistance and fell on multiple occasions.A review of Resident #14's medical record on 02/06/2026 at 12:43 PM, revealed the resident was admitted to the facility in January 2026 with multiple diagnoses, including, hemiplegia (weakness) and hemiparesis (paralysis) affecting the left non-dominant side, muscle weakness, difficulty walking, and lack of coordination. Further review revealed the resident had an unwitnessed fall in January and February 2026.A review of the baseline care plan dated January 2026 indicated the resident required one person assistance with transfers.A review of Minimum Data Set (MDS) date January 2026 revealed impairment to upper and lower extremities. The record indicated that the resident required partial to moderate assistance for toilet transfers.A review of the care plan revealed the resident had a fall on 01/21/ 2026. A care plan goal was initiated on 01/22/2026 indicating the resident will use the call bell and wait for staff assistance.During an interview with the Administrator on 02/11/2026, the surveyor asked whether there was a timeframe for staff to answer call bells. The Administrator stated that staff are expected to respond immediately, but no longer than 20 minutes. The surveyor requested to review the facility's policy regarding call bell response times, and the call bell response log for Resident #14's room between January and February 2026.A review of the call bell log on 02/11/2026 at 9:30 AM, revealed multiple call bell instances in which response time exceeded 20 minutes.On 02/11/2026 at 11:09 AM, during an interview, Geriatric Nursing Assistant (GNA) #17, stated that the facility is not adequately staffed to meet care needs of the residents.During an interview on 02/11/2026 at 1:13 PM, Resident #14's family member expressed concerns regarding the resident's functional status. The family member reported that the resident, who was continent of bowel and bladder at the time of admission, has experienced episodes of incontinence due to prolong call bell response times. When asked to provide a specific date and timeframe of an occurrence, the family member stated that the most recent incident occurred on 02/09/2026, during the evening. The surveyor reviewed Resident #14's cell bell response log time for 02/09/2026 and identified that the call bell was activated at 6:59 PM. Staff responded to the call bell 24.31 minutes later. The surveyor reviewed these findings with the administrator on 02/11/2026 2:30 PM.

Based on medical record review and interview, it was determined that the facility failed to perform appropriate revision to care plan goals and interventions as resident care needs became apparent or changed over time. This was found to be evident in 1 (Resident #33) of 35 residents reviewed during the investigation phase of the survey.The findings include:A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.Resident #33's electronic medical record was reviewed on [DATE] at 1:54 PM. Resident #33 had an active order that was placed on [DATE] that read NO CPR (Cardiopulmonary Resuscitation) OPTION A-2, DO NOT INTUBATE (DNI). Review of Resident 33's current care plan focus of CODE STATUS: I want my resuscitation status to be ATTEMPT CPR (including any and all medical efforts that are indicated during arrest) had not been updated to reflect current resuscitation wishes of the resident and had been initiated on [DATE] with no revision noted.On [DATE] at 3:02 PM, care plan concern was addressed with the Director of Nursing (DON). The DON stated the care plan should have been revised to reflect Resident #33's current CPR status.

Based on record review and staff interview, it was determined that the facility failed to notify residents and representatives of transfers or discharges in writing. This was evident in 2 (Resident #1 and #5) out of 2 residents reviewed for hospitalization. The findings include: On 2/05/2026 at 12:37 PM, a review of Resident #1 and #5's records were conducted. Resident #5 was transferred to the hospital on 1/11/2026 according to progress notes. Resident #1 was transferred to the hospital on [DATE] according to progress notes. On 2/09/2026 at 8:55 AM, further review of Resident #1 and #5 records were conducted. Both residents' transfer notes indicate the residents' representatives are being notified of their transfers via phone call. No evidence of a written notification of transfer was found in Resident #1 or #5's medical record. On 2/09/2026 at 11:39 AM, an interview with the Director of Nursing (DON) was conducted. When asked if the facility has a process in place to notify the resident or representative in writing of a transfer or discharge. The DON stated that the facility currently only notifies representatives of transfers or discharges via Phone call. This surveyor made the DON aware of the requirement to provide residents and representatives with written notification of transfers and discharges.

Based on interviews and record review, it was determined that the facility failed to permit the resident's representative to speak directly with state surveyors. This was evident for 1 (Resident #14) out 1 resident in the recertification survey. The findings include: On 2/11/2026 at 1:25 PM, an interview with Resident #14's family member was conducted. The family member stated that on 2/9/2026 GNA #23 told her that residents and representatives were not allowed to speak directly to the state surveyors. The family member stated that GNA #23 provided them with the contact information to OHCQ to file a complaint rather than bringing them to one of the surveyors on site. On 2/11/2026 at 2:12 PM, a review of Complaint 2739563 was conducted. The complaint receipt date was on 2/10/2026 at 8:30 AM by Resident #14's family member according to the complaint information.On 2/11/2026 at 2:21 PM, an interview with the Nursing Home Administrator (NHA) was conducted. The survey team made the NHA aware of the findings. The NHA stated that he would ensure all staff are aware of resident and representative rights to speak with surveyors at facilities.

