Every finding on record at Madison, The

Based on record review and staff interview, the facility failed to ensure Resident #65's Physician Orders for Scope of Treatment (POST) form was honored by directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1).This has to potential to affect all residents that reside in the facility. Resident identifiers: 65.The facility was notified of the Immediate Jeopardy (IJ) at 4:35 PM on [DATE]. The facility submitted their first abatement plan of correction (POC) at[DATE] at 5:29 PM. The state agency requested changes and the second abatement POC was submitted [DATE] at 6:01PM. The abatement POC was accepted by the state agency at 6:05 PM on [DATE]. After observation of the implementation of the abatement POC, the IJ was abated on [DATE] at 10:20 AM. The IJ started on [DATE] and ended on [DATE].The facility's approved abatement POC consisted of the following:Correction action for area of concern-Resident #65 was found unresponsive on [DATE]. A note was entered into PCC stating the resident was unresponsive, however, the resident was not sent out to the hospital and instead remained in the facility. Resident #65 passed away on [DATE]. All residents of the facility have the potential to be affected.Upon notification of the Immediate Jeopardy, the Director of Nursing (DON)/designee immediately reinforced expectations with all licensed nursing staff that any resident found unresponsive represents a medical emergency requiring immediate action in accordance with resident advance directives. Staff were instructed that documenting a note alone is not sufficient and that immediate notification of the medical provider and DON is required, along with activation of emergency medical services when a resident is unresponsive or experiencing a significant decline. Re-education was immediately provided by the Director of Nursing (DON)/designee to all licensed nursing staff regarding recognition of a change in condition, including what constitutes a resident being unresponsive. Education included clear instruction that unresponsiveness includes inability to arouse, altered level of consciousness, abnormal respirations, or inability to respond appropriately, and that these findings require immediate escalation. Education further emphasized the requirement to notify the medical provider and DON immediately and to initiate emergency transfer when clinically indicated in accordance with resident advance directives. A post-test was administered to validate understanding. Licensed nurses not present during this education were re-educated prior to working their next scheduled shift. New licensed nurses will receive this education during orientation. The Director of Nursing (DON)/designee initiated an audit process of all residents experiencing a change in condition or clinical decline to ensure timely assessment, notification of the medical provider and DON, and appropriate intervention, including hospital transfer when indicated in accordance with resident advance directives. The audit process also includes review to ensure residents and families are engaged in discussions regarding expectations and decisions during emergency situations when a resident shows signs of decline. The Director of Nursing (DON)/designee will monitor all changes in condition beginning immediately to ensure proper recognition, timely notification of the medical provider and DON, and appropriate emergency response actions are taken. Monitoring will occur daily for two weeks, including weekends and holidays, then five times per week for four weeks, then three times per week for four weeks, and then randomly thereafter. Results of monitoring will be reviewed by the Director of Nursing/designee and reported to the Quality Improvement Committee (QIC) for oversight, follow-up, and additional education as needed to ensure sustained compliance. Findings included:Resident #65 A Physician Orders for Scope of Treatment (POST) form completed by the directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1) was completed with the signature of Resident #65.CPR: Attempt Resuscitation, including mechanical ventilation, defibrillation, and cardioversion.Full interventions, Goal: Attempt to sustain life by all medically effective means. Provide appropriate medical and surgical treatments as indicated to attempt to prolong life, including intensive care.Resident #65's Minimum Data Set (MDS) Five (5) Day admission with an Assessment Reference Date (ARD) of [DATE] noted the resident had a score of Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact. Continued review found that physician determination of capacity was completed on [DATE].-- Demonstrates Capacity to make decisions was marked.A review of Resident #65's care plan revealed:.Focus:Activate Resident's advanced directive as indicated as FULL CODE- attempt resuscitation, including mechanical ventilation, defibrillation, and cardio-version. Full treatments-PROVIDE A FEEDING THROUGH NEW OR EXISTING SURGICALLY-PLACED TUBES on her POST ORDER. Created on: [DATE].Goal:Resident wishes as expressed in Advance Directive will be followed as FULL CODE- Created on: [DATE].Continued review of Resident #65s Medical record found a Progress note from the Physician Assistant (PA) on [DATE] Stated that on [DATE] Resident #65 declined in condition and the staff was concerned that the resident was still a full code. Resident has Decision Making Capacity. PA spoke to the resident on [DATE] about her prognosis and offered Hospice and comfort measures, The resident declined and wanted to stay Full Code with heroic efforts to sustain her life.Subsequent review of [DATE] Medication was held due to decline in condition.On [DATE]t 11:54 AM a PA progress note stating patient seen per facility request for evaluation of decline. Patient with decreased participation with therapy. Increased weakness. She has poor oral intake. Resident has been complaining of fatigue. Facility noted low blood pressure and resident has been refusing medications. She does have wound on coccyx which now has an odorXXX[DATE] at 4:06 PM Subsequent review from stating Resident #65 remains on a steady decline in condition. Unresponsive to sternal rub and other physical stimuli, with irregular increased pulse 124, and difficulty getting breath. Physician tried to call her son two (2) to three (3) times to attempt to change Resident 65s Post form to a status of Do not Resituate (DNR). The facility was unable to reach her son at this time. They continued to monitor and document changes.On [DATE] Progress note verified Family notified staff of Resident #65 being unresponsive. Licensed Practical Nurse (LPN) started chest compressions and AED placed. EMS arrived and took over chest compressions and emergency medications. Time of death called at 10:14 AM.On [DATE] at 11:10 AM a Progress note: Resident has ceased to breathe.During an interview on [DATE] at 1:35 PM the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated they called her SON for direction on [DATE]. The DON The DON did state that she was aware that the POST was full code and full interventions. During Interview 0n [DATE] at 2:15 DON and ADON stated they were unable to find any other information from that date. They continued to say that she could not make decisions on [DATE] (date of passing) so that's why they called the son. The DON stated that they did not follow Resident #65's Directive.

Based on observation, interview and policy review, the facility failed to properly store food in accordance with professional standards of practice. This failed practice had the potential to affect more than a limited number of residents who are served food from the kitchen. Facility census: 52 Findings included:a) On 01/19/26 at 11:45AM, during Initial Brief Tour of Kitchen, opened boxes of food unclosed and left open to air was observed in the freezer. This was true for:frozen sausage links, frozen biscuit dough. and frozen pizza dough. b)The Utensils were not placed in the utensil drawer in all of the same direction but were observed to be scattered in different directions.c) A bottle of onion spice on the shelf above the stove was left open to air.On 01/20/26 at 1:00 PM a review facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.d) Tray Line Prep Observation:On 01/19/2026 at approximately 11:40AM, while preparing resident trays, Employee #72 was observed touching the inside of a plate with her bare hands and touching cabinet doors without washing her hands or changing her gloves and Employee #76 was observed to leave tray line prep and move a full tray cart out to the hall and return to tray line without washing his hands or changing his gloves.e) Staff Interviews:-In an interview with Employee #72 on 01/19/26 at 11:45AM, she acknowledged she didn't wash her hands after touching the cabinet doors and that she had touched the inside of a plate with her bare hands. -In an interview with Employee #76 on 01/19/26 at 11:48Am, he stated he did forget to wash his hands and change his gloves before returning to the tray line-During an interview with The Kitchen Manager On 01/19/26 at approximately 11:55AM, He acknowledged the unsealed boxes of sausage links, pizza dough, and biscuit dough in the freezer left open to air, the incorrect storage of the utensil drawer, spice box lid left open to air on the shelf in the kitchen, and observations of absence of hand sanitation on the tray line with employee #'s 74, and 76.-During an interview with the corporate Kitchen Manager on 01/20/26 at approximately 11:15AM, he stated he was aware of the 2 opened boxes of dough,1 opened box of sausage link left open to air in the freezer, the open spice box, and the observations of employee #'s 74, and 76 absence of hand sanitation on the tray line.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for resident rooms/bathrooms on the 100 hall.This was a random opportunity for discovery. Rooms: 101, 102, 103, and 104. Facility census: 52.Findings included:a) Observations:Upon survey entrance walkthrough on 01/19/26 at 1:30 PM, the following issues were observed:room [ROOM NUMBER]:-Bathroom brownish smears behind toilet handrail dark red smeared substance on toilet hand rail -brown substance smeared behind toilet hand rail room [ROOM NUMBER]:-Room: Sticky yellowish substance on the wall behind resident's bed-Bathroom: observed dusty residue build up on base of empty hand sanitizer dispenser Room103:-bathroom observed smeared brownish substance on wall behind toilet handrails and on the wall under the soap dispenser-blackish substance around toilet base Room104:-bathroom observed cobwebs and built up of hair and dusty residue under the sink.-black substance build-up around baseboards and toilet baseOn 01/20/26 at 9:40AM, during a second facility walkthrough to resident room #'s 101, 102, 103, and 104, it was observed the issues had not been resolved. b) Staff Interviews: On 01/20/26 at 12:50 PM, during a brief walk through of the facility was completed with Corporate RN who acknowledged the issues in resident rooms and bathrooms, and stated she would bring it to the attention of the Administrator. On 01/20/26 at 2:35 PM the facility Administrator acknowledged the issues in the resident rooms and bathrooms and stated she would have them taken care of.

Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to unsanitary practices. This failed practice was a random opportunity of discovery. Resident identifier: #10 Facility census: 52.Findings Included:a) Dining Room ObservationOn 01/19/26 at approximately 12:15PM, during dining room observations, it was observed that Employee #23 failed to properly sanitize her hands between assisting with one resident's wheelchair and then assist in feeding Resident #10 without washing her hands and changing her gloves.b) Staff Interviews-On 01/19/26 at 12:45PM in an interview with Employee #23, she acknowledged she did not use properly sanitizer her hands before returning to feed Resident #10.-During an interview with the Corporate Kitchen Manager on 01/20/26 at approximately 11:15 AM, he stated he was aware of the lack of hand sanitization in the dining room on 01/19/26.

Based on observation and staff interview, the facility failed to ensure the daily nursing staff form posted was accurate and complete. The daily census was not included on the posting for three (3) of four (4) days observed. Facility census: 52.Findings included:Upon entrance to the facility on [DATE] at approximately 11:15 AM, the daily nursing staff form was observed to be incomplete for January 17, 2026, January 18, 2026, and January 19, 2026. The daily census was not included on the posting for these days. During an interview on 01/18/26 at approximately 11:45 AM, the Director of Nursing (DON) concurred the nurse staff posting forms had not been accurately completed.

Based on observation and interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible in regards to bed safety. This was a random opportunity for discovery. Resident identifier: #28. Facility census: 52. Findings included:a) Resident #28During an initial tour of the facility an observation, completed on 01/18/26 at 12:26 PM, revealed Resident #28 was lying on a bariatric mattress (a heavy-duty, wider hospital-grade mattress) that was placed on a standard bed frame. Approximately 12 inches were hanging over the frame, creating an unsupported area for the resident which had potential to rise to the resident sustaining an injury from a fall off the bed. During an interview on 01/18/26 at 12:45 PM, the Director of Nursing verified the mattress was hanging over the frame of the bed and stated that it should not be larger than the frame. The DON stated that she would get the Maintenance Director to assess the issue.On 01/21/2026 at 10:35 AM, the Maintenance Assistant stated that he replaced the bariatric mattress, because it was too big for the frame.