Based on medical record review and interview, the facility failed to accurately document medical information in a resident's medical record (Resident #7). This was evident for 1 out of 12 residents reviewed during a compliant survey. The findings include: Review of complaint MD00214151 on 4/25/25 at 3:00pm revealed resident #7's family complained that the facility failed to provide ADL care for the resident during his/her stay causing the resident to develop a preventable wound. Review of resident #7's medical records on 4/25/25 at 3:15pm revealed the facility nursing staff failed to document ADL care on 1/15/25 (day shift), 1/20/25 (evening shift) and 1/23/25 (night shift). During an interview with the Director of Nursing (DON) on 4/25/25 at 3:40pm, the DON confirmed that facility nursing staff failed to document ADL care for resident #7 on 1/15/25, 1/20/25, and 1/23/25.

Based on medical record review and interview, the facility staff failed to thoroughly investigate a complaint of missing personal items (Resident #6). This was evident for 1 out of 12 residents reviewed during a complaint survey. Findings include: Review of resident #6's complaint (MD 00214419) on 4/25/25 at 11:52 am revealed the resident's family made an allegation that the resident's personal items (an adult puzzle and a electronic sound amplifier device) are missing. The surveyor reviewed the resident #6's medical record on 4/25/25 at 12:05pm. The review revealed the resident's records had no evidence of an inventory sheet that listed the puzzle or electronic sound amplifer device. Interview with the Director of Nursing (DON) on 4/25/25 at 1:00pm revealed a grievance/complaint that the complainant reported that a search of the resident #6's room revealed several missing personal items: a puzzle and a electronic sound amplifier device. The surveyor stated that there was no evidence that the facility investigated the complaint. The DON confirmed that the investigation was not done and agreed that the resident would be reimbursed for the missing items.

Based on review of medical records, facility investigative file, and interviews it was determined that the facility failed to adequately assess and assist a dependent resident during Activity of Daily Living (ADL) care, which led to a resident's fall from bed causing actual harm to Resident #70. This was evident for 1 of 4 (#70) residents reviewed for accidents. The findings include: On 9/17/24 at 11:32 AM, the surveyor reviewed Resident #70 ' s medical record. The review revealed that Resident #70 was admitted to the facility in early 2023 from another facility. On further review, an admission note written on 3/24/23 by Resident #70 ' s Physician and the facility ' s Medical Director (MD) #3, documented Resident #70 had left-sided hemiparesis (one sided paralysis), and the Patient requires total care and is unable to participate in any medical decision making. On 9/18/24 at 7:10 AM, the surveyor reviewed Resident #70 ' s Activities of Daily Living care plan. The interventions for bed mobility were initiated on 4/10/23 for resident #70. The intervention stated, I require 1-2 staff participation in bed mobility. On 7/28/23 the care plan was revised and stated, I require 2 staff participation in bed mobility. On review of Resident 70's Minimum Data Set (MDS) assessment, completed on 6/30/23 both functional status and functional abilities were assessed for Resident #70. Bed mobility in the functional status assessment coded Resident #70 as needing extensive assist on self performance (resident involved in activity, staff providing weight-bearing support) and needing Two + person physical assist as the most support staff needed to provide cares. In the functional abilities assessment for rolling left and right in bed, Resident #70 was coded dependent (helper does all the effort. The resident does none of the effort to complete the activity. Or, the assistance of 2 or more helper is required for the resident to complete the activity). Review of a progress note written by Licensed Practical Nurse (LPN) #29 on 7/15/23 revealed that a staff Geriatric Nursing Assistant (GNA) was performing afternoon care and while attempting to roll Resident #70 onto his/her side Resident #70 ' s legs slid out of bed and Resident #70 ' s upper torso remained in bed. The note further stated that no injuries were noted and that Resident #70 was currently prescribed a blood thinner that reduces blood clots and would be monitored. Additionally, on 7/17/23 LPN #29 wrote a skin/wound note that described two skin locations. First site was the lateral (outer) side of the left breast that noted a large discolored bruise and the second site was the left upper arm just below the shoulder that noted a yellow/blue faded discoloration. The surveyor reviewed a progress note written on 7/19/23 by MD #3 that stated, Due to evidence of pain and possible fracture, ordered patient to be transferred to ER for evaluation. On further review of MD #3's progress notes a note written on 7/28/23 summarized the history of present illness for Resident #70. The summary stated that after Resident #70 fell from his/her bed and developed bruising. The resident was transferred to the emergency room for evaluation. An x-ray showed a mildly impacted humeral (upper arm bone) neck fracture with recommendations for sling and nonoperative management. It further states Cat Scan (CT) showed a left pectoral (chest) muscular hematoma (a collection of blood that pools outside the blood vessel). Resident #70 was found to be anemic (low red blood cells) and required a transfusion of 2 units of packed red blood cells. The surveyor reviewed the paper medical record for Resident #70. During the review a GNA care plan communication form dated 4/14/23 was reviewed. The form was filled out by GNA #30. The question on the form was, How much help does the resident need with ADL's? Total was written for bed mobility, transfers, toileting, dressing upper and lower body, personal hygiene and bathing. On 9/18/24 at 11:54 AM, the surveyor interviewed GNA #30. During the interview GNA #30 stated that total meant that the resident would be dependent for staff to do everything and would require a 2 person assist with ADL cares including bed mobility. GNA #30 further stated she remembered Resident #70 and stated he/she required assist of 2 staff for all ADL cares. On 9/18/24 at 12:02 PM, the surveyor interviewed LPN #7. During the interview LPN #7 stated she was involved in care planning development for Residents. She stated that she was the supervisor the day that Resident #70's bruises were noticed. She further stated that residents who are dependent on care similar to Resident #70 would be care planned for 2 person assist with ADL cares. Review of the facility ' s investigation report related to Resident #70's fall from bed while receiving ADL care revealed a statement from the Nursing Assistant in Training (NAT) #26 that stated, while she performed incontinence care Resident 70's legs slipped out of bed. She further stated Resident #70's upper body remained in bed and that she got the nurse and other staff to help the resident back to bed. Further in the investigation file training completed on 7/17/23 by NAT #26 was found. The training was titled, Safe Resident Lifting and Transfers. Safe resident lifting was described as 1. The use of proper body mechanisms; 2. enlisting the assistance of additional staff 3. the use of appropriate mechanical lifting devices to lift, transfer, and reposition resident. Adequate personal and/or assistive devices are to be used as indicated. The education described that totally dependent/extensive assistance needed residents require mechanical lift devices for transfers. It also described protocol for lifts from the floor. Lastly, repositioning was addressed. The education stated, All repositioning in bed will be performed by at least two staff. If resident requires more than two staff members, a mechanical lift should be used. On 9/18/24 at 12:19 PM the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor asked the DON why Resident #70 would have assistance of 1-2 for ADL cares when he/she was dependent for care. The DON stated she was not DON at the time of the incident but perhaps it was in reference to some of the ADL care that could be done by one person such as placing a pillow. The DON confirmed that the care plan was adjusted after the fall that indicated the resident required two people to provide all ADL care.

Based on record review, and interview, it was determined that the facility failed to offer to help formulate or obtain a Resident ' s Advanced Directive. This was found to be evident in 2 (Resident #54, & #162) of 16 Residents reviewed for Advanced Directives during an annual survey. The finding include: Advance directives are legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes. The two most common advance directives for health care are the living will and the durable power of attorney for health care. 1a) On 9/11/14 at 12:25 PM, the surveyor reviewed Resident #54 ' s medical record. The review revealed that Resident #54 was admitted to the facility in late August of 2024. On further review the surveyor noted that a social worker assessment was completed on 8/22/24. In the section labeled Advanced Directives no box was checked to indicate if the Resident had an advanced directive or if the Resident did not if he/she would like to formulate one. On 9/13/24 at 9:10 AM, the surveyor interviewed the Social Director Staff #10. During the interview Staff #10 stated that once a Resident is admitted to the facility she completes a social service assessment. She further stated in that assessment she asks the Resident if they have advanced directive and if so to bring in the document. If they don ' t have one I ask if they would like to formulate one. The surveyor reviewed Resident #54 ' s advanced directive documentation. The social worker agreed there was no indication if Resident #54 had advanced directives and that the Resident was not offered to formulate one if he/she did not have one. 1b) On 9/12/24 at 6:36 AM, the surveyor reviewed Resident # 162 ' s medical record. The review revealed that Resident #162 was admitted to the facility in early September of 2024. On further review the surveyor noted that a social worker assessment was completed on 9/6/24. In the section labeled Advanced Directives no box was checked to indicate if the Resident had an advanced directive or if the Resident did not would he/she like to formulate one. On 9/13/24 at 9:10 AM, the surveyor interviewed the Social Director Staff #10. During the interview Staff #10 stated that once a Resident is admitted to the facility she completes a social service assessment. She further stated in that assessment she asks the Resident if they have advanced directive and if so to bring in the document. If they don ' t have one I ask if they would like to formulate one. The surveyor reviewed Resident #162's advanced directive documentation with Staff #10. The social worker agreed there was no indication if Resident #162 had advanced directives.