Based on record review, resident interview and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #8 requested the facility transport him to the bank in the facility van. The facility had decided prior to Resident #8's request to go to the bank that power wheelchairs could not be used on the facility van any longer. As a result of this decision the resident requested his manual wheelchair and chose to use the manual wheelchair in the van to go to the bank. The resident had not been in his manual wheelchair for at least a year prior to this. Since then, he had lost use of his legs and was paralyzed in both lower extremities. The resident slid from the wheelchair while on the van. A nurse aide was with him and another nurse aide responded to the scene where the van had pulled over after the resident slid from the wheelchair. The resident denied pain (please note the resident is a paraplegic and cannot feel his legs.) He stated he did not want to go to the hospital. The two (2) Nurse Aides who were on site lifted the resident back into his wheelchair and he was transported back to the facility. The facility policy indicates a resident should not be moved after a fall until a physician/advanced practice provider (APP), nurse or emergency medical services has evaluated them for possible injuries. Once evaluated and if the individual has no physical or verbal indication of injury, the patient can be moved to a safe and comfortable place when applicable. The resident was found to have bilateral tibia and fibula fractures. Based on the failure to ensure the resident was safe to be transferred in a manual wheelchair and the facility's failure to follow their policy after the fall it was determined this was an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ on 11/19/24 at 5:45 PM. The State Agency (SA) accepted the facility's plan of correction (POC) at 6:10 PM. After observation of implementation of the POC which included staff interviews and record review of the required audits and education the IJ was abated at 5:10 PM on 11/20/24. This was true for one (1) of three (3) residents reviewed for the care area of accidents during the long term care survey process. Resident Identifier: #8. Facility Census: 54. Findings Included: a) Resident #8 On 09/17/24 Resident #8 asked the facility to transport him to the bank in the facility van. A decision was made some time back by the Nursing Home Administrator (NHA) that power wheelchairs would no longer be used in the facility van for transport due to safety concerns. An interview with the NHA on 11/19/24 at 12:27 PM confirmed that sometime back (exact time frame is unknown) that due to the VA and (Name of Local ambulance company) a decision was made to no longer allow power chairs on the van. When asked if the two (2) residents who have power chairs were notified of this decision at the time, he indicated they had not been notified because they had not requested to go anywhere since the decision was made. The NHA stated that on this date Resident #8 had demanded to go to the bank and asked for his manual chair so he would be able to ride in the van to the bank. The NHA stated, therapy and nursing tried to convince him to wait but he was insistent and wanted to go no matter what. The NHA stated he was not in the facility on this date because he was at a meeting. An interview with The Director of Rehab # 59 at 2:00 PM on 11/19/24 found on 09/17/24 Resident #8 had come to the rehab door and was beating on the door demanding his manual wheelchair from the therapy shed because he wanted to go to the bank. She stated, she tried to convince him to wait until the NHA returned to the facility tomorrow and give them time to find a safe way for him to go but he was insistent and did not want to wait. She stated, I told him I did not think it was safe. I feel it wasn't safe because he had not been in that wheelchair for quite some time and was not sure if he had enough trunk control to hold himself in the chair. I have been working with him for [AGE] years, but just had not had him in that wheelchair for a while. I was not ready to say he was safe in it The Director of Rehab #59 further stated, He came to the door demanding that wheelchair. He was with nursing and activities and I told them all that I did not feel he was safe in that wheelchair. The surveyor also asked the Director of Rehab if she felt the power wheelchair could safely be strapped in the van? She replied, Yes. An interview with the Activity Director at 2:18 PM on 11/19/24 found that when Resident #8 slid from his chair in the van the activity assistant had called her and she left the facility to go and assist the resident. When she arrived, she indicated the resident was sitting with his legs crossed between his wheelchair and the back of the seat in front of him. She indicated she asked him if he was hurt and he stated No. When asked if the lift pad was under the resident or in the wheelchair, she stated it was still in the wheelchair. She stated, There was no room to get the lift into the van to get him out of the floor so she and the activity assistant (who are both nurse aides) two armed the resident, lifted him up while the driver slid the wheelchair under him. She stated, before we lifted him up I straightened his legs out. She stated, The resident did not want us to call 911. He wanted to go to the bank, but we took him back to the facility. An interview with the Activity Assistant on 11/19/24 at 2:30 PM found she was in the van while the resident was being transported to the bank. She stated, the resident started saying I'm sliding I'm sliding. She continued to state, When I looked back he was sitting on the floor with his back against his wheelchair and his legs were crossed. She stated while they were waiting for the Activity Director, she moved the resident's wheelchair and laid him on his back with his head on a towel so he would be comfortable. She stated his legs remained crossed when she laid him back. She stated that she and the activity director then lifted him up and the driver slid the chair under him. She stated they asked if he wanted to go to the ER and he said no he wanted to go to the bank, but they returned him to the facility instead. The NHA provided the following typed document (Typed as written), Resident (Initials of Resident #8) was evaluated by the licensed nurse upon return to the facility, orders received to obtain x-rays of bilateral lower extremities (BLE) from the physician on 09/17/24. On 09/17/24 the Director of Nursing (DON) interviewed the van driver, the nurse aide assisting with transport and the resident who is alert and orientated to identify if the van was traveling too fast, if driver hit the brakes to hard or negotiated a turn too fast causing residents to slide out of the wheelchair onto floor of the facility van. All staff interviewed indicated No to the above questions. The NHA interviewed the Director of Rehab (DOR) who was present when (Initials of Resident #8) requested his manual wheelchair for transport to the bank in the facility van. The Director of Rehab,(Initials of Resident #8) was demanding his manual wheelchair and did not want to wait. (Initials of Resident #8 was secured with the facility van seatbelt and wheelchair was locked into place in the van with securing straps per van protocol. All residents have the potential to be affected. The Director of Rehab (DOR)/designee initiated an audit on 09/23/24 for all residents in wheelchairs that utilize the facility van to determine safety for transport. Corrective action implemented immediately upon discovery. The Director of Rehab (DOR)/designee will reeducate all interdisciplinary team, medical records/resident appointment scheduling and van driver with a posttest to validate understanding regarding: appropriateness of van utilization for transportation, positioning/devices in wheelchairs . The Director of Nursing (DON)/designee will reeducate all Certified Nursing Assistants on removal of lift sling prior to transport in facility van on or before 10/04/24. Medical Records/resident appointment scheduling will bring the upcoming week's transportation schedule to IDT on Thursdays for review to ensure the appropriateness of the van for transportation. Any appointments added after the review must be discussed with the IDT team prior to transporting the Resident. An interview with Resident #8 on 11/18/24 at 2:26 PM found that on 09/17/24 he wanted to go to the bank because he had finalized the sale of his house, and he needed to go to the bank. He stated the administrator had told him he could not take his power wheelchair in the van, and he would have to use his manual chair. He stated that he had not been in his manual chair for three (3) years and in that he did not know he could take his power chair on the van, he had to get to the bank that day. He stated, It was one of the highest points I have had lately because I was finalizing the sale of my house, and the devil just knocked it out from under me. A review of a Wheelchair training session therapy note dated 11/14/24 found the following, W/C (wheelchair) management: analysis of patient body alignment and functional skills in new or existing w/c and assessment of current seating system for appropriate modifications. Patient in power wheelchair for positioning and safety with on facility van. Patient positioning maintained in wheelchair on van with use of wheelchair seatbelt (lap) which patient is able to release on command 100 percent of the time. Once positioned safely in van power system turned off for safety. Patient able to follow all directions for safe use of power wheelchair on van. Patient demonstrated safe mount and dismount of wheelchair van ramp. Van safety equipment functioned properly with power wheelchair. No issues noted. DON and Administrator present for session. A review of the hospital history and physical from the hospital for the date of 09/19/24 confirmed the resident had bilateral tibia fractures. A review of the facility policy titled Accident/incidents found the following, 1. Response: . 1.1.3 DO NOT move the individual until a physician/advanced practice provider (APP), nurse or emergency medical services has evaluated them for possible injuries. Once evaluated and if the individual has no physical or verbal indication of injury, the patient can be moved to a safe and comfortable place when applicable. When the facility was notified of the immediate jeopardy the NHA asked if this would be past noncompliance. The NHA was advised it would be current noncompliance because the education he provided to the staff failed to address ensuring the policy is followed in regards to moving resident prior to them being assessed by appropriate individuals. b) Facility Plan of Correction The facility submitted the following Plan of Correction (POC) typed as written: F- 689 Resident #8 Resident was evaluated by the licensed nurse upon return to the facility, orders received to obtain x-rays of bilateral lower extremities (BLE) from the physician on 09/17/24. On 09/17/24 the Director of Nursing (DON) interviewed the van driver, the aide assisting with transport and the resident who is alert and orientated to identify if the van was traveling too fast, if driver hit the brakes to hard or negotiated a turn too fast causing residents to slide out of the wheelchair onto floor of the facility van. All staff interviewed indicated No to the above questions. The NHA interviewed the Director of Rehab (DOR) who was present when Resident #8 requested his manual wheelchair for transport to the bank in the facility van. The Director of Rehab, Resident #8 was demanding his manual wheelchair and did not want to wait. (Initials of Resident #8 was secured with the facility van seatbelt and wheelchair was locked into place in the van with securing straps per van protocol. All residents have the potential to be affected. The director of rehab (DOR)/designee initiated an audit on 09/23/24 for all residents in wheelchairs that utilize the facility van to determine safety for transport. Corrective action implemented immediately upon discovery. The Director of Rehab (DOR)/designee will reeducate all interdisciplinary team, medical records/resident appointment scheduling and van driver with a posttest to validate understanding regarding appropriateness of van utilization for transportation, positioning/devices in wheelchairs . The Director of Nursing (DON)/designee will reeducate all Certified Nursing Assistants on removal of lift sling prior to transport in facility van on or before 10/04/24. The Director of Nursing (DON)/designee will reeducate all nursing staff on the post fall process, including any resident that has a fall must be evaluated by a nurse or medical provider prior to moving the resident on 11/19/24 and prior to nursing staff's next scheduled shift. Medical Records/resident appointment scheduling will bring the upcoming week's transportation schedule to IDT on Thursdays for review to ensure the appropriateness of the van for transportation. Any appointments added after the review must be discussed with the IDT team prior to transporting the Resident. Results of monitors will be reported by the NHA/designee monthly to the quality improvement committee for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter.

Based on resident interview, record review, staff interview and observation, the facility failed to ensure a resident did not develop avoidable pressure ulcers. Resident #8 returned from the emergency room with bilateral leg immobilizes. The facility failed to implement a plan to prevent Resident #8 from developing pressure ulcers because of the leg immobilizers. Resident #8 developed bilateral unstageable pressure ulcers to both calves. The wounds have worsened and required the resident to be hospitalized and undergo debridement procedures on each of the wounds. The resident has voiced concerns and fears that his right leg will need an amputation because of the wound. The state agency (SA) determined the failures related to Resident #8 placed him and any other residents with medical devices such as leg braces in an immediate jeopardy (IJ) situation. The SA notified the facility of the IJ at 6:30 PM on 11/19/24. The SA accepted the facility's plan of correction (POC) at 8:09 PM on 11/19/24. After the SA observed for implementation of the POC which included staff interviews, resident interviews and record reviews of the required audits and training the SA abated the IJ at 5:10 PM on 11/20/24. After the immediacy was removed a deficient practice remained for Resident #4 and Resident #40. A deficient practice remains for Resident #4 who developed a blister to his lower leg because of a leg immobilizer. The facility identified it as an edema blister instead of a pressure ulcer. The facility also failed to perform a wound evaluation on the wound when it was discovered and weekly there after until it was resolved. A deficient practice was also present for Resident #40 because the facility failed to provide wound care consistent with current standards of practice. This was true for three (3) of four (4) residents reviewed for the care area of pressure ulcers during the long-term care survey process. Resident Identifiers: #8, #4, and #40. Facility Census: 54. Findings Included: a) Resident #8 Resident #8 was admitted on [DATE] and has the following diagnoses MS, DM, paraplegia lower extremities, Bipolar, PTSD, osteoporosis, HTN, Depression, GERD, Neurogenic bladder, MDRO, and fractures of both lower extremities and arthritis. Scored 15 on the Brief Interview for Mental Status (BIMS) which indicates cognitively intact. 1) Resident Interview During an interview with Resident #8 at 2:26 PM on 11/18/24 the resident stated, I fell and broke my legs on 09/17/24 and came back with a brace on each leg. He continued to state, They did not know what to do with the braces when I came back, and they did not take them off for a week. He stated, after a week they took them off to give him a shower and said, Oh Sh(x)t. He stated, it was then that the wounds were identified. He indicated he had been to the hospital because of the wounds, and he was scared he was going to lose his right leg. He indicated the leg he was talking about by tapping his right leg. The surveyor asked Resident #8, They never removed the brace or looked at your skin for seven (7) days? He stated, No the first time was after a week when they gave me a shower. 2) Record Review A review of Resident #8's medical record found a hospital history and physical dated 09/20/24 which indicated the resident was to wear bilateral immobilizers during transfers and as tolerated related to bilateral tibia fractures. A review of the resident's skin only evaluation dated 09/20/24 completed at 4:42 PM found the answer to question #2. External device(s) (cast, prosthetic, brace) present was answered with No. A further review of Resident #8's care plan found no care plan focus, goal, or intervention related to the removal of the braces for checking skin integrity. The treatment administration record (TAR) for the month of September 2024 was reviewed and found the following, Bilateral Knee immobilizers as resident tolerates. CMS(Circulation, motion and sensation) and skin observations/hygiene QS while in place every day and night shift. This was initialed on the TAR as being done on the night of 09/23/24, and the day and night of the 24, 25, and 26. However, Resident #8 who is completely cognitively intact denies them doing this. He stated, No the first time was after a week when they gave me a shower. It should also be noted Resident #8 has a diagnosis of paraplegia which was entered into his medical record on 09/15/19. Paraplegia is defined as a chronic condition that results in the loss of motor or sensory function in the lower half of the body, including the legs, feet, and sometimes the abdomen. Resident #8 confirmed in an interview on the afternoon of 11/18/24 that he had no sensation or motion in his legs or feet at all. 3) Left Calf The following are the wound assessments completed by the facility for the left medial calf. The facility refers to the wound being on the left lateral calf and the left medial calf, however this is the same wound. -- Wound was evaluated on 09/26/24 at 4:25 PM by RN #41 the wound care nurse. The wound was classified as a deep tissue injury. It was indicated the wound was a pressure injury caused by a medical device. The wound is located on the left medial calf. It was classified as a new wound and was an in-house acquired pressure ulcer. There was no PUSH score included in this assessment. Pressure Ulcer Scale for Healing (PUSH) was developed by the National Pressure Ulcer Advisory Panel (NPUAP) to categorize the ulcer with respect to surface area, exudate, and type of wound tissue. There is no depth measurement with this tool. Scores can range from 0 (healed) to 17 most serious. The Dimensions of the wound are as follows: The area was 9.93 cm^2 (Centimeter). The length was 4.2 cm. The width was 3.12 cm. There was no depth recorded with this assessment. The wound bed was not described in this assessment. There was no exudate present. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The goal for the wound is to be healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was not signed by RN #41 until 09/27/24 at 1:19 PM. -- The wound was assessed on 09/30/24 at 11:23 AM by RN #41 the wound care nurse. The wound was classified as a Stage III pressure ulcer related to a medical device and was in house acquired. The wound age was identified as being four (4) days old. There was no PUSH score included in this assessment. The Dimensions of the wound were as follows: The area was 5.85 cm^2 (Centimeter) a decrease of 41 % since the previous assessment. The length was 2.42 cm a decrease of 42 % since the previous assessment. The width was 3.02 cm a decrease of 3 % since the previous assessment. There was no depth recorded with this assessment despite the fact the staging was changed from a deep tissue injury to a stage III pressure ulcer. In order for the wound to be a Stage III pressure ulcer there has to full thickness tissue loss therefore the wound would have a depth measurement. In addition, the medical record contained a picture of the wound at the time of the assessment. In the picture the full thickness tissue loss is noticeable, and the wound has a noticeable depth which was not measured by RN # 41 when completing this assessment. The wound bed was not described in this assessment, other than noting there was no signs of infection. There was a light amount of serous exudate present. There was no odor from the wound. The edges of the wound were attached, and the surrounding tissue was described as erythema and fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as improving and the goal was healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was not signed by RN #41 until 10/01/24 at 12:02 PM. -- The wound was evaluated on 10/08/24 at 2:41 PM by RN #41 the wound care nurse. The wound was classified as a Stage III pressure ulcer related to medical device. The wound is located on the left medial calf. It was assessed as deteriorating with a wound age of 12 days and was noted to be in-house acquired. The residents' PUSH score was 12 at the time of this assessment. The Dimensions of the wound were as follows: The area was 8.66 cm^2 (Centimeter) an increase of 48 % from the previous assessment. The length was 3.69 cm, an increase of 52 % from the previous assessment. The width was 3.01 cm and remained the same as the previous assessment. The deepest point was recorded at 0.3 cm, which was an increase of 100 % from the previous assessment. The wound bed was described as having no granulation, 50 % Slough, and no eschar. There was no evidence of an infection. The wound was noted to be bleeding. There was a light amount of Serosanguineous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as Deteriorating and the goal was healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident lethargic and does not acknowledge understanding on education provided. This assessment was signed by RN #41 the wound nurse on 10/09/24 at 8:28 AM. -- The wound was evaluated on 10/13/24 at 8:29 PM by RN #41 the wound care nurse. The wound was classified as an unstageable pressure ulcer related to Slough and/or eschar. The wound is located on the left medial calf. It was assessed as stable with a wound age of 25 days and was noted to be present on admission (It should be noted the resident was hospitalized from 10/08/24 to 10/11/24 and upon his return the facility changed the wound from in-house acquired to present on admission despite it being the same wound). The residents' PUSH score was 16 at the time of this assessment. The Dimensions of the wound are as follows: The area was 37.35 cm^2 (Centimeter). No comparison noted since this is the first assessment since his return from the hospital. The length was 11.51 cm No comparison noted since this is the first assessment since his return from the hospital. The width was 5.08 cm No comparison noted since this is the first assessment since his return from the hospital. There was no depth recorded with this assessment. The wound bed was described as having no granulation, 40 % Slough, and 60 % eschar. There was no evidence of an infection. There was a moderate amount of serous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as stable, and the goal was healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was signed by RN #41 the wound nurse on 10/16/24 at 12:22 PM. -- The wound was evaluated on 10/21/24 at 11:08 AM by RN #41 the wound care nurse. The wound was classified as an unstageable pressure ulcer related to slough and/or eschar. The wound is located on the left medial calf. It was assessed as stable with a wound age of 18 days and was noted to be present on admission. The residents' PUSH score was 16 at the time of this assessment. The Dimensions of the wound are as follows: The area was 18.01 cm^2 (Centimeter) a decrease of 52 % from the previous assessment. The length was 6.11 cm, a decrease of 47 % from the previous assessment. The width was 4.03 cm, a decrease of 21 % from the previous assessment. The deepest point was recorded at .1 cm which was an increase of 100 % from the previous assessment. The wound bed was described as having no granulation, 10 % Slough, and 90 % eschar. There was no evidence of an infection. There was a moderate amount of serous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as eczematous and fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as stable, and the goal was healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was signed by RN #41 the wound nurse on 10/22/24 at 1:57 PM. --The wound was evaluated on 10/28/24 at 10:57 AM. This evaluation was completed by the Director of Nursing. The wound was classified as an unstageable pressure ulcer related to Slough and/or eschar. The wound is located on the left medial calf. It was assessed as stalled with a wound age of one month and was noted to be present on admission. The residents' PUSH score was 15 at the time of this assessment. The Dimensions of the wound were as follows: The area was 12.49 cm^2 (Centimeter) a decrease of 31 % from the previous assessment. The length was 6.1 cm which was the same value as the previous assessment. The width was 2.61 cm, a decrease of 35 % from the previous assessment. There was no depth recorded, which was a decrease of 100 % from the previous assessment. The wound bed was described as having no granulation, 10 % Slough, and 20 % eschar. There was no evidence of an infection. It was noted the wound was bleeding. There was a moderate amount of Serosanguineous/bloody exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were not attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The dressing was described as intact. The goal of care was noted to be healable, and the progress of the wound was noted as stalled. No other information was contained in this wound assessment. -- The wound was evaluated on 11/08/24 at 3:03 PM. This wound evaluation was completed by LPN # 9. The wound was classified as a Stage 4 pressure ulcer. The wound was located on the left lateral calf. It was assessed as a new wound with an unknown age and was noted to be present on admission. The residents' PUSH score was 15 at the time of this assessment. The wound bed was described as having 50 % granulation and 50 % eschar. There was no evidence of an infection. Under the section titled other the nurse noted the wound was bleeding and the tendon was exposed. There was a moderate amount of Serosanguineous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as slow to heal, and the progress was noted as new (indicating the wound is a new wound). The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding but is non-compliant with turning and repositioning. This assessment was not signed by RN #41 the wound nurse until 11/14/24 at 10:57 AM. -- The wound was evaluated on 11/14/24 at 2:53 PM by Licensed Practical Nurse (LPN) #9. The wound was classified as an unstageable pressure ulcer related to slough and/or eschar. The wound is located on the left medial calf. It was assessed as improving with a wound age of two (2) months and was noted to be present on admission. The residents' PUSH score was 16 at the time of this assessment. The Dimensions of the wound are as follows: The area was 14.43 cm^2 (Centimeter) an increase of 16 % from the previous assessment. The length was 9.36 cm, an increase of 54 % from the previous assessment. The width was 3.09 cm, an increase of 19 % from the previous assessment. The wound bed was described as having 50 % granulation, 10 % Slough, and 40 % eschar. There was no evidence of an infection. There was a moderate amount of Serosanguineous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as erythema. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as healable, and the progress was noted as improving. The following note was entered, Wound assessment completed per (Facility Corporate Initials) policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. This assessment was signed by wound care nurse #41 on 11/15/24 at 4:58 AM. 4) Right Calf The following are the wound assessments completed by the facility for the right calf. The facility referred to the wound as being on the right medial calf and the right lateral calf, however it is the same wound. -- The wound was evaluated on 09/27/24 at 11:23 AM. This assessment was completed by RN #41 the wound care nurse. The wound was classified as a medical device related to pressure deep tissue injury. This wound was located on the right medial calf and is a new pressure area. The wound was in-house acquired. There was no PUSH score included with this assessment. The Dimensions of the wound were as follows: The area was 9.48 cm^2. The length was 3.97 cm. The width was 2.63 cm. The depth was not recorded on this assessment because there is no depth to the wound on this date. The wound bed was not described in this assessment other than stating there were no signs of infection. There was no exudate from the wound on this date. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The goal for the wound is healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was signed by RN #41 on 09/27/24 at 2:45 PM. -- The wound was evaluated on 09/30/24 at 11:19 AM by RN #41 the wound care nurse. The wound was classified as a deep tissue injury related to a medical device. The wound was located on the right lateral calf. It was assessed as being three (3) days old and was in-house acquired. This assessment did not contain a PUSH score. The Dimensions of the wound were as follows: The area was 9.31 cm^2 a decrease of 2 % since the previous assessment. The length was 4.13 cm, an increase of 4 % since the previous assessment. The width was 2.27 cm, a decrease of 14 % since the previous assessment. The wound had no depth. The wound bed was not described other than noting there was no sign of infection. There was no exudate or odor noted. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The goal for the wound is healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following was noted as education provided to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident verbalized understanding and provided accurate teach back. This assessment was not signed by RN #41 until 10/01/24 at 12:14 PM. -- The wound was assessed on 10/08/24 at 2:37 PM by RN #41 the wound care nurse. The wound was classified as a Stage III pressure ulcer related to a medical device and was in-house acquired. The wound age was identified as being 11 days old. There was no PUSH score included in this assessment. The Dimensions of the wound were as follows: The area was 29.91 cm^2 (Centimeter) an increase of 221% since the previous assessment. The length was 6.29 cm, an increase of 52 % since the previous assessment. The width was 5.99 cm, an increase of 164 % since the previous assessment. There was no depth recorded with this assessment despite the fact the staging was changed from a deep tissue injury to a stage III pressure ulcer. In order for the wound to be a Stage III pressure ulcer there has to full thickness tissue loss therefore the wound would have a depth measurement. In addition, the medical record contained a picture of the wound at the time of the assessment. In the picture the full thickness tissue loss is noticeable, and the wound has a noticeable depth which was not measured by RN # 41 when completing this assessment. The wound bed was not described in this assessment except for noting there were no signs of infection, and the wound was bleeding. There was a light amount of Serosanguineous exudate, and the wound had no odor. The edges of the wound were attached, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as deteriorating and the treatment goal was healable. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The following education was noted as given to the resident, Educated resident on ways to maintain good skin health; keeping skin clean and dry, moisturizer as needed, frequent position changes, including off-loading heels, adequate hydration and nutrition. Resident lethargic and does not verbalize understanding. This assessment was not signed by RN #41 the wound nurse until 10/09/24 at 12:50 PM. -- The wound was assessed on 10/28/24 at 10:49 AM by the Director of Nursing. The wound was classified as an unstageable pressure ulcer related to slough and/or eschar. The wound is located on the right lateral calf. It was assessed as being one (1) month old and being present on admission (It should be noted the resident was hospitalized from 10/08/24 to 10/11/24 and upon his return the facility changed the wound from in house acquired to present on admission despite it being the same wound). There was no push score included in this assessment. The Dimensions of the wound were as follows: The area was 59.1 cm^2. The length was 13.6 cm. The width was 5.6 cm. The wound bed was described as having no granulation, slough was checked as being present, but a percentage was not identified, and 90 % eschar. There was no evidence of an infection. Under the section titled, other, the nurse noted, bleeding indicating the wound was bleeding. There was a moderate amount of Serosanguineous/bloody exudate and there was a moderate odor noted after cleansing the wound. The edges of the wound were not assessed, and the surrounding tissue was described as fragile. There was no induration or edema noted. The peri wound temperature was warm. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The dressing was described as intact, and Dakin's solution was used for cleaning. The wound was described as deteriorating and the goal was healable. It was noted that the wound had a suspected infection. -- The wound was evaluated on 11/08/24 at 3:02 PM. The wound evaluation was completed by RN #41 who was the wound nurse. The wound was classified as an unstageable pressure ulcer related to slough and/or eschar. The wound is located on the right lateral calf. It was assessed as being a new wound which was present on admission. The residents' PUSH score was 16 at the time of this assessment. The Dimensions of the wound are as follows: The area was 115.99 cm^2. The length was 27.53 cm. The width was 6.11 cm. The deepest point was recorded as 1 cm. The wound bed was described as having 10% granulation and 90% eschar. There was no evidence of an infection. Under the section titled, other the nurse noted, bleeding and tendon indicating the wound was bleeding and the tendon was exposed. There was a moderate amount of Serosanguineous exudate and there was a faint odor noted after cleansing the wound. The edges of the wound were attached, and the surrounding tissue was described as erythema and fragile. There was no induration or edema noted. The peri wound temperature was normal. The resident had no pain noted on the wound assessment. (It should be noted that the resident is paraplegic and has no feeling or movement in his legs.) The treatment section of this assessment was not completed. The wound was described as slow to heal and was identified as a new wound. The following note was entered, Wound assessment completed per GHC policy. See care plan for interventions. Wound care/ treatment per HCP orders. See TAR for treatment plan. No evidence or complaints of pain or discomfort related to assessment or treatment. No indications of infection. The