Based on record review, and interviews, it was determined that the facility failed to provide a Resident's Representative/guardian the right to be involved in the initial care planning process. This was found evident in 1 (Resident #162) of 5 residents reviewed for rights. The finding include: On 9/12/24 at 6:36 AM, the surveyor reviewed Resident #162's medical record. The review revealed that Resident #162 was admitted to the facility in early September of 2024 with a past medical history that includes, but is not limited to, schizophrenia, epilepsy (brain disorder that causes seizures), and edema (swelling). The surveyor reviewed Resident #162's baseline care plan. The care plan designated that the Resident was his/her own representative. At the end of the baseline care plan there is a place for a written summary and a place for a signature where the care plan could be acknowledged as reviewed with the Resident or/or the Resident's Representative or Responsible Party (RP). No summary was written and no signatures were documented in either of the two designated signature lines. The Social Work Director Staff #10 and Nurse supervisor Staff #4 both signed and dated the document on 9/6/24. On further review of Residents #162's medical record, a discharge summary was noted from the hospital stay prior to admission to the facility. A capacity and advanced care planning notation indicated that Resident #162's capacity to make own care decisions was updated on 8/30/24 at 11:07 PM. No copy of this record was in the medical record. On 9/13/24 at 9:10 AM, the surveyor conducted and interview with the Staff #10 and the Nursing Home Administrator (NHA). During the interview Staff #10 stated on admission she conducts a social service assessment and conducts a Brief Interview for Mental Status (BIMS) screen. The surveyor asked how the facility determines if the Resident can be his/her own representative. Staff #10 stated that the medical doctor completes a certification of capacity, and the staff can speak with family and, if appropriate, ask for guardianship or healthcare power of attorney papers. She further stated they can look through hospital records. The surveyor asked Staff #10 While completing the social work assessment was she aware that resident #162 had a guardian. Staff #10 stated that she had spoke Resident #10's guardian and asked the guardian to bring in the paper work. The surveyor interviewed the NHA on 9/13/24 at 9:24 AM and during the interview the NHA stated that Admissions should be aware if a resident has a guardianship filed and that nursing also should have been aware of the situation. The surveyor reviewed the concern that because the assessment of the responsible party was incorrect the facility failed to evolve Residents #162's guardian in the initial baseline care planning.

Based on record review, and interview, it was determined that the facility failed to inform the Resident ' s Responsible Party (RP) of the need to alter treatment. This was found evident of 1 (Resident #70) of 3 residents reviewed for notifications. The findings include: On [DATE] at 11:32 AM, the surveyor reviewed Resident #70's medical record. The review revealed that Resident #70 was admitted to the facility in early 2023 from another facility. On further review, an admission note written on [DATE] by Resident #70's Physician and the facility's Medical Director (MD) #3, wrote Resident #70 had a history of ischemic CerebroVascular Accident (CVA), (condition where blood flow to the brain is blocked) with left-sided hemiparesis (one sided paralysis), and wrote Patient requires total care and is unable to participate in any medical decision making. Resident #70's Responsible Party was identified in the profile page as Resident's granddaughter. The surveyor reviewed a progress note written on [DATE] by Licensed Practical Nurse (LPN) #28. The note was written at 5:52 PM. The note stated that around 10:00 AM, Resident #70 was noted to have a lot of perspiration (sweating) and an assessment was done. Resident #70 was noted to have a distended (swollen or bloated) abdomen along with hypoactive bowel sound (indicating slower digestion). The note further stated that the physician Staff #3 was notified at 10:30 AM and an abdominal x-ray was ordered. The note stated the Residents RP was notified at 3:30 PM and that the call was delayed due to pending abdominal x-ray results. Next the surveyor reviewed the discharge summary written by Staff #3. The note described that in the morning the nurse was concerned because Resident #70 became diaphoretic (sweating). Staff #3 stated the nurse reported the abdomen was mildly distended. An x-ray was ordered, and tube feeding placed on hold. Staff #3 wrote Resident #70 had coffee-ground emesis later that afternoon and according to staff had chest congestion that required suctioning. Following these events Resident #70 was pronounced at 3:10 PM. On [DATE] at 7:02 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that if a physician is contacted and there is a change in the plan of care the RP should be notified of those changes. She further stated that the nurse will update the physician and then call the RP to update them on the plan of care changes. She further stated the timing of notification depends on the situation. The DON agreed that LPN #28 documented there was a delay in notification. The family was not notified of the morning events until after Resident #70 was deceased .

Based on record review, and interview with residents and staff, it was determined that the facility failed to answer call bells timely to attend to the needs of dependent residents. This was evident for 1 (Resident #19) on the Second Floor Nursing Unit. The findings include: During an interview conducted with Resident #19 on 9/10/2024 at 8:40AM, the Surveyor was informed that over the weekend the resident used the call bell to get assistance to the bathroom and it took a long time for the staff to answer the call bell and provide assistance. The resident continued, stating that he/she has to wait and wait for long periods of time for the staff to assist him/her with his/her needs. The resident communicated that it is hard to wait when you have to go. On 9/17/2024 at 11:21AM, a review of Resident #19's electronic medical record revealed that the resident has impairment on one side and was dependent on staff for toileting and transferring needs. On 9/17/2024 at 12:14PM, the Surveyor requested call light response time log for Resident #19 for the dates 9/5/2024-9/11/2024, as well as the Call Light policy for the facility. On 9/17/2024 at 12:55PM, the Surveyor and Director of Nursing (DON) #2 reviewed the call light response log, [NAME]-CARE Report, and confirmed that on 9/8/2024 at 7:47AM the call light was on for 28 minutes and at 9:37AM the call light was on for 55 minutes and 51 seconds. Review of the Call Light Policy revealed that employees are not to walk by call lights and ignore them; call lights are not to be turned off until the need of the resident has been met and if the staff is unable to meet the resident's need, the staff would leave the light on and notify an appropriate staff member. The policy is to be signed and dated by facility staff. Review of the Routine Resident Checks policy revealed that timely observation of all residents will be provided. According to procedure 3.) Resident call bells will be answered in a timely manner, not to exceed 20 minutes. On 9/23/2024 at 11:02AM, the Surveyor conducted an interview with Second Floor Supervisor #33. The Surveyor was informed that the call light should be answered within 20 minutes and that it should not be turned off until the resident's need has been met. The Surveyor and Second Floor Supervisor #33 reviewed Resident #19's [NAME]-Care Report which showed on 9/8/2024 at 7:47AM the call light was on for 28 minutes and at 9:37AM the call light was on for 55 minutes and 51 seconds. The Surveyor stated that the resident complained that he/she had to wait for a long period of time before he/she could go to the bathroom. Second Floor Supervisor #33 was unable to explain why the resident waited so long for assistance and stated she would look into the situation. On 9/23/2024 at 11:36AM, Second Floor Supervisor #33 informed the Surveyor that she was unable to determine the reason the call light was unanswered for so long and that the expectation is for staff to answer call lights timely, within 20 minutes, and to turn the call light off once the residents need has been met. Second Floor Supervisor #33 provided the Surveyor with a copy of an educational Inservice regarding Call light Expectations which was reviewed and signed by facility staff.

Based on medical record review and interview of facility staff it was determined the facility staff failed to initiate interventions related to the prevention/development of and/or worsening of pressure ulcers, failed to document weekly assessments of a stage 3 pressure ulcer, failed to develop a care plan with appropriate goals and interventions and failed to follow the wound care specialist's treatment recommendations. This was evident for 2 of 40 sampled residents selected for review. Resident #5 and Resident #36 were affected by the deficient practice. The findings include: 1. Resident #5 was admitted to the facility on [DATE]. The resident's medical record was reviewed on 10/16/15 and 10/19/15. Medical record review revealed that on the day of admission, 8/13/15, the resident was assessed with [REDACTED]. x 3 cm. Additionally on 8/13/15, the resident was assessed with [REDACTED]. The physician's admission orders [REDACTED]. Further review of the medical record revealed there is no documented evidence that interventions were initiated to reposition the resident in order to relieve pressure from the resident's area of skin breakdown or bony prominences, including elevating the resident's heels. Additionally, there were no interventions related to incontinence care. Incontinence places the resident at increased risk of skin breakdown. Medical record review revealed that on 8/17/15 the resident was assessed by the Dietitian. The Dietitian documented in the assessment note that there was no noted skin breakdown. Typically, dietary interventions are initiated to ensure that residents with skin breakdown are receiving adequate protein intake needed for wound healing. Medical record review revealed that on 8/18/15 the resident was seen and examined by the nurse practitioner. The nurse practitioner documented that facility staff reported that the resident had a sacral wound that was unstageable due to slough. The nurse practitioner documented in the exam that he/she did not assess sacral wound. Review of the physician's orders [REDACTED]. Santyl is an enzymatic [MEDICATION NAME] agent typically used when there is slough or necrotic tissue covering the pressure ulcer. Review of the Skin Integrity Report for Resident #5 revealed that on 8/19/15 the resident was assessed with [REDACTED]. x 2.0 cm. The appearance of the wound was described as slough. Slough is non-viable