Based on observation and staff interview, the facility failed to ensure menus were followed for the noon time meal on 11/18/24. This was true for 10 residents who were eating their noontime meal in the dining room on 11/18/24. Facility Census: 54 Findings Included: a) Noon time Meal Observation An observation of the noon meal service on11/18/24 found the Certified Dietary Manager (CDM) was serving the meal from a steam table located in the dining room. Near the end of the service, it was noted the residents were no longer being served broccoli with their meal. The residents were only served pinto beans, pan fried potatoes, and corn bread. An interview with the CDM immediately following the meal service confirmed she ran out of broccoli. When asked why there was not enough broccoli for all the residents she stated, I must of over scooped (gave too much) you made me nervous. When asked how many residents did not receive broccoli, she stated 10 residents. A review of the menu for this meal found each resident should have received one half of a cup of broccoli.

Based on record review and staff interview, the facility failed to ensure the medical record was complete and accurate for 18 residents reviewed during the long-term care survey process. Resident identifiers: #4, #209, #47, #23, #8, #160, #11, #15, #14, #13, #161, #3, #59, #164, #24, #35, #165, and #166. Facility Census: 54. Findings Included: a) Resident #4 An interview with Resident #4 on 11/20/24 at approximately 4:45 PM, Resident #4 stated, I have to wear this brace all the time. I changed braces recently because the bar on the other rubbed a blister on my lower leg, but it is healed now. When asked if the facility staff remove the brace daily to look at his skin he stated, Yes they take it off every day and look at my skin underneath it and then put it back on. A review of Resident #4's treatment administration record for the months of October 2024 and November 2024 found no documentation to indicate the resident's brace was removed and the skin was checked for integrity. During an interview with the Director of Nursing (DON) in the morning of 11/21/24 when asked if they were monitoring the resident skin for skin integrity she provided the surveyor with an ordered dated 11/21/24 which read as follows, Left knee immobilize at all times while out of bed. Remove QS for hygiene and skin check. When asked if there was documentation prior to this order about the brace being removed she reviewed the Treatment Administration Records and handed them back to the surveyor and said, I just gave you the updated current order. b) Resident #8 1) Code Status A review of Resident #8's medical record on 11/19/24 found a Physician Orders for Scope of Treatment (POST) form which indicated the resident wanted to be a full code and receive all life sustaining treatment. This form was signed by the resident on 10/11/24 and by the physician on 10/14/24. The record also contained a POST form signed by the resident on 11/09/24 and by the physician on 11/11/24 which also indicated the resident wanted to be full code and received all life sustaining treatment. A review of the Social Service Assessment and Documentation Dated 11/11/24 indicated under section 5. Resident Rights/Healthcare Decision Making/Advance Directives under letter g. Social Worker #4 had entered DNR/Select Treatments to indicate the resident did not want to be a full code and receive full medical treatment. An interview with the Social Service Director on the morning of 11/21/24 confirmed the social service assessment was not accurate. 2) Diagnosis of Post Traumatic Stress Disorder (PTSD) A review of Resident #8's medical record found he had a diagnosis of PTSD entered into his medical record 10/01/15. Further review of the medical record found Social Services Assessment and Documentation assessments completed on 10/11/24 and 11/11/24. Contained in the assessments was this question, Does the patient/resident report or does the medical record reflect any history of trauma and/or Post Traumatic Stress Disorder (PTSD)? Social Worker #4 answered no to this question on all of the above referenced assessments despite an active diagnosis of PTSD since 2015. An interview with the Social Service Director on the morning of 11/21/24 confirmed the social service assessment was not accurate. c) 07/08/24 While reviewing the medication administration record for multiple residents related to an incident which occurred on 07/31/24 it was noted there were blanks for the same residents and medications for 07/08/24. When asked why the medications were not given on 07/08/24 the Director of Nursing (DON) stated, I will have look and see why there are blanks on the MAR for 07/08/24. In an interview on 11/21/24 at 11:17 AM the DON reported the Internet was down at this time and the staff were not able to document the medication as given in the electronic medical record. She was asked if they had a backup paper system where the medications were documented. She indicated there should have been, but she could not locate it. The following residents medical record was inaccurate in regard to medication administration for 07/08/24 for the following medications. The following residents missed medications which are considered significant medications and omission of the medications are considered significant medication errors: Resident #160: - Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for Afib -- TEGretol Oral Tablet 200 MG (Carbamazepine) Give 0.5 tablet by mouth three times a day for Trigeminal neuralgia (Trigeminal neuralgia (TN) is a chronic pain disorder that causes sudden, severe facial pain. It's also known as tic douloureux, and it affects the trigeminal nerve, which controls sensation and movement in the face.) Resident #11: -- INSULIN GLARGINE-YFGN OUTER, SUV 100UNIT/1ML INSULN PEN Inject 14 unit subcutaneously at bedtime for a diagnosis of diabetes. Resident #15: -- Rivaroxaban Oral Tablet 10 MG (Rivaroxaban) Give 1 tablet by mouth one time a day for clot prevention (This medication thins the blood to prevent blood clots). Resident #14: - Carvedilol Tablet 25 MG Give 1 tablet by mouth two times a day for Hypertension - Furosemide Tablet 20 MG Give 3 tablet by mouth two times a day for edema Resident #13: -- Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN (Hypertension) Resident #161: -- HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 70 - 149 = 8 BS 70 to 149 give 8 units; 150 - 199 = 11 BS 150-199 give 11 units; 200 - 249 = 14 BS 200-249 give 14 units; 250 - 400 = 17 BS 250-400 give 17 units, subcutaneously before meals for Diabetes Resident #3: -Keppra Solution 100 MG/ML (LevETIRAcetam) Give 5 ml by mouth two times a day for Seizures - Metoprolol Tartrate Tablet 100 MG Give 1 tablet by mouth two times a day for HTN Resident #59: -Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 50 unit subcutaneously at bedtime for DM. -HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 untis; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units If BS is over 400 call the physician for orders, subcutaneously before meals and at bedtime for DM if BS <70 or > 400 notify MD (Medical Doctor) for a Diagnosis of Diabetes. Resident #23: -- Lyrica Capsule 100 MG (Pregabalin) Give 1 capsule by mouth two times a day for nerve pain Resident #164: --Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN Resident #35: -- Insulin Glargine-yfgn Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Glargine-yfgn) Inject 30 unit subcutaneously at bedtime for Diabetes. Resident #165: -- Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for blood clot prevention Resident #166: - Acyclovir Oral Tablet 400 MG (Acyclovir) Give 1 tablet by mouth two times a day for hemophilia A (Free Bleeder) d) Resident #23 On 11/20/24 at 1:30 PM, a record review was completed for Resident #23. The review found the resident was transferred to an acute care facility on 08/15/24 for altered mental status. However, the transfer form listed the transfer date as 03/02/24. On 11/21/24 at 9:45 AM, the Director of Nursing was notified and confirmed the date listed on the transfer form was incorrect. e) Resident#47 During record review on 11/20/24 the following orders were noticed for Resident #47 who was ordered Nothing by Mouth (NPO); As written in the medial record: NPO (nothing by mouth) diet, NPO texture, NPO consistency Diet Active10/17/2024 09:54 Acetaminophen Tablet 325 MG (Acetaminophen) Give 2 tablets by mouth every 4 hours as needed for Mild Pain More than 3 doses in 48 hours, notify physician/advanced practice provider(APP).Do not exceed 3g/day. (standing order) Acetaminophen Tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for Temp 100F or above Notify Physician/Advanced Practice provider. Do not exceed 3g/day Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide) Give 30 ml by mouth as needed for Constipation give at bedtime if no BM in 3 days Midodrine HCl Tablet 5 MG Give 1 tablet by mouth three times a day for Hypotension Pharmacy Active 10/18/2024 21:00 Sennosides Tablet 8.6 MG Give 2 tablets by mouth two times a day for constipation During an interview with the Director of Nursing (DON) on 11/20/24 at 3:00 PM, who states, some of those orders are prepopulated standing orders and was clicked by the admitting nurse, and a nurse that did not do the admission are supposed to check the orders within 24 hours after admission, and only new orders are looked at daily. f) Resident #209 Record review on 11/19/24 at 3:05 PM revealed Resident #209 had an order for a catheter due to urinarily retention, and was care planned for a catheter for urinary retention, however, does not have a medical diagnosis for urinary retention in the diagnosis list on the medical record. An interview on 11/19/24 at 3:28 PM the Director of Nursing ( DON) confirmed the Urinary Retention diagnosis was not listed on the medical Diagnosis portion of the medical record. 45173 49751