tissue that requires debridement. Slough is indicative of a stage 3 or 4 pressure ulcer. When a large amount of slough is present, it is difficult to determine the stage of the pressure ulcer, therefore, the wound is considered unstageable. Also, on 8/19/15, the resident was assessed with [REDACTED]. Despite the resident experiencing incontinence and actual skin breakdown, review of the treatment administration record (TAR) revealed the facility staff failed to initiate treatment to the resident's right buttock pressure ulcer that was ordered on [DATE] until 8/20/15. Additionally, there is no documented evidence that interventions were initiated to reposition the resident in order to relieve pressure from the resident's areas of skin breakdown or bony prominences, including elevating the resident's heels or incontinence care. Review of the Minimum Data Set (MDS), an assessment tool, dated 8/20/15 revealed that the resident required extensive assistance for bed mobility. It was further documented in the MDS that the resident was not on a turning and positioning program. Additionally, the resident was assessed to be frequently incontinent of bowel and bladder. Medical record review revealed on 8/24/15 the resident was evaluated by the physician specializing in wound care. The physician's assessment revealed that the resident's right buttock wound was a stage 3 which measured 1.5 cm. x 3.0 cm. x 0.2. The physician's recommendations included adding calcium alginate to the resident's current treatment. The physician further recommended off-loading the wound and repositioning per the facility's protocol. Medical record review revealed that on 8/25/15, 12 days after the resident was admitted to the facility, the physician gave a verbal order to turn and reposition the resident every 2 hours and as needed. On 8/25/15 the facility staff initiated a care plan for alteration in skin integrity and continued risk for further impaired skin due to pressure and immobility. Interventions included the provision of incontinence care and turning and positioning every 2 hours. However, interventions did not include elevating the resident's heels. Review of the Skin Integrity Report revealed that on 8/27/15 the resident was assessed with [REDACTED]. x 5 cm. The appearance is described as slough. It was not until 8/29/15 that the facility staff initiated interventions to elevate the resident's heels. Medical record review revealed that on 8/31/15 the resident was evaluated by the wound care physician. The resident's right buttock wound measured 2.5 x 1.5 x 0.2 with 90% necrotic tissue. The wound care physician debrided the resident's right buttock ulcer. The wound care physician's recommendations included continuing the same treatment to the pressure ulcer. A new recommendation was to limit the resident's sitting to 60 minutes. There is no documented evidence that the facility staff implemented the wound care physician's recommendation to limit the resident's sitting to 60 minutes. The wound care physician did not assess the resident's right heel pressure ulcer on 8/31/15. Medical record review revealed that on 9/7/15 the resident was evaluated by the wound care physician. The physician assessed the resident with an unstageable deep tissue injury to the left heel that measured 2.7 cm x 2.1 cm. The wound care physician recommended the application of Skin Prep, a protective barrier, to the resident's left heel every shift. There is no documented evidence that the facility implemented the wound care physician's recommendation to use Skin Prep every shift to the resident's heel. 2. Review of Resident #36's medical record on 10/14/2015 revealed the resident has a stage III pressure ulcer on the sacrum. A stage III pressure ulcer is defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. Review of the consulting wound physician's documentation dated 9/21/2015 revealed the wound was identified at least 37 days prior. Review of nursing documentation reveals that an unstageable pressure ulcer was identified on 8/14/2015. An order was obtained to provide daily treatment written as cleanse sacral wound with normal saline, pack with calcium alginate and cover with dry sterile dressing . This order is still in effect as of 10/14/2015. The consulting wound physician's report of 9/21/2015 indicated to discontinue calcium alginate, and silver absorbing agent and continue dry protective dressing. A nurse practitioner's note of 9/22/2015 does not indicate any documentation revealing acceptance or decline to the consulting wound physician's recommendations. The resident's attending physician's note of 10/7/2015 does not reveal acceptance or decline to the consulting wound physician's recommendations. The attending physician documented: Continue to follow with wound care. Turn Q (every) 2 hours and monitor closely, pt (patient) at a high risk for skin breakdown . Review of the resident's care plans did not reveal a care plan to address the development and care for this resident with a stage III pressure ulcer. The nurse, Staff #1, who provided treatment to Resident #36 on 10/19/2015 was asked at 10:52 AM if there is any documentation of weekly skin assessments. The nurse responded, No, if there is any they did not tell me. Interview of the Assistant Director of Nursing, Staff #2, at 10:55 AM and subsequent medical record review revealed that there is not a skin sheet for the stage III wound that was found on 8/14/2015. Nursing failed to document weekly assessments of the resident's wound that should include the length, width, depth, pain, drainage, odor, tissue type and/or stage of the wound.

Based on medical record review and interview of facility staff it was determined the facility staff failed to promptly notify the physician of a mental status change after Resident #186 had experienced a fall. This was evident for 1 of 40 sampled residents selected for review. The findings include: Resident #186 was a [AGE] year admitted to the facility [DATE]. The resident's medical record was reviewed on [DATE] and [DATE]. Review of the facility's fall risk assessment dated [DATE] revealed that the resident had a history of [REDACTED]. Medical record review revealed that on [DATE] at 4:45 A.M. the resident was found on the floor next to the bed. A neurological observation sheet was initiated at 4:50 A.M The resident was conscious, knew his/her name and his/her speech was clear. Neurological assessments were documented again at 4:50 A.M., 5:05 A.M., 5:20 A.M., 5:35 A.M., 6:05 A.M. and 6:35 A.M. and were within normal limits. The resident's blood pressure remained stable and at 6:35 A.M. the resident's blood pressure was ,[DATE]. Review of the neurological observation sheet revealed that on [DATE] at 7:35 A.M. the nurse documented that the resident did not know his/her name and his/her speech was unclear and the resident's blood pressure was ,[DATE]. This represented a significant change in the resident's mental status and blood pressure. Interview of the geriatric nursing assistant (GNA), Staff #5, on [DATE] at 3:10 P.M. and review of the GNA's investigation statement revealed that the GNA was assigned to provide care to the resident on [DATE]. The GNA stated that when he/she arrived for his/her shift on [DATE], at approximately 7:05 A.M., the GNA entered the resident's room. The GNA said good morning to the resident and the resident did not respond to the GNA. The GNA stated the resident usually would respond back. The GNA stated that when he/she assisted the resident to stand the resident was unable to do so. The GNA stated that the resident had previously been able to stand up from the bed with minimal assistance. The GNA stated that he/she had to use maximum assistance to transfer the resident from the bed to the chair. The GNA further stated that the resident would normally converse with him/her and usually ate 100% of breakfast. However, on the morning of [DATE] the resident did not eat breakfast and did not talk. The GNA stated he/she reported the resident's change in condition to the nurse, Staff #7. Interview of the Director of Nursing (DON) and review of the DON's investigation statement revealed that on [DATE] while making 9:00 A.M. clinical rounds, the nurse caring for the resident, Staff #7, advised the DON that the resident had fallen during the 11:00 P.M. - 7:00 A.M. shift, and that the resident's daughter wanted the resident sent to the hospital emergency department. The DON asked the nurse what his/her assessment was, and the nurse told the DON that the resident was unable to talk. When further questioned about the resident's neurological assessments, the nurse did not respond. The DON then asked the Assistant Director of Nursing (ADON) and the MDS Coordinator to complete a thorough assessment of the resident. The assessment revealed that the resident's speech was unclear, which was not normal for the resident. Medical record review revealed that on [DATE] at 9:16 A.M. the nurse, Staff #7, sent an e-mail to the resident's attending physician which stated: Pt (patient) had a fall early this morning. (He/She) is alert, but confused. Pt not eating food and not talking. All vitals and blood sugar stable. Please advise . Per the ADON's statement, the physician gave an order to send the resident to the hospital emergency room for evaluation. The resident left the facility at approximately 9:45 A.M., which was 2 hours and 40 minutes after the resident had been noted with a change in his/her mental status. Review of the resident's hospital medical record revealed that the resident was diagnosed with [REDACTED]. Per information obtained from the resident's family member, the resident expired on [DATE].

Based on medical record review and interview of facility staff it was determined the facility staff failed to provide appropriate care and timely assessment or treatment to residents with changes in their medical condition. This was evident for 2 of 3 sampled residents selected for review. The findings include: 1) Resident #3 is a [AGE] year old with a [DIAGNOSES REDACTED]. The resident's medical record was reviewed on 12/5/13 and 12/9/13. review of the resident's medical record revealed [REDACTED]. On 12/2/13 at 8:04 p.m. the nurse notified the physician via electronic mail that the resident had an elevated temperature of 102 degrees Fahrenheit and that Tylenol was administered. The physician responded and advised staff to hold Tylenol, wait to see how high the temperature goes, and if the temperature goes beyond 101.5F, take blood cultures x 2 and then give Tylenol. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There is no documented evidence on the MAR indicated [REDACTED] On 12/7/13 at 5:03 p.m. the nurse documented a late entry for a change in condition that occurred on 12/3/13 in the nursing progress notes. On 12/3/13 the nurse documented that the resident's appetite was poor and the resident was holding food in his/her mouth. The nurse further documented that the resident's temperature was 101.2 degrees Fahrenheit. The nurse practitioner was notified. Review of the physician order [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. [MEDICATION NAME] is an antibiotic medication used to treat serious infections. In addition to the orders given by the nurse practitioner on 12/3/13, the physician also gave a telephone order for a speech therapy evaluation to assess the resident's swallow function secondary to the resident holding solid foods in his/her mouth. The speech language pathologist (SLP) evaluated the resident "urgently" on 12/3/13. Interview of the SLP on 12/9/13 revealed that the resident was evaluated at lunch time on 12/3/13. At that time the SLP observed that the resident was lethargic and his/her eyes were closed. The GNA had been feeding the resident prior to the SLP's evaluation. The SLP further reported that the resident was unable to swallow the pureed food and was slow to initiate the swallow with thin liquids. The SLP documented