Based on record review and staff interview, the facility failed to ensure all residents were free from significant medication errors. This was a random opportunity for discovery found during the investigation of a facility complaint. Resident Identifiers: Resident # #160, #11, #15, #14, #13, #161, #3, #59, #23, #164, #24, #35, #165, #166. Facility Census: 54. Findings included: a) 07/31/24 A review of a complaint received by the state agency on 08/02/24 and reviewed during a complaint survey which began on 11/18/24 found on 07/31/24 several residents missed there night time medication. A review of the incident reports found the nurse had reported to work after being involved in an accident. It was observed she was not able to perform her duties, so she was sent home, and another nurse came to take her place about an hour after she left. The nurse before leaving gave a report to the nurse who was working at the facility, but it was not clear if the medications had been administered or not. Because it was not clear if the medication had been administered the oncoming nurse who arrived at the facility an hour later did not administer any of the medications. The facility identified the errors the next morning and the physician had seen each resident who had missed medications, and no adverse reactions were identified. The facility-initiated education for nurses which included the following: Nurse hand off responsibilities/emergency situations: In the event a nurse must leave their shift unexpectedly the On- Coming nurse must ensure that they ask what tasks have been completed and what tasks haven't. - Medication that have been passed - Medications that still need to be administered - Any documentation that needs to be completed - Controlle Count If you have questions or concerns regarding mediation (administering late) contact the MD for an order to GIVE or HOLD the medications and document a short note in each residents chart. - MD verbal order obtained to administer 9a/9p/etc medication late resident/representative aware. Or MD verbal order obtained to hold all 9a/9p/etc. medications, resident/representative aware. However the facility failed to put in place a plan to ensure if the nurse was unable to give a report what they would do to ensure medications were not missed. An interview with the Director of Nursing (DON) in the early afternoon of 11/21/24 confirmed licensed nurse #200 reported to work on the evening of 07/31/24. However, on her way to work she had been involved in an automobile accident. The nurse working with Licensed Nurse #200 phoned the DON and told her she seemed off and should not be working. They decided to send her home and have Registered Nurse (RN) #41 cover her shift. The DON indicated Licensed Nurse #200 left around 9:00 PM and RN #41 arrived at the facility between 10:00 PM and 10:30 PM. When asked why RN #41 did not give the medications considering they were not initialed off on the Medication Administration Record and were showing red on the electronic medical record system. The DON replied she was not sure if License Nurse #200 had given them because the report she received was not good. She stated, she didn't want them to have double doses. She indicated that is why they educated nursing on ensuring and accurate and comprehensive report was given if they had to leave their shift early. The following residents missed medications which are considered significant medications and omission of the medications are considered significant medication errors: Resident #160: - Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for Afib -- TEGretol Oral Tablet 200 MG (Carbamazepine) Give 0.5 tablet by mouth three times a day for Trigeminal neuralgia (Trigeminal neuralgia (TN) is a chronic pain disorder that causes sudden, severe facial pain. It's also known as tic douloureux, and it affects the trigeminal nerve, which controls sensation and movement in the face.) Resident #11: -- INSULIN GLARGINE-YFGN OUTER, SUV 100UNIT/1ML INSULN PEN Inject 14 unit subcutaneously at bedtime for a diagnosis of diabetes. Resident #15: -- Rivaroxaban Oral Tablet 10 MG (Rivaroxaban) Give 1 tablet by mouth one time a day for clot prevention (This medication thins the blood to prevent blood clots). Resident #14: - Carvedilol Tablet 25 MG Give 1 tablet by mouth two times a day for Hypertension - Furosemide Tablet 20 MG Give 3 tablet by mouth two times a day for edema Resident #13: -- Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN (Hypertension) Resident #161: -- HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 70 - 149 = 8 BS 70 to 149 give 8 units; 150 - 199 = 11 BS 150-199 give 11 units; 200 - 249 = 14 BS 200-249 give 14 units; 250 - 400 = 17 BS 250-400 give 17 units, subcutaneously before meals for Diabetes Reisdent #3: -Keppra Solution 100 MG/ML (LevETIRAcetam) Give 5 ml by mouth two times a day for Seizures - Metoprolol Tartrate Tablet 100 MG Give 1 tablet by mouth two times a day for HTN Resident #59: -Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 50 unit subcutaneously at bedtime for DM. -HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 untis; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units If BS is over 400 call the physician for orders, subcutaneously before meals and at bedtime for DM if BS <70 or > 400 notify MD (Medical Doctor) for a Diagnosis of Diabetes. Resident #23: -- Lyrica Capsule 100 MG (Pregabalin) Give 1 capsule by mouth two times a day for nerve pain Resident #164: --Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN Resident #35: -- Insulin Glargine-yfgn Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Glargine-yfgn) Inject 30 unit subcutaneously at bedtime for Diabetes. Resident #165: -- Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for blood clot prevention Resident #166: - Acyclovir Oral Tablet 400 MG (Acyclovir) Give 1 tablet by mouth two times a day for hemophilia A (Free Bleeder)

49751 Based on record review and interview the Pharmacist failed to accurately review and complete monthly Medication Regimen Review (MRR). This failed practices was found to be true for 3 of 5 residents reviewed for the unnecessary medication care area during the Long Term Care Survey process. Resident identifiers: #47, #8, #33. Facility census: 54. Findings included: a) Resident # 47 During record review on 11/20/24 the following orders were noticed for Resident #47 who was ordered Nothing by Mouth (NPO): (as written in medial record) NPO (nothing by mouth) diet, NPO texture, NPO consistency Diet Active 10/17/2024 09:54 Acetaminophen Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Mild Pain More than 3 doses in 48 hours, notify physician/advanced practice provider(APP).Do not exceed 3g/day. (standing order) Acetaminophen Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for Temp 100F or above Notify Physician/Advanced Practice provider. Do not exceed 3g/day Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide) Give 30 ml by mouth as needed for Constipation give at bedtime if no BM in 3 days Midodrine HCl Tablet 5 MG Give 1 tablet by mouth three times a day for Hypotension Sennosides Tablet 8.6 MG Give 2 tablet by mouth two times a day for constipation Further record review on 11/20/24 revealed the following progress note 10/18/2024 15:17 General Note: All medications reviewed with (Dr. name here). In agreement with regimen. During an interview with the Director of Nursing (DON) on 11/20/24 at 3:10 PM who confirmed the MRR completed after admission did not identify the orders for resident to not receive medications by mouth. b) Resident #8 Resident #8's medical record on 11/20/24 found the pharmacist completed a drug regimen review on 05/20/24 and made recommendations according to the pharmacist note in the electronic medical record. A copy of the recommendations made by the pharmacist on 05/20/24 was requested from the Director of Nursing (DON) in the afternoon of 11/20/24. She later confirmed she could not locate the recommendation made by the pharmacist on 05/20/24. c) Resident #33 A record review on 11/20/24 at 1:18 PM, revealed a Pharmacy Review for 05/2024 that reads as follows: A medication regimen review was performed- see report for comments/recommendations noted. During an interview on 11/20/24 at 1:19 PM, the Director of Nursing (DON) stated, I cannot find what the recommendation was for May. I have a doctor's note that she started Ativan 5 days later. If that helps you any. The DON later confirmed that she can not find what the pharmacy recommended for the Month of May 2024 for Resident #33.

Based on record review, resident interview and staff interview, the facility failed to develop and/or implement a comprehensive care plan regarding food dislikes for Resident #23, a skin condition for Resident #14, behaviors and emotional status for Resident #8 and prevention of pressure ulcers for Resident #4. This was true for four (4) of 21 residents reviewed during the survey process. Resident Identifiers: #23, #14, #8 and #4. Facility Census: 54. Findings Included: a) Resident #23 On 11/18/24 at 11:45 AM, an interview was held with Resident #23. The resident stated, They sent my salad with chicken on it .I detest chicken and turkey .it's on my ticket. On 11/18/24 at 12:30 PM, a record review was completed for Resident #23. The review found the care plan did not list the food dislikes under any focus area on the care plan. On 11/21/24 at 9:45 AM, the Director of Nursing (DON) was notified and confirmed the dislikes were not listed in the care plan. b) Resident #14 On 11/20/24 at 10:30 AM, a record review was completed for Resident #14. The review found the care plan had a focus area of Impaired skin (intertigo) from refusing hygiene, obesity and moisture. The goal was listed as Resident's skin will remain intact. However, there were no interventions listed under the focus area. On 11/21/24 at 9:45 AM, the DON was notified and confirmed no interventions were listed under the focus area. c) Resident #8 During the initial screening process of the long term care survey it was discovered Resident #8 had an Minimum Data Set (MDS) trigger for Post Traumatic Stress Disorder (PTSD). During an interview with Resident #8 on 11/18/24 at 4:19 PM when asked if he had any problems related to PTSD he stated, I was in the army and also loosing our son was very traumatic. He further stated, I have been here for a long time and have lost many friends here and that is hard on me. A review of Resident #8's care plan found no mention of PTSD. The care plan also did not mention Resident #8's army service, the loss of his son, nor the trauma of losing friends while being at the facility. When asked what services the facility had provided to him to assist with his PTSD he stated, None really. He indicated that he talks to a counselor at the Veteran Administration (VA) on a video chat. He stated, I set that up myself. A review of the care plan found this also was not included in the care plan. During an interview with the Social Service Director at 12:00 PM on 11/21/24 she confirmed the care plan did not mention the residents PTSD. She agreed his triggers had not been assessed and there was no treatment plan in place. 2) Leg Immobilizers Review of Resident #8's medical record found a hospital history and physical dated 09/20/24 which indicated the resident was to wear bilateral immobilizers during transfers and as tolerated related to bilateral tibia fractures. A further review of Resident #8's care plan found no care plan focus, goal, or intervention related to the removal of the braces for checking skin integrity. An interview with the Director Of Nursing (DON) on the afternoon of 11/19/24 confirmed this finding. d) Resident #4 An observation of Resident #4 at 3:00 PM on 11/20/24 found he had a knee immobilizer on his left leg. A review of his medical record found an order dated 10/14/24 which read, Maintain knee immobilizer at all times except when bathing. A review of the treatment administration record for the months of 10/2024 and 11/2024 found there was not an order to remove the brace and check the integrity of the skin. However, during an interview with the resident on the evening of 11/20/24, he indicated they do remove the brace at least once a day and look at his leg to make sure there are not any sores present. An interview with Resident #4 on 11/20/24 at approximately 4:00 PM confirmed he did at one point have a blister to his left lower leg. He stated, It is healed now. When asked what had caused the blister her stated, I had another brace that had rods in it and it was rubbing there and caused a blister. That is why I switched to this brace. (He tapped his knee immobilizer which was currently in place on his left leg.) At 4:34 PM on 11/20/24 an interview was completed with the Director of Nursing (DON). The DON was asked where the information regarding the blister Resident #4 spoke of could be found, she stated, There should be a SWIFT assessment. She then reviewed the electronic record with the surveyor and a SWIFT assessment for the blister was not located. She stated, Let me check with (First Name of RN #41 ) it should be in there. A few minutes later the DON returned with RN #41. RN #41 stated the wound was an edema blister and not related to the splint he was wearing. She confirmed she missed putting in the SWIFT assessment. She stated, It should have been done when it was discovered. RN #41 was asked what day she had discovered the blister and was asked if the physician had been notified. She stated, I will look and let you know. At approximately 5:00 PM on 11/20/24 RN #41 stated there was no evidence in the record to indicate the physician had been notified of the blister. She indicated the blister was identified on 11/10/24 because this is the date the treatment order was implemented. RN #41 indicated she removed the bandage from the area this morning and the area was resolved. She was asked how she determined it was related to edema and not to the brace the resident was wearing on his leg? She stated, He has self reported chronic edema blisters. RN #41 was then asked if Resident #4 was capacitated and able to relay such information. RN #41 and the DON both confirmed the resident was cognitively able to do so and was capacitated. RN #41 and the DON was then advised of the interview the surveyor had conducted with Resident #4 earlier where he had stated the wound was from the rod rubbing his leg. At this time the DON accompanied the surveyor back to Resident #4's room to determine if there was a different brace in his room. At this time Resident #4 was again asked what had caused the blister to his left lower leg and he stated, That other brace had a rod in it that rubbed that blister there. The DON was able to locate the other brace in the resident's closet. The resident was then asked if he had problems with blisters related to edema (swelling) in his legs. He stated, I have in the past, but this was not caused by that it was caused by the brace. The DON was present for this interview. A review of Resident #4's care plan found there was no focus statement, goal or intervention related to how the resident's skin integrity will be maintained while he has orders to wear the knee immobilizer. The only place on the care plan the knee immobilizer is mentioned is in regards to Resident #4's Activities of Daily living care plan where it notes the knee immobilizer is to be in place at all times except when bathing. In addition, the identified blister is not addressed on the residents care plan. In addition, the residents risk for developing a pressure ulcer as a result of the knee immobilizer is not addressed on the residents care plan. This finding was confirmed with the DON on the afternoon of 11/20/24. 45173

Based on observation, record review, staff interview and resident interview, the facility failed to ensure one (1) resident's call lights were within reach. This was a random opportunity for discovery. Resident identifiers #15. Facility Census was 54. Findings included: a) Resident # 15 During a resident interview on 11/18/24 at 11:45 AM, Resident #15 was observed reaching for her call light. She attempted to move her chair but could not. She also mentioned that her reaching tool was on the other side of the room. Resident stated that the Nurse Aide (NA) must have moved the call light when she made her bed. At 12:16 PM the surveyor rang Resident #15's call light and at 12:18 PM the Director of Marketing and Admissions #8 answered the light and acknowledged that resident's call light and reacher were not within her reach. He gave both to the resident and stated that he was sure the NA would come back. Review of resident's care plan revealed the following: -Focus Resident requires assistance and is dependent for Activities of Daily Living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to recent illness, hospitalization resulting in fatigue, activity intolerance. -Invention included: Resident with staff assist of two (2), total lift, split leg sling. Arrange resident environment as much as possible to facilitate ADL performance. 50551