that he/she had to suction the patient's mouth. Based on the SLP's evaluation, the physician gave a telephone order to discontinue the resident's previous diet and change the resident's diet to pureed solids with honey thick liquids, only feed the resident when alert and awake and watch for pocketing of food. On 12/3/13 at 8:38 p.m. the result of the resident's complete blood count was completed and revealed that the resident's white blood count was elevated, which may indicate infection. On 12/3/13 at 9:06 p.m. the result of the resident's comprehensive metabolic panel was completed. The results revealed that the resident's blood urea nitrogen (BUN) was 52 (normal range is 5 - 25) and creatinine was 1.2 (normal range is 0.5 - 1.4) An elevated BUN indicates deteriorating kidney function. There is no documented evidence that the nurse notified the physician of the results of the comprehensive metabolic panel on the evening of 12/3/13. Further review of the resident's medical record and interview of the Director of Nursing on 12/9/13 revealed that the resident's urine specimen for urinalysis with culture and sensitivity was not collected until 12/4/13 at 5:00 a.m. (15 hours after it was ordered stat) and the blood specimen for the blood culture was never collected. There is no documented evidence that the resident's physician was notified that there was a delay in collecting the urine specimen or that the blood specimen for culture had not been collected. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Additionally, there is no documented evidence that nursing notified the resident's physician to report that [MEDICATION NAME] had not been administered to the resident. Review of the SLP's progress note dated 12/4/13 revealed that the SLP was unable to get the resident to open his/her eyes and arouse for a snack or liquids. Multiple attempts were made. Interview of the SLP on 12/9/13 revealed that the time of the attempt to feed the resident was sometime between 9:10 a.m. - 10:10 a.m. on 12/4/13. Review of the nursing progress note dated 12/4/13 at 3:56 p.m. revealed that the resident had experienced a change in condition at 3:00 p.m. The nurse documented that the resident was asleep in bed, difficult to awaken with verbal commands and did not respond to physical stimuli. The resident's temperature was 101.7 degrees Fahrenheit. The nurse practitioner was notified of the resident's condition at 3:00 p.m. The nurse practitioner examined the resident and documented that the resident was unresponsive and would not respond to deep sternal rub. Deep sternal rub is a test performed to illicit a response to painful stimuli in an unconscious patient. Based on the nurse practitioner's assessment of the resident, the nurse practitioner gave an order to transfer the resident to the hospital emergency room via 911. In summary, the resident presented with a change in condition on 12/2/13 sometime during the 3:00 p.m. to 11:00 p.m. shift at which time the resident was assessed with [REDACTED]. The blood culture was not done as ordered. The urine specimen was not collected until 5:00 a.m. on 12/4/13, 15 hours after the physician gave the stat order. There is no documented evidence that nursing reported the results of the comprehensive metabolic panel to the physician on the evening of 12/3/13 although the results were available. The antibiotic medication [MEDICATION NAME] was never administered. The nursing staff failed to notify the resident's physician that the blood specimen for culture was never collected, there was a 15 hour delay in collecting the urine specimen for urinalysis and culture, and the antibiotic injection of [MEDICATION NAME] was never administered. On 12/4/13 at 3:00 p.m. the resident was assessed by the nurse practitioner and was unresponsive. Based on the nurse practitioner's assessment, the resident was transferred to the hospital via 911. The resident was subsequently admitted to the hospital and treated for [REDACTED]. The resident remained hospitalized until 12/9/13. 2) Resident #2 is an [AGE] year old with a [DIAGNOSES REDACTED]. On 11/26/13 the Office of Health Care Quality received a complaint from the resident's family member alleging that the family member arrived at the facility to find his/her mother in the hallway in apparent medical distress and called 911 himself after the facility staff failed to act immediately. The resident's medical record was reviewed on 12/5/13 and 12/9/13. review of the resident's medical record revealed [REDACTED]. On 11/20/13 at 10:07 p.m. the nurse documented in the progress notes that the resident had experienced a change in condition at 3:30 p.m. that day. The nurse documented that the resident had nasal drainage and the resident's lungs were congested. The nurse practitioner was notified and ordered a chest x-ray and the medications [MEDICATION NAME] and [MEDICATION NAME]. There was no further documentation that nursing staff performed a respiratory assessment of the resident after 11/20/13 at 3:30 p.m. A respiratory assessment should include respiratory rate, rhythm, depth and effort as well as auscultation of breath sounds. On 11/21/13 at 3:30 p.m. the nurse documented that the resident was experiencing altered mental status. The nurse documented that the son was present at the bedside. The nurse documented that the resident's breathing was "unlabored." The nurse further documented that the nurse practitioner was notified at 3:30 p.m. and that 911 was called by the resident's son, as well as, the nurse. On 12/9/13, after surveyor intervention, the nurse practitioner documented his/her assessment of the resident performed on 11/21/13. The nurse practitioner documented that at the time he/she assessed the resident, the resident was unresponsive with agonal breathing (inadequate, gasping breaths which do not provide adequate oxygenation to the body). The nurse practitioner documented that the resident was sent out via 911 for evaluation. In summary, between 11/20/13 at 3:30 p.m., when the resident experienced nasal drainage and congested lungs, through 11/21/13 at 3:30 p.m. there is no documented evidence that nursing performed a respiratory assessment on this resident until the resident was noted to be unresponsive and had to be transferred emergently to the hospital. The resident was subsequently admitted to the hospital.