Based on record review and staff interview, the facility failed to identify diagnosis of Traumatic Brain Injury (TBI), mood disorder, personality disorder, and Post Traumatic Stress Syndrome (PTSD) on the Pre-Admission Screening and Resident Review (PASARR). This failed practice was found true for (2) two of (4) four residents reviewed for PASARR during the Long-Term Care Survey Process. Resident identifiers: #33 and #8. Facility Census: 54. Findings included: a) Resident #33 A record review on 11/18/24 at 4:09 PM, of Resident #33's diagnosis, revealed a diagnosis of TBI as an admitting diagnosis. Further record review of Resident #33's PASARR dated 04/28/22 revealed a PASARR that did not include the diagnosis of TBI. During an interview on 11/19/24 at 3:05 PM, the Licensed Social Worker (LSW) stated, I did not do hers, so I am not sure. The lady who did hers is off this week. The LSW confirmed that the diagnosis of Traumatic Brain injury was not on the PASARR. b) Resident #8 A review of Resident #8's medical record on 11/18/24 found Resident #8's diagnosis list contained the following diagnosis: Personality disorder as of 04/02/13, bipolar disorder as of 04/02/13, post-traumatic stress disorder (PTSD) as of 10/01/15, insomnia as of 09/15/19, and mood disorder due to known physiological condition with depressive features as of 04/02/13. A review of Resident #8's most recent Pre-Admission Screening (PAS) found it was dated 12/02/23 and was completed by the facility. The only mental illness diagnosis contained on the PAS was Bipolar which was noted to be controlled well with medication. Resident #8's diagnosis of personality disorder, PTSD, Mood disorder, and insomnia was not included on the PAS. The PAS did not trigger for a level II evaluation. An interview with the Social Service Director in the morning of 11/21/24 confirmed the PAS needed to be updated to include all the current diagnosis. 49465

Based on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS)for Resident #8 accurately reflected whether his pressure ulcer was in house acquired or present on admission. This was true for one (1) of three (3) residents reviewed for the care area of pressure ulcers during the long-term care survey process. Resident Identifier: #8. Facility Census: #54. Findings included: a) Resident #8 A review of Resident #8's medical record found the following MDS's: An MDS with an Assessment Reference Date (ARD) of 10/29/24 identified Resident #8 as having three (3) unstageable pressure ulcers, all of which were present on admission. However, a review of the skin evaluations found Resident #8's two (2) pressure ulcers to his calves were in house acquired. An MDS with an ARD of 11/11/24 identified Resident #8 as having three (3) unstageable pressure ulcers, all of which were present on admission. However, a review of the skin evaluations found Resident #8's two (2) pressure ulcers to his calves were in house acquired. An interview with Clinical Reimbursement Coordinator #38 at 12:04 PM on 11/20/24 confirmed the above mentions MDS's were inaccurate.

Based on record review and staff interview, the facility failed to provide a bed hold policy to Resident #23 for two (2) transfers to an acute care facility. This was true for one (1) of four (4) residents reviewed under the care area of hospitalization s. Resident identifier: #23. Facility Census: 54. Findings Included: a1) Resident #23 On 11/18/24 at 1:02 PM, a record review was completed for Resident #23. The review found the resident had been sent to an acute care facility on 03/02/24 for altered mental status. An interview was held with Business Office Manager (BOM) #36. BOM 36 stated, we don't have a bed hold policy for the transfer on 03/02/24. On 11/21/24 at 9:45 AM, the Director of Nursing (DON) was notified and confirmed the bed hold policy should have been completed. b1) Resident #23 On 11/18/24 at 1:02 PM, a record review was completed for Resident #23. The review found the resident had been sent to an acute care facility on 08/15/24 for altered mental status and increased urinary incontinence. An interview was held with Business Office Manager (BOM) #36. BOM #36 stated, We don't have a bed hold policy for the transfer on 08/15/24. On 11/21/24 at 9:45 AM, the DON was notified and confirmed the bed hold policy should have been completed.

Based on record review and staff interview, the facility failed to ensure the receiving facility received adequate information to ensure a safe and effective transition of care for Resident #8 when he was transferred to the hospital. This was true for one (1) of three (3) residents reviewed for the care area of hospitalization s during the long-term care survey process. Resident Identifier: #8. Facility Census: 54. Findings included: a) Resident #8 A review of Resident #8's medical record found he was transferred to the hospital on 10/08/24. The resident record contained a SNF/NF to the hospital transfer form. The facility staff indicated this is the form which is sent with the resident to the hospital at the time of transfer. This form was reviewed and found no skin issues were identified. However, further review of the record found the resident had a pressure ulcer to his sacrum, to his left and right calf and to his right thigh. None of the wounds were identified on the transfer form. This was confirmed with the Director of Nursing (DON) on 11/20/24 at 10:10 AM.

Based on record review and staff interview, the facility failed to ensure the attending physician for Resident #4 was notified when the resident developed a blister to his lower leg. This was true for one (1) of three (3) residents reviewed for the care area of pressure ulcers during the long-term care process. Resident Identifier: #4. Facility Census: 54. Findings Included: a) Resident #4 A review of Resident #4's medical record on 11/20/24 found an order for Cleanse burst blister to the left lower leg with wound cleanser, pat dry and cover with bordered dressing. Change weekly and PRN for loose or soiled dressing. This order was dated 10/31/24. Further review of the medical record found no indication the physician was notified of the residents change in condition. An interview with the Director of Nursing (DON) on 11/21/24 at 12:39 PM confirmed there was no evidence in the medical record to indicate the physician was notified of the blister to Resident #4's left lower leg.

Based on record review and staff interview, the facility failed to treat each resident with dignity by placing undignified pictures in their medical record. This was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers #40 and #43. Facility Census 54. Findings Included: a) Resident #40 A record review on 11/20/24 at 4:56 PM, revealed that Resident # 40 had a Stage II pressure ulcer on her sacrum upon admission. Further record review found (2) two pictures of Resident #40's Stage II pressure ulcer to her sacrum. The picture dated 10/07/24, revealed a brown lumpy substance in Resident #40's brief. The picture dated 10/28/24, revealed a brown substance smeared up Resident # 40's intergluteal cleft. During an interview on 11/20/24 at 5:00 PM, Registered Nurse (RN) #41 (who is the wound nurse for the facility) stated, We clean the wounds, then take a picture of the area. The area is cleaned before we take the picture. State Agency (SA) showed RN #41 and the Director of Nursing (DON) the pictures in Resident #40's medical record. RN #41 had no reply. The DON stated, I see what your talking about The DON confirmed that the pictures were undignified. b) Resident #43 A record review on 11/20/24 at 4:56 PM, revealed that Resident #43 had a Stage II pressure ulcer on her sacrum upon admission. Further record review found (2) two pictures of Resident #43's Stage II pressure ulcer to left gluteus. The picture dated 06/18/24, revealed a brown substance in Resident #43's brief. The picture dated 07/02/24, revealed a brown substance in Resident #43's brief. During an interview on 11/20/24 at 5:00 PM, Registered Nurse (RN) #41 (who is the wound nurse for the facility) stated, We clean the wounds, then take a picture of the area. The area is cleaned before we take the picture. State Agency (AS) showed RN #41 and the Director of Nursing (DON) the pictures in Resident #43's medical record. RN #41 had no reply. The DON stated, I see what you're talking about The DON confirmed that the pictures were undignified. 49751

Based on record review, staff interview and observation, the facility failed to provide services to a resident that are necessary to avoid death, physical harm, pain, mental anguish or emotional distress by not following the Resident's original signed West Virginia Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice affected Resident #54, who is now deceased . This deficient practice had the potential to also affect one of the fifty-one (51) residents at the facility with POST forms. Resident identifiers: #54. Facility census 51 The facility was notified of the IJ (Immediate Jeopardy) at 1:12 PM on [DATE]. The facility submitted their abatement plan of correction (POC) at 2:13 PM on [DATE] and was forwarded to the State Office for review. The State Office approved the POC at 2:41 PM on [DATE]. After observation, staff interview, review of facility documentation, and record review determining the implementation of the abatement POC, the IJ was abated at 9:20 AM on [DATE]. The IJ started on [DATE] when the POST form was changed and ended on [DATE] at 9:20 AM. The facility's approved abatement POC consisted of the following: Action steps to be completed by the nursing home to remove the allegation of Immediate Jeopardy: (Name of facility) Abatement Plan On [DATE] Center Executive Director and Center Nurse Executive implemented the following plan: 1. The nursing staff immediately verified all POST forms with capacitated residents and all POST forms with MPOA/HCS for all incapacitated residents with findings reported to the Center Nurse Executive for any corrective action immediately upon discovery. 2. All current residents of the facility have the potential to be affected. 3. Assistant Director of Nursing (ADON) will immediately initiate re-education with a posttest to validate understanding beginning [DATE] at 2:30 PM to all licensed nursing staff, social services, and Medical Provider prior to his/her next scheduled shift regarding the appropriate and thorough completion of the POST form. Licensed nursing staff, social services and Medical Providers not available during this timeframe will be provided reeducation including posttest prior to the next scheduled shift by the ADON/designee. New Licensed nursing staff, social services and Medical Providers during orientation by the ADON/Designee will receive education and complete a posttest prior to completion of orientation. The CNE (Center Nurse Executive)/Designee will monitor the POST forms on Admission and with every change made to the POST Form with any corrective action immediately upon discovery and re-education upon discovery for 30 days and then quarterly. Center Nurse Executive/Designee will review findings with the Center Executive Director/Designee daily. 4. The Center Nurse Executive/designee will present results of audits or monitoring monthly to the Quality Improvement Committee for any additional follow up and/or in servicing until the issue is resolved and randomly thereafter as determined by the Quality Improvement Committee. All corrective actions were completed. All licensed nursing staff working night shift and day shift were in-serviced. This was evidenced by the in-service sing-in sheet produced by the Administrator and surveyor interview of staff at the facility. All POST forms were in the process of being reviewed by the ADON. Once the IJ was abated, the deficient practice remained, and the scope and severity (S/S) was decreased from a J to an E. A deficient practice remained for Residents # 54. Findings Included: a) Resident #54 Resident #54 was admitted on [DATE] to the facility. On [DATE] Resident #54 completed a POST form with the following sections filled out. POST form dated [DATE] was marked under the following sections: Section A is marked Attempt Resuscitation/CPR Section B is marked Limited Additional Interventions Use medical treatment, Iv Fluids and cardiac monitoring as indicated Do Not use intubation or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care unit. Section C is marked IV fluids for a trial period of no longer than TBS and no Feeding tube Section D is discussed with patient/Resident. Resident did not mark the box to give authorization for anyone else to make decisions if she would lose capacity Post form on [DATE] is signed by Resident and Facility Physician On [DATE] two staff members called Resident # 54's son to obtain a new POST form. Licensed Practical Nurse #26 (LPN) and a Registered Nurse 25 (RN) took a verbal consent for a POST form with the following sections filled out. POST form dated [DATE] was marked under the following sections: section A is marked Do not Attempt Resuscitation/DNR Section B is marked Comfort Measures: Treat with dignity and respect. Keep clean, warm, and dry. Use medications by and route, positioning, wound care and other measures to relieve pain and suffering and promote comfort. Use oxygen, suction and manual treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C is marked No IV fluids (provide other measures to assure comfort) and no Feeding tube; Section D is discussed with other -Son. Telephone consent per Son-- LPN #26 / and RN #25 signed Post form on [DATE] is signed by Facility Physician The Resident did not initial the POST form indicating if the resident lost capacity, the POST form could be changed by the medical representative. Therefore, the POST form should not have been changed. A review of the medical record reveals a physician determination of capacity dated [DATE] stating Resident #54 had capacity. Further review of the medical records reveals a nurses note dated [DATE] at 17:18 that reads as follows: Residents daughter (Redacted) called facility asking about residents status, this nurse explained to daughter that resident has not been eating and refused [MEDICATION(S)] today and is unable to participate with therapy. Residents daughter stated that she wanted resident to go have a feeding tube placed and I explained to her that resident signed her POST form when she came to facility and clearly stated that resident did not want a feeding tube. I went to residents room and asked her if she wanted a feeding tube and resident stated that she did not want one. Daughter asked if she could come in for a compassion visit DON approved for this to happen. Notified of (Redacted) Facility Physician the above. A continued review of the medical record reveal a nurses note dated [DATE] at 5:20 AM, that reads as follows: The resident's breathing was labored around midnight, 2L of oxygen was applied via nasal cannula. MD aware. Contacted the Resident's daughter, (Redacted), at 0520 to let her know that the resident was declining and she could come in to the facility to see her. In an interview on [DATE] at 11:30 the Administrator confirmed that Resident did not have a medical power of attorney (MPOA) form on file. The administrator did not know why the new POST form was completed. On [DATE] at 1:23 PM, the surveyor contacted the resident's son by telephone with no answer. A message was left for the son. On [DATE] at 2:23 PM, the Son called back and stated the facility called him to get a POST form signed. He stated he was told there was no paperwork on file and they needed to know if he wanted them to do CPR or not if something should happen to his mother. He could not remember the time but can remember that it was late because he was afraid he would fall asleep if he tried to drive to the facility that night. Further review of the medical records found that Resident #54 expired on [DATE] and did not received CPR per the Resident's wishes. Resident #54 did not receive CPR and in addition was not transferred to the hospital when her condition deteriorated per her wishes. Resident #54 expired at the facility.

Based on observation, record review, resident and resident representative interview, and staff interview, the facility failed to identify and provide needed care and services that are resident centered and in accordance with the residents' plans of care and orders. The facility failed to promptly identify and intervene for an acute change in Resident #13's condition. This harmed Resident #13 by causing increased pain and by affecting the resident's ability to be independent in bed mobility, ambulating, eating, and toileting. The facility also failed to perform neurological assessments when Resident #13 had an unwitnessed fall. Additionally, the facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice had the potential to affect four (4) of 18 residents reviewed during the long-term care survey process. Resident identifiers: #13, #33, #38, and #105. Facility census: 51. Findings included: a1) Resident #13 - change in condition During an interview on 12/06/21 at 11:14 AM, Resident #13's Medical Power of Attorney (MPOA) stated that the resident had fallen and broken his hip. She stated that the facility did not send the resident to the hospital for evaluation until hospice asked the facility to do so. Review of Resident #13's medical records showed a note written on 9/2/2021 at 12:32 PM that stated as follows: Resident was attempting to ambulate from bed to bathroom and fell . He has complaints of left hip pain and is guarding that leg. X-ray ordered. Later in the day resident not guarding leg and ambulating on that leg. An incident report was completed on 09/02/21 at 12:32 PM and stated, This nurse heard a resident calling for help. Observed resident lying on floor. Head towards doorway. Wheelchair locked beside resident. Back of wheelchair facing restroom door. Resident observed bleeding from cancerous lesion from face. This nurse called for CNA [Certified Nursing Assistant] to get additional nurses for assistance. Resident assisted back to bed by CNE and ADON. Resident was not bearing weight on LLE [left lower extremity] at time of transfer. Passive range of motion performed. Resident had complaints of pain all over. Two slightly reddened areas on bony prominence's present during skin inspection being performed by CNE [Center Nurse Executive]. CNE stated x-rays would be ordered. Resident resting comfortably in bed with even non-labored respirations and call bell within reach when this nurse left the room. At that time, Resident #13 had capacity to make medical decisions. According to a nurse's note written on 9/2/2021 at 1:10 PM, mobile x-ray was notified that an x-ray had been ordered for the resident. On 9/2/2021 at 8:32 PM, a nursing note stated the resident reported left leg pain and received [MEDICATION(S)]. Resident #13 had cancer of the submandibular gland and was on hospice. He had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He had been utilizing this medication prior to the fall. The x-ray was attempted on 9/3/2021 at 12:10 AM. The nursing note stated, X-ray tech [technician] in to perform x-ray of L) [left] hip and asked us for assistance. Staff went in to reposition resident and resident would not turn. Was screaming out in pain. L) leg contracted up and anytime we attempted to straighten it or turn him so the tech could perform x-ray he began yelling again. Attempted to inform resident of need of xray d/t [due to] fall and c/o [complaint of] pain. He continued to refuse to move and assist in positioning for the x-ray. Unable to obtain x-ray at this time. DON [Director of Nursing] and MD [physician] made aware. No further orders at this time. On 9/3/2021 at 4:32 AM, a nursing note stated the resident continued to report pain in the left hip, which he rated as a 2 on a scale from 1-10, with 10 being the worst pain The nursing note also stated, Continues to refuse to cooperate w/ [with] care. On 9/3/2021 at 6:28 AM, a nursing note stated, Resident continues to yell out when staff attempting to perform care. Had been incontinent and CNAs were attempting to change him; however, he grabs their hands/arms and pushes them away, continues to guard his L) leg and will not move it. Is laying on his R) [right] side and will not turn. Will continue to try. Will notify MD. On 9/3/2021 at 7:42AM, a nursing note stated, Notified Dr. [name redacted] about resident's increased after his fall and inability to obtain x-ray. He stated to notify Hospice and see how they wanted to proceed w/ this. Day shift charge nurse notified. On 9/3/2021 at 8:18 AM, a late entry note that stated physical therapy was awaiting results of x-ray prior to completing screen secondary to fall. The resident was seen by the hospice nurse on 09/03/21 at 9:00 AM. The note stated, Spoke to the facility nurse [name redacted], reports patient had a fall yesterday 09/02/21 around 12:30 PM-1:00 PM, a couple hours after the fall patient continued to walk to the bathroom with no issues. Throughout the evening, patient started guarding the left hip, leg contracted up towards chest. Facility ordered x-ray. [Facility nurse's name redacted] reports Pt. [patient] refused all evening meds and was not able to give comfort meds prior to x-ray. Upon arrival, Pt lying in bed with left let up towards chest. Blood all over sheets from pt. chin. Pt was able to turn and reposition with assistance, slightly moved left leg, but was not able to straighten left leg. FLACC score [pain score] 4 .Facility nurse [name redacted] will contact facility Dr. to see about increasing pain meds and will contact hospice with changes . A nursing note on 9/3/2021 at 12:32 PM stated, Patient did fall yesterday and was c/o hip pain. An X-ray was ordered but patient would not cooperate to get the x-ray . Patient is still c/o hip pain and I am going to ask the DON what the plan may be for him at this point. A nursing note on 9/3/2021 at 8:32 PM stated, Resident continues to c/o left hip pain r/t recent fall, x-ray attempt unsuccessful, resident receiving PRN [as needed] pain medication for c/o pain with some effectiveness voiced, resident in bed resting with LLE [left lower leg] drawn up at this time, no other complaints of pain voiced or s/s [signs and symptoms] of distress noted, VSS [vital signs stable], will continue to monitor . The hospice nurse saw the resident on 09/04/21 at 1:15 PM. The nursing note stated, Pt. hasn't been able to move left leg since Thursday evening. Pt. refused to let this nurse to an assessment. Pt. reports it hurts too bad. Pt FLACC score 5. Facility nurse [name redacted] administered [MEDICATION(S)] 1 ml. [name redacted] contacted Dr. [facility doctor's name redacted], ordered another STAT x-ray and [facility nurse's name redacted] reported she will medicate pt. prior to x-ray. Dr. [hospice physician's name redacted] contacted and suggested pt. to be send to hospital. They can CT [cat scan] and pt. wouldn't have to reposition as much. Reported Dr. [hospice physician's name redacted] suggestion to [facility nurse's name redacted]. [Facility nurse's name redacted] will notify hospice with results. A nursing note written on 9/4/2021 at 3:24 PM stated, Patient still complaining of left hip pain. Hospice nurse was in and the hospice physician suggested patient to go to the hospital. I spoke with Dr. [facility doctor's name redacted] and we are going to order a stat x-ray. A progress note written on 9/4/2021 at 5:45 PM stated, X-ray did arrive but was unable to obtain the x-ray due to the patient can not straighten his left leg. A nursing note written on 9/4/2021 at 5:47 PM stated, X-ray was unable to obtain because patient would not straighten his leg. Patient was sent to [hospital name redacted] via [name redacted] ambulance. Report was called to the ED [emergency room ] . A nursing note written on 9/5/2021 at 5:02 AM stated, [Name redacted] hospital called and stated resident was admitted with DX [diagnosis] of (L) Hip Fracture . Resident #13 had surgical repair of his hip and returned to the facility on [DATE]. The resident had a decline in his condition due to his cancer and was unable to be interviewed regarding the matter during the survey. The facility had reported the matter to the ombudsman, Adult Protective Services, and the Office of Health Facility Licensure and Certification. Review of Resident #13's medical records showed that prior to the fall he was independent in bed mobility, walking in room, locomotion (ambulation) on unit, toileting, transferring, and eating. On 09/03/21, the resident was totally dependent for bed mobility and toileting. On 09/04/21, the resident required extensive assistance for bed mobility and toileting. Following the fall, walking in room, locomotion (ambulation) on unit, and transferring did not occur on 09/03/21 and 09/04/21. On 09/03/21, the medical records report the resident either did not eat lunch or dinner on 09/03/21. He was able to feed himself for dinner on 09/03/21. He required total assistance for meals on 09/04/21. On 12/07/21 at 4:02 PM, the resident's physician was interviewed. The physician had no independent recollection of the resident's hip fracture. The physician stated that he tries to hold off sending residents to the hospital if it can be avoided. He also stated that he defers to the hospice service's decisions on treating residents on hospice. a2) Resident #13 - neurological assessment Review of Resident #13's medical records revealed the resident had experienced a fall on 07/30/21 at 2:58 PM. According to the incident/accident report, the resident stated he had fallen and hit his knees and head. The fall had been partially witnessed by Resident #13's roommate, who was not able to see whether the resident had hit his head in the fall. No neurological assessments could be located in the resident's medical record. Neurological assessments were important to determine whether the resident had received a head injury from the fall. During an interview on 12/07/21 at 1:56 PM, the Director of Nursing (DON) stated that she was unable to locate neurological assessments for Resident #13's fall on 07/30/21. She agreed neurological assessments should have been performed for this fall in which the resident reported that he hit his head. No further information was provided through the completion of the survey. a3) Resident #13 - laboratory testing Review of Resident #13's medical records showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The laboratory tests to be performed were a complete blood count and a comprehensive metabolic panel. The results could not be located in the resident's medical records. On 12/07/21 at 2:13 PM, the Director of Nursing confirmed that Resident #13 had not had laboratory testing performed on 09/11/21 as ordered by the physician. No further information was provided through the completion of the survey. b1) Resident #33 - weights Review of Resident #33's medical records showed an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical records gave the following information: - On Monday 08/16/21, the resident was weighed - On Monday 08/23/21, the resident was not weighed - On Monday 08/30/21, the resident was weighed - On Tuesday 09/01/21, the resident was weighed - On Monday 09/06/21, the resident was not weighed - On Monday 09/13/21, the resident was not weighed - On Monday 09/20/21, the resident was not weighed - On Monday 09/27/21, the resident was not weighed - On Friday 10/01/21, the resident was weighed - On Monday 10/04/21, the resident was not weighed - On Monday 10/11/21, the resident was weighed - On Monday 10/18/21, the resident was not weighed - On Monday 10/25/21, the resident was not weighed - On Monday 11/01/21, the resident was not weighed - On Thursday 11/04/21, the resident was weighed - On Monday 11/08/21, the resident was not weighed - On Monday 11/15/21, the resident was not weighed - On Monday 11/22/21, the resident was weighed - On Monday 11/29/21, the resident was weighed During an interview on 12/07/21 at 11:04 AM, the Director of Nursing (DON) stated that she was unable to locate weights for the missing dates. No further information was provided through the completion of the survey. b2) Resident #33 - palm protector Resident #33 was interviewed on 12/06/21 at 9:04 AM. The resident stated he move his left side very well. The resident's left hand appeared to be contracted. The resident was noted to have no devices on his left hand. Review of Resident #33's medical records showed an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #33's medical records showed he had a contracture of the left hand. On 12/07/21 at 10:00 AM, Resident #33 was observed to not have a palm protector applied to his left hand. The resident stated that he has had a palm protector before, but he doesn't like to wear it because it itches his hand. He said that he took off the palm protector himself in the past. Resident #33's medical records contained no documentation of application or removal of a palm protector or of refusals by the resident to wear the palm protector. During an interview on 12/07/21 at 11:14 AM, the Director of Nursing (DON) confirmed Resident #33's medical records contained no documentation of application or removal of a palm protector or of refusals by the resident to wear the palm protector. The DON stated that the palm protector application and removal was not on the Treatment Administration Record (TAR) because the order had been entered incorrectly. No further information was provided through the completion of the survey. c) Resident #38 On 12/06/21 at 9:42 AM, Resident #38 was interviewed. The resident stated that her feet were swollen. The resident was noted to be wearing socks. The resident stated that she did not have any stockings or anything else under the socks. Review of Resident #38's medical records showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #38's medical records contained no documentation of application or removal of compression stockings. During an interview on 12/07/21 at 3:18 PM, Resident #38 stated that she continued to have swollen feet. She stated she had a doctor's appointment tomorrow for evaluation of her swollen feet. The resident stated she did not have any compression stockings on her legs. On 12/07/21 at 3:23 PM, Licensed Practical Nurse (LPN) #21 confirmed the resident was not wearing compression stockings. LPN #21 stated that she did not know the resident had been ordered compression stockings. On 12/07/21 at 3:30 PM, LPN #21 stated that Resident #21's order for compression stockings had been incorrectly ordered. LPN #21 stated this is why she was unaware that the resident had been ordered the compression stockings. No further information was provided through the completion of the survey. d) Resident #105 Review of Resident #105's medical record found the resident was admitted to the facility on [DATE] at 5:43 PM, with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of discharge summary dated 11/30/21, found a recommendation from the discharging hospital to follow-up with the pulmonologist in one (1) week due to acute exacerbation of [CONDITION(S)] for intensification of bronchodilator therapy. Review of Resident #105's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of the admitting physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic record of weights summary found a weight recorded on 11/30/21 at 11:45 am (this weight was recorded prior to the resident's admission). Review of the admission nursing assessment found a weight dated 07/15/21(was weight from previous admission). She had been discharged to home on 07/19/21. No weights could be found after her admission on 11/30/21. On 12/08/21 at 1:15 pm, during an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) both verified Resident #105 had no weights recorded after admission on 11/30/21 and the referral to consult the pulmonologist had not been completed. No further information provided.

Based on family interview, observation, resident interview, staff interview, and record review, the facility failed to ensure provision of respiratory services. The facility failed to ensure staff were knowledgable about how to provide care for Resident #83's [MEDICAL CONDITION] (an artificial opening through the neck into the trachea, usually for the relief of difficulty in breathing). Investigation during the survey indicated as of 09/25/17 nurses had not been provided training regarding [MEDICAL CONDITION] care and suctioning. Observation included RN #86 failed to suction Resident #83 when he required suctioning. RN #86 was unable to identify location of emergency equipment in the resident's room. On 09/25/17 at 6:00 PM, the facility administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Regional clinical education specialist (CES) were notified of an Immediate Jeopardy (IJ) situation as the result of the facility's failure to train staff to provide care for a resident with a [MEDICAL CONDITION] and to ensure the resident was suctioned correctly when required. On 09/25/17 at 8:10 PM, and revised on 09/26/17 at 11:40 am, the facility provided an acceptable plan of correction (P(NAME)) and the IJ was abated. After the plan of correction for the immediate jeopardy was implemented, a deficient practice at a scope and severity of a E remained for inability of the facility to complete re-education for 1 of 18 licensed nurses, lack of completion of observation audits and QA review. Additionally, the facility failed to ensure Resident #26 recieved humidification of his oxygen, and failed to ensure Resident #39 received tube feedings as ordered. Resident identifiers: #83, #26, and #39. Facility census: 48. Findings include: a) Resident #83 Clinical record review revealed Resident #83 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His 08/27/17 physician orders [REDACTED].#6 Shiley (extra [MEDICAL CONDITION]) and Ambu bag at bedside, change disposable inner cannula every day and as needed, [MEDICAL CONDITION] weekly and as needed., [MEDICAL CONDITION] valve (passy muir) every night and as needed, may use 14 french red robin urinary catheter [MEDICAL CONDITION] or sterile 14 french suctioning kits as needed, [MEDICAL CONDITION] care every day and night shift and as needed. A 09/11/17 physician order [REDACTED]. A 09/02/17 admission Minimum Data Set (MDS) assessment indicated Resident #83 had short term memory loss and was severely impaired in decision making. He required extensive assistance of two or more persons for all activities of daily living. He required a wheelchair for locomotion. A 09/18/17 care plan included interventions: 1. change disposable inner cannula daily and as needed, [MEDICAL CONDITION] after bath or shower, weekly, and as needed, 2. check jet net set at 80% every shift, 3. [MEDICAL CONDITION] valve every night and as needed, 4. keep ambu bag and [MEDICAL CONDITION] (#6 Shiley) at bedside, 5. monitor and report oxygen saturation levels via pulse oximetry every shift to keep oxygen saturation greater than 92%, 6. observe for respiratory rate, signs/symptoms of dyspnea, use of accessory muscles indicating respiratory distress and report to physician as indicated, 7. observe respiratory status and assess for changes as well as changes in mental status, 8. speaking valve in place when resident has family/visitors or interaction with staff and then remove and [MEDICAL CONDITION] collar back on, 9. suction trach/airway as needed. May use 14 french red robin urinary catheter [MEDICAL CONDITION] or sterile 14 [MEDICAL CONDITION] kits 10.[MEDICAL CONDITION] with hydrogen peroxide twice daily and as needed for extra secretions. On 09/21/17 at 10:39 am, Resident #83 was in bed. Nurse Aide (NA) #13 had finished bathing him. Resident #83 was not wearing his [MEDICAL CONDITION] and machine was not on. On 09/21/17 at 10:58 am, Registered Nurse (RN) #10 stated when we suction him (Resident #83) with a red robin catheter or sterile catheter, I only go to the end of [MEDICAL CONDITION]. I don't deep suction him RN #10 stated I haven't had any problems with bleeding with suctioning other than one day. RN #10 stated Resident #83 was to wear a humidified mask at 80% with 2 liters of oxygen via concentrator when he was in bed. During an interview on 09/21/17 at 3:45 PM, the Administrator stated the facility had only had 3 residents in the facility with a [MEDICAL CONDITION]. During an interview on 09/21/17 at 4:01 PM, Assistant Director of Nursing (ADON) #2 provided education and competency which was provided to all nurses which included guidelines: when to contact respiratory therapy, directed cough and [MEDICAL CONDITION] care. Nurses competency with the 3 respiratory procedures was done in orientation. ADON #2 stated when Resident #83 arrived she asked the nurses if they were ok with [MEDICAL CONDITION]. The nurses said they were ok. ADON #2 stated she provided licensed nurses copies of facility policies regarding [MEDICAL CONDITION] care. ADON #2 stated she provided no training for the nurses related [MEDICAL CONDITION], suctioning or the use of the red robin catheter. On 09/25/ 17 2:39 PM, Resident #83 was in bed and not wearing his [MEDICAL CONDITION] and the machine was not on. On 09/25/17 at 2:49 PM, RN #86 entered the room to provide care. Resident #83 started coughing, his face turned red, he repeatedly coughed and brought up thick yellow secretions at 2:51 PM. RN #86 wiped around [MEDICAL CONDITION] a washcloth. Resident #83 started coughing again, his face turned red, he continued to cough and brought up thick yellow secretions at 2:55 PM. RN #86 wiped the secretions from around the trach. RN #86 did no respiratory assessment of the resident, check his pulse oximetry or suction him. RN #86 stated RN #10 had suctioned him at 7 am and [MEDICAL CONDITION]. I only use the Yankaour to suction him at the top. I do not feel comfortable suctioning him with red robin catheter. I was told by my DON it was up to me to suction as I felt comfortable. I have never deep suctioned him. I will be inserviced tomorrow. There is no normal saline in the room to suction. RN #86 could not locate [MEDICAL CONDITION] in the room, specifically, the extra #6 [MEDICAL CONDITION] ambu bag. During an interview on 09/25/17 at 3:15 PM, ADON #2 stated stated the facility had no competency on [MEDICAL CONDITION] suctioning. ADON #2 stated a respiratory therapist was coming to the facility on [DATE] to provide inservice training for all nurses. On 09/26/17 at 9:00 am, respiratory therapist (RT) #103 was observed providing inservice training and competency training for 15 of the facilities 18 licensed nurses which [MEDICAL CONDITION], suctioning with red robin catheter and sterile catheter and a review of oxygen concentrators, oxygen cylinders, oxygen nasal cannula, non-rebreather mask, oxygen mask, ambu bag, cleaning of speaking valve (passy muir), placement of speaking valve (passy muir) and [MEDICAL CONDITION]. During an interview, on 09/26/17 at 10:30 AM, ADON #2 reviewed current training completed by RT #103 on 09/26/17. RN #19 had not received any training yet. RN #10 and RN #89 had not received training from the respiratory therapist. ADON #2 reviewed current observation audits which were being conducted by ADON #2, the DON and, the Regional Corporate Education Specialist. During a followup interview, on 09/26/17 at 11:35 AM, ADON #2 confirmed the education records for RN #10 (date of hire 03/29/12), RN #86 (date of hire 06/01/17), RN #80 (date of hire 04/16/16), LPN #19 (date of hire 03/05/97), RN #5 (date of hire 03/05/97 and LPN #83 (date of hire) contained no competency validation [MEDICAL CONDITION], directed cough or when to contact respiratory therapy prior to the training provided on 09/26/17. Review of [MEDICAL CONDITION] Suctioning policy, revised 12/08/14 stated .establish need for suctioning by evaluating patient for breath sounds, respiratory rate, and pulse oximetry .If patient requires hyperoxygenation prior to suctioning, use non-sterile hand to deliver breaths (refer to ambu bag procedure) Hyperoxygenation is required: if pulse oximetry is below 90% or per ordered parameters, or to relieve hypoxemia. Attempt to time catheter insertion with inspiration. With sterile hand and without applying suction, insert catheter into [MEDICAL CONDITION] stoma/trach tube until resistance is felf, then pull back 1 centimeter. With non-sterile hand, apply suction and gently withdraw catheter slowly rotating catheter with fingertips. Do not apply suction for longer than 15 seconds. Investigation during the survey indicated as of 09/25/17 nurses had not been provided training regarding [MEDICAL CONDITION] care and suctioning. Observation included RN #86 failed to suction Resident #83 when he required suctioning. RN #86 was unable to identify location of emergency equipment in the resident's room. On 09/25/17 at 6:00 PM, the facility administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Regional clinical education specialist (CES) were notified of an Immediate Jeopardy (IJ) situation as the result of the facility's failure to train staff to provide care for a resident with a [MEDICAL CONDITION] and to ensure the resident was suctioned correctly when required. On 09/25/17 at 8:10 PM, and revised on 09/26/17 at 11:40 am, the facility provided an acceptable plan of correction (P(NAME)) and the IJ was abated. The P(NAME) included: 1. The resident was immediately assessed by ADON with no signs or symptoms of respiratory distress identified. 2. The resident was then assessed by DON with no signs or symptoms of respiratory distress identified. The resident's room was checked for the [MEDICAL CONDITION] supplies including saline bullets, ambu bad and [MEDICAL CONDITION] with all being present. 3. There are no other residents in the center with trachs. 4. The resident was examined by Medical director and attending physician on 09/25/17 at 5:30 PM with no signs or symptoms of respiratory distress noted. Resident was deemed to be stable with no need to transfer to acute care. 5. The DON and ADON were re-educated on 09/25/17 as to care and treatment of [REDACTED]. Both passed competency testing. 6. All other licensed nurses in the center at this time will be re-educated by the Regional CES, DON or ADON regarding the care and treatment of [REDACTED]. All will be required to successfully pass competency testing. 7. All oncoming licensed nurses will be reeducated by Regional CES, DON or ADON on care and treatment of [REDACTED]. 8. Inservices regarding [MEDICAL CONDITION] care were previously scheduled for 09/26/17 will be conducted by_____(name of company). The re-education trainings will be mandatory for all nurses. Additional competency testing will be required for each nurse. New nurses during orientation will receive education and complete competencies by nurse practice educator (NPE)/ADON/designee. 9. Observation audits of licensed nurses performing oxygen administration, humidifier application and [MEDICAL CONDITION] care will be completed daily for 14 days including weekends then 3 times per week x 2 weeks across all shifts by NPE/ADON/designee. 10. Trends identified will be reported by the nursing home administrator (NHA) monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or inservicing until the issue is resolved and randomly thereafter as determined by the QIC committee. After the plan of correction for the immediate jeopardy was implemented, a deficient practice at a scope and severity of a E remained for inability of the facility to complete re-education for 1 of 18 licensed nurses, lack of completion of observation audits and QA review. Additionally, the facility failed to ensure Resident #26 recieved humidification of his oxygen, and failed to ensure Resident #39 received tube feedings as ordered. b) Resident #26 During a family interview conducted on 10/05/17 at 10:28 a.m., the family member voiced a concern that Resident #26 was on four (4) liters of oxygen with humidification at the recommendation of Resident #26's pulmonologist. The family member stated the humidification was frequently empty a and stated it was an ongoing problem with the facility. A random observation was conducted of Resident #26 on 10/10/17 at 9:33 a.m. and the humidification bottle on the oxygen concentrator was empty. Resident #26 was interviewed at that time and he said It's getting to be time for them to change it. This matter was discussed with his nurse, registered nurse(RN) #89 on 10/10/17 at 9:35 a.m. She stated that night shift fills the water and signs it of on the treatment administration record (TAR). At 9:38 a.m. on 10/10/17 this matter was discussed with the assistant director of nursing (ADON) and she said she would fix the empty water bottle. RN #89 clarified her statement about filling the oxygen water bottles at 10:48 a.m. on 10/10/17. She said that a stock person or a supply person takes care of oxygen needs once a week and nursing fixes any problems in between that time. A review of the current care plan for Resident #26 was performed on 10/10/17. There was an intervention stating O2 at 4 liters per nasal canula continuously. Humidity at all times to concentrator. This intervention was created on 08/26/15 and remained in effect during the time of the survey. c) Resident #39 Resident #39, a hospice resident, received nutrition via a gastrostomy tube (G tube). Glucerna 1.5 Cal feeding was ordered to meet the resident's nutritional needs. Eighteen hundred (1800) milliliters (ml) of Glucerna was ordered, to be infused at a rate of 100 milliliters (ml) an hour (hr) continuous for 18hrs. The feedings were scheduled to begin at 4:00 p.m. each evening and infuse via a Kangaroo pump until 10:00 a.m. the following morning. Nurses were to sign and record the date and the start time on each container of feeding when it was hung. The pump recorded the total volume of feeding infused. The nurses were to zero out the total volume on the pump one time a day, at the beginning of each 18 hour period a new feeding was started. By zeroing the pump out the staff could monitor the actual volume amount infusing during the current feeding, thereby ensuring 1800 ml. of feeding was received. The nurses did not always clear the volume infused on the pump at 4:00 p.m., the start of the new 18 hour period the feeding was to be infused, therefore the feeding infused volume numbers recorded on the pump could not be accurate. Observations revealed some nurses discarded what was left of a feeding at 10:00 a.m. (the end of the scheduled 18 hour feeding period) and hung a new 1000ml container. While other nurses left partially used containers of feeding hanging so that the partially used containers could be started again at 4:00 p.m. (the begining of the next 18 hour feeding period). In a 24 hour period two (2) 1000 ml containers would have to be used to provide 1800ml of Glucerna 1.5 Cal feeding with approximately 200 ml of feeding not infused if two (2) new unopened containers were used, however staff did not consistently use (2) new unopened containers. On 09/19/17 at 10:30 a.m. RN#76 turned off the tube feeding. Review of the container with RN#76 revealed feeding container was dated 09/18/17 at 0115 AM (1:15 a.m.). RN#76 went to dispose of the feeding container, when this surveyor asked the nurse what was she going to do with the feeding. RN#76 said, I am going to throw it away, I always do when the 18 hours is up, because at 4:00 p.m. I hang a new feeding. RN#76 confirmed 325 ml was left in the container she was discarding. When asked is that usually the amount of feeding left at the end of 18 hours, the nurse replied, I'm not sure, I just throw it away cause I know I'll be hanging a new one. RN#76 was asked if the feeding discarded was hung on 09/18/17 at 1:15 a.m., would that be 18 hours. RN#76 did not reply, and was then asked where the nurses track the feedings to ensure the resident gets the feedings as ordered. RN#76 said the nurses check it off on the MAR. A copy of the MAR indicated [REDACTED]. Director of nursing (DON) interview, on 09/21/17 at 3:45 p.m., revealed the DON had called the nurse that worked the evening of 09/18/17 and said she admitted she dated the feeding container wrong. The DON said it should have been 09/19/17 not 09/18/17. The DON said the pump does count down the amount of feeding given, and agreed there should not have been that much feeding left over at that time, even with the water flush the nurses have to manually do. The DON said he did not have an answer and would have to investigate more and get back to the surveyor. The DON did not provide any further information concerning the differences in amounts of feedings remaining after the end of the scheduled 18 hour feeding period. Observations, on 09/26/17 at 10:08 a.m., revealed RN#89 disconnecting the tube feeding and flushing the feeding tube. There was 700 ml of feeding left in the feeding container. The container was dated 09/26/17 with no start time recorded. RN#89 was asked how long the container had been running and how much feeding did the resident get. RN#89 looked at window screen of the pump and hit a button, and said, I don't know. They are suppose to clear the pump and reset it, no one did. When asked what the nurse would do with the feeding left in the container. RN#89 said, I will start it at 4:00 p.m. The surveyor asked, This bottle? RN#89 said, Yes. The surveyor asked, How do you know when it was started? RN#89 pointed at the container (the date was on the container but no time) and said, It was started today. The surveyor said, So you will leave it hang there on the pole and restart that container at 4:00 p.m. RN#89 said, Yes. RN#89 confirmed she had disconnected Resident #39's tube feeding before. When asked if this is the usual amount left over after the feeding ran 18 hours, RN#89 considered for a moment and replied, No, usually not as much. RN #89 was unable to say why so much feeding was left. RN #89 said, sometimes it may be turned off if you have to clean the resident up or something, maybe someone forgot to turn it back on for awhile, I don't know. On 09/26/17 at 10:30 a.m., an interview with the DON revealed he would expect his nurses to throw out the feeding container and hang a new feeding if no start time was recorded on the container label. The DON was informed the RN#89 said she would hang this one even though it was not timed. The Don was ask to provide evidence that resident was getting feeding as ordered. Phone interview with Dietitian, Employee#88, on 09/26/17 at 3:57 p.m. revealed the current tube feed of Glucerna 1.5 calories (dense) 100 ml until1800ml for 18 hrs was what the resident needed to met his nutritional requirements. The resident had a 5.34% weight loss, but due to his medical condition could be expected. The Dietitian's agreed if the resident was not getting his feedings as ordered could also contribute to the weight loss. The Dietitian's expectations of the nursing staff to ensure the resident gets the required amount of feeding, is for nursing to track the time the feeding container is spiked and the start time of a changed bottle to ensure it infuses for 18 hours at a rate of 100ml an hour; to note how the resident is tolerating the feedings; and any reasons why the resident might not be getting his feedings. When asked how the Dietitian monitors the resident is getting 1800 ml in 18 hours. The Dietitian replied that she reviewed the nurse notes to see if the resident is tolerating the feedings and look at the MAR indicated [REDACTED]. On 10/04/17 at 9:15 a.m. observations revealed Resident #39 tube feeding was turned off. LPN#19 entered room at 9:18 a.m., feeding container was dated 10/04/17 and timed 0200 (2:00 a.m.) and had approximately 475 ml left in a 1000 ml container. LPN #19 was asked to describe how she provided Resident #39 his tube feedings. LPN #19 said, at 4:00 p.m. she would clear the pump settings; enter the volume 1800 ml at a rate of 100 ml; clear my settings of what had been infused; verify placement check to see if any residual and flush the tube as ordered; make sure the head of the bed was at 35 degrees; if a bottle of feeding was hanging she would check the date and time, and hang a new bottle if needed. LPN #19 checked the history on the pump, and said according to the pump the resident had 5347 ml infused for the past 72hrs. should have had off 6 hrs q D therefore it would have run 54hrs out of the 72hr and should have infused at a rate of 100 cc/hr 5400cc --flush =0 missing 53cc According to the label on the container of Glucerna, each container held approximately 1000 ml of feeding. The instructions on the Glucerna label stated Hang product up to 48 hours after initial connection when clean technique and only one new feeding set are used. Otherwise, hang no longer than 24 hours. Observations, staff interviews, and review of records revealed the feedings were not consistently administered or appropriately monitored to ensure the resident received the required nutrition to meet the resident's nutritional needs. It was noted on the Medication Administration Record [REDACTED]. Nowhere in the records could it be found where staff tracked the amount of feeding the resident received on different shifts, whether a 1000ml container was hung or a partially filled container at the beginning of the scheduled eighteen (18) hour feeding period, nor could staff provide upon request any evidence that the amount of feeding given to the resident or amount wasted was tracked or monitored by staff.

Based on resident interview, staff interview, clinical record review, review of facility records and review of facility policy and procedures, the facility failed to ensure the safety of residents from physical and verbal abuse. Resident #1 reported on [DATE] that Registered Nurse (RN) #10 had verbally and physically abused her roommate Resident #22 on [DATE]. Resident #1 reported incident to Social Worker (SW) #39 on [DATE]. The facility initiated an investigation regarding verbal abuse but did not investigate the allegation of physical abuse. On [DATE] RN #10 verbally abused Resident #51. The incident was witnessed by an anonymous family member, Nurse Aide (NA) #23. NA #23 attempted to report the incident on [DATE] to the Director of Nursing (DON) #35. The facility failed to protect the resident or conduct any investigation. Resident #51 expired on [DATE]. On [DATE] Resident #86 reported NA #26 had verbally abused him on [DATE]. Resident #26 reported the incident to NA #23. NA #23 reported allegation to RN #80. The facility failed to protect the resident or conduct any investigation of the allegation. On [DATE] at 4:45 PM, the Administrator was notified of Immediate jeopardy (IJ) related to based on the center's failure to identify and report allegations of physical and verbal abuse in a timely manner; to protect residents from potential harm during the investigative process; and to implement the facility policy and procedures regarding abuse. On [DATE] at 8:40 PM, the facility provided an acceptable plan of correction (P(NAME)) and the IJ was abated. The P(NAME) included: At the time that the allegation of verbal abuse was brought to the attention of the Administrator and DON, Resident #22 was assessed by Assistant Director of Nursing (ADON) on [DATE] (date of the allegation) and no signs or symptoms were identified. The involved nurse was suspended at the time of the allegation [DATE] per phone by the Administrator, center initiated an investigation and was unable to substantiate verbal abuse and the nurse was returned to work on [DATE] at 6:59 AM. The nurse was again suspended regarding the allegation of physical abuse on [DATE] at 1:59 PM with the investigation initiated by the Administrator. Resident #22 was reassessed by a licensed Social Worker to ensure the resident was not exhibiting signs of fearfulness, guarding or tearfulness on [DATE] at 6:15 PM and no signs or symptoms were noted. Resident #51 no longer resides in the center. Resident #86 was interviewed by a licensed Social Worker on [DATE] at 5:30 PM. He stated to the Social Worker that he did not feel abused by the Rehab Transport person per Interview, One day I can't remember which initials of NA,( NA #23) walked by 3 times, and said I don't see you doing your finger exercises, if you did them you might be able better feed yourself He doesn ' t ' ' believe she was the one who actually fed him later that shift, so the social worker asked, How does that make you feel, and the resident responded she's a good girl, I think she was just being a smart ass. The Rehab Transport Person (RTP) who is a CNA was suspended pending investigation on [DATE] at 10:40 AM regarding an unrelated event. The RTP remains on suspension at this time. The Administrator spoke to the OHFLAC surveyors on [DATE] requesting the names of the persons reporting the allegations of abuse to the surveyors so that the facility can initiate the center's policies and procedures regarding abuse prohibition. The Regional Vice President of Operations (RVPO) and Vice President Clinical Operations (VPCO) provided reeducation to the Administrator and DON on [DATE] regarding abuse prohibition policies and procedures, including reporting to state entities, identifying abuse and/or neglect and initiating a thorough investigation. A posttest was completed to validate understanding. Reeducation of all staff on duty regarding abuse prohibition policies and procedures, including reporting to state entities, identifying abuse and/or neglect and initiating a through investigation began on [DATE] at 6:00 PM by Regional Educator/designee and will be conducted with all employees prior to beginning work on the next scheduled shift. A posttest will be completed to validate understanding. New staff during orientation will receive education and completed posttest on abuse prohibition. Staff interviews regarding alleged abuse and/or neglect allegations have been initiated by the Regional Educator and Social Services on [DATE] following completion of reeducation and will be continued shift to shift until all staff have received reeducation at the beginning of shift prior to taking an assignment to validate understanding. All interviewable residents will be interviewed by Nurse Practice Educator and/or designee regarding any concerns of abuse and/or neglect starting [DATE]. All non-interviewable residents will have body audits completed by the licensed staff to ensure no signs or symptoms of abuse have occurred starting [DATE]. RVPO and/or Clinical Quality Specialist/designee will review each abuse and/or neglect allegation x 4 weeks then monthly x 3 months to ensure reporting to state entities, identifying abuse and/or neglect and initiating a thorough investigation has occurred. Trends identified will be reported monthly by the Administrator/designee to the Quality Improvement Committee until the issue has resolved and randomly thereafter as determined by the Quality Improvement Committee. After the plan of correction for immediate jeopardy was implemented, a deficient practice at a scope and severity of D remains for the failure of the staff to immediately initiate a thorough investigation of the allegations, and the failure of the facility to implement its policies and procedures. This deficient practice affected three (3) residents, but had the potential to affect more than a limited number of residents. Resident identifiers: #22, #51 and #86. Facility census 48. Findings include: a.) Resident #22 Clinical record review revealed a [DATE] care plan for behaviors. Interventions include: explain all care, including procedures (one step at a time), and the reason for performing the care before initiating, observe for non-verbal signs of aggression, e.g. rigid body position, clenched fists etc, approach the resident in a calm, unhurried manner, reassure as needed, if resident becomes combative or resistive, postpone care/activity and allow time for her to regain composure. A [DATE]:48 AM nurses note (written by RN #10) stated resident refused to swallow these pill, she was hitting and scratching. behaviors are very bad this morning. MD is aware of resident's behaviors. Review of facility documents revealed Resident #1 reported to SW #39 on [DATE] that RN #10 had threatened her roommate. The [DATE] 12:45 PM typed statement signed by administrator and DON on [DATE] stated that on Saturday around 12 noon She indicated that Nurse (RN #10) entered the room with (Resident #22's) medications. She stated something about (resident #22) still being in bed at this time of day. (NA #8) was present during the exchange. Resident #1 stated NA #8 asked RN #10 to wait until she got Resident #22 up in the chair, RN #10 did not, she got a cloth and wiped Resident #22 eyes, which Resident #22 made and got her riled up. Resident #22 was then hitting RN #10. RN #10 was holding her hands and trying to get Resident #22 to take her medications. Resident #22 keep resisting. RN #10 then said 'you have to take these behavior meds or they will take you out of here to----(name of psychiatric hospital). The statement written by NA #8 stated she asked RN #10 to wait to give Resident #22 her meds until she got her out of bed. RN #10 got a washcloth and washed Resident #22's face and made her mad and then she tried to give her meds she spit her meds out and she yelled at Resident #22 telling her to take her meds. She only got some of her meds in her she was a little harder to get up. The initial 24 hr report on [DATE] to the state entities was for verbal threatening comments. The report did not include any allegation of physical abuse. The final [DATE] report substantiated conversation but not in a threatening manner. RN #10 was reeducated and returned to duty. The investigation included a statement from RN #10 (alleged perpetrator), NA #8 and LPN #83. The investigation did not include any evidence of investigation of physical abuse, no physical examination of Resident #22. No other interviewable residents were interviewed. During an interview with DON #35, ADON #2, Administrator #38 and SW #39, at [DATE] at 6:30 PM, SW #39 stated she completed the initial and final reports to OHFLAC, APS and Ombudsman. SW #39 stated she did not interview other interviewable residents. SW #39 only interviewed Resident #1 the roommate. The Administrator stated the file contained no evidence of any physical examination of Resident #22. DON #35 stated he did not examine resident #22. The ADON #2 made no comment. The Administrator after reviewing Resident #1's statement of RN #10 holding Resident #22's hands down, the facility should have reported an allegation of physical abuse and conducted an examination of the resident at the time of the allegation. The Administrator stated the facilities expectation is for staff to attempt other measures than forcing residents to take their medications. Administrator stated I cannot state why the nurse didn't get the resident out of bed before giving the medications. During an interview with Administrator, DON #35, ADON #2 and Clinical Quality Specialist (CQS) #94, on [DATE] at 3:50 PM, the Administrator stated we have not further investigated the aspects of physical abuse, involving Resident #22, because we would not be able to see evidence of physical abuse. b) Resident #51 On [DATE] at 8:15 p.m., during a confidential interview, the interviewee said one (1) night last week there was only one (1) nurse for the whole nursing home. The interviewee said, A nurse was so disrespectful to (Resident #51's name) and his aunt. I have never seen anything like it. She was screaming over top of (Resident #51), and he was suffering. When asked, Who was the nurse screaming at? The resident? The interviewee replied, No, (Registered Nurse #10) was screaming at his aunt. (Resident #51) was in so much pain and agony, and his aunt just wanted them to send him to the hospital to get him help, so he wouldn't be hurting like he was. I felt so sorry for the aunt and (Resident #51). No one should be treated like that. It was just awful. When asked, Did you report it to anyone? The interviewee stated when she had told the administrator about things before, the administrator had told her to mind her own business. I didn't know who I could tell, that's why I wanted to tell you. It was awful no one deserves to be treated like that. On [DATE] at 9:27 a.m. review of records revealed Resident #51 first entered the facility on [DATE]. The resident had multiple health issues, including but not limited to [MEDICAL CONDITIONS] also known as a stoke, [MEDICAL CONDITION] (loss or impairment of the power to use or comprehend words), dysphagia (difficulty in swallowing), occlusion and stenosis of bi-lateral Carotid Artery, [MEDICAL CONDITIONS], left above the knee amputation (AKA), right eye [MEDICAL CONDITIONS] a liver disease with ascites/ [MEDICAL CONDITION], inoperable kidney abscess, perineal abscess, Opiod dependent with withdrawal, [MEDICAL CONDITIONS], and convulsions. Death occurred in the facility on [DATE]. On [DATE] at 10:54 a.m., review of Licensed Practical Nurse (LPN) #19's nurse's progress note dated [DATE] at 7:16 a.m. revealed a physician visit to resident with new orders for [MEDICATION NAME] ([MEDICATION NAME]), and a [MEDICATION NAME]. order sent to pharmacy. On [DATE] at 9:36 a.m., review of the physician's orders [REDACTED]. Review of physician orders [REDACTED].>-- An order dated [DATE] for [MEDICATION NAME] HCl Tablet 10 milligrams (mg) give one (1) tablet by mouth every six (6) hours as needed for pain. -- An order dated [DATE] was noted for [MEDICATION NAME] 72 hour 12 MCG/hr (micrograms/hour) apply one (1) patch [MEDICATION NAME] one (1) time a day every three (3) days for pain and remove per schedule. -- An order dated [DATE] for [MEDICATION NAME] (Concentrate) Solution, 20 mg/ml (milligram per milliliter) Give 10 mg (0.5 ml) by mouth every one (1) hour as needed for pain. -- On [DATE] at , the [MEDICATION NAME] (Concentrate) Solution 20 mg/ml was increased from 10 mg/0.5 ml to 20 mg/1 ml by mouth every one (1) hour as needed for pain. Review of Medication Administration Record [REDACTED] - [MEDICATION NAME] HCl Tablet 10 mg at 3:09 a.m. and 11:03 a.m., the resident could have one (1) tablet by mouth every six (6) hours as needed for pain. - [MEDICATION NAME] (Concentrate) Solution 0.5 ml (10 mg) at 3:47 p.m., 7:20 p.m., 9:02 p.m.,10:30 p.m., the resident could have this every hour as needed for pain. Review of Medication Administration Record [REDACTED] - No [MEDICATION NAME] was given to the resident on [DATE] according to the MAR. - According to the MAR [MEDICATION NAME] (Concentrate) Solution 0.5 ml (10 mg) was given at 12:41 a.m. and 1:45 a.m., the resident could have 0.5 ml (10 mg) every hour as needed for pain. - [MEDICATION NAME] (Concentrate) Solution 1 ml (20 mg) was given at 4:02 a.m., the resident may have every hour as needed for pain. - The MAR indicated [REDACTED]. On [DATE] at 10:54 a.m., review of nurse's progress note (written LPN#19) dated [DATE] at 18:22 (6:22 p.m.), (typed as written), Was called back to room by residents aunt (aunt's name), went into room and she started to question me on what I had done this afternoon. told her I would be glad to speak with her if she asked the other residents to leave the room or she came out into the hall way, (Aunt's name) came in to the hall and asked me about the new orders, told her that I heard (doctor's name) speak with resident about new orders for pain and if he wanted to go to the hospital I heard resident tell (doctor's name) he did not want to go out to the hospital that he knew he was dying and he was ready to die. I also told her what time I administered the pain meds, told her what time then she asked me to take his temp. (temperature) it was 98.4. she began crying and wanted to know if I thought he needed to go out to the hospital I told her it was not my decision it was a decision made by (Resident's name) and as a nurse I have to respect his wishes. she began to cry and walked away from me. On [DATE] at 11:17 a.m., review of nurse's progress note (written by RN #10) dated [DATE] at 18:47 (6:47 p.m.), revealed the following: (typed as written) At about 540 pm (Aunt's name) resident's Aunt came to the nurses station demanding he be sent to the ER (emergency room ) now, Explained to her that (Resident) has capacity and his wishes were to be kept in the facility and be made comfortable. (Resident #74 ) and (roommate's visitor) were in the resident's room at the bedside when I went into talk with (Resident #51) and would not leave the room. I asked (Resident #51) 4 times if he wanted sent to the Hospital and all 4 times he said NO, (Resident's aunt) was angry that I would not send him to the ER, I tried to explain the end of life process to (Aunt's name) and she told me to just get the hell out of the room. I walked out of the room and called (Doctor's name) at 550 pm, (Doctor's name) said he spoke with the resident this morning about 8 am himself and the resident did not wish to be sent to the Hospital unless we can not keep him comfortable in house. Also given a verbal order to start D5 ,[DATE] NSS at 75 ml/hr again for 3 days for hydration. This morning (LPN #19's name) LPN received scripts from (Doctor's name) for [MEDICATION NAME] and Fent(anyl) Patch and (Resident's name) was aware of the medication prescribed. She also called (Resident's aunt's name) and told her about the new orders. (Resident's aunt) was demanding copies of the medication record this evening and (LPN #19's name) and I told her medical records is the only one who can print and give her copies of the medical records. I took the IV (intravenous) fluids into the room and started them in Left Upper Arm .(Resident's aunt and Resident's name) were both notified of the order for IV fluids Review of nurse's progress note dated [DATE] at 2:28 a.m. (written by LPN #14), on [DATE] at 10:06 a.m., revealed the resident was showing signs and symptoms of shortness of breath, gasping for air, upper quad lungs sound gurgling .trying to cough but unable. MPOA agreed to take him off fluids, got verbal order ok from (doctor's name) and disconnected intravenous fluids per request. Resident showing signs and symptoms of pain such as wincing, blinking and saying yes when asked if he is in pain, resident unable to verbally say what is hurting him or verbalize a numbered pain scale, [MEDICATION NAME] as ordered every hour .continuing to monitor. When asked whether Confidential Interviewee #1 knew Resident #51, the interviewee started crying and became very emotional. The interviewee said, When I came into work that day I went in to check on him because they said he was dying. I have been a (staff position and how long in that position) and have never seen anyone die like that, suffering in that way. He was begging for help. The resident was groaning, and kept saying over and over, 'Please help me. Please help me' and groaning 'Oh God.' When asked whether RN #10 was aware of the situation and the resident's suffering, the interviewee said, Yes, and added RN was aware, because I saw her go into the resident's room and saw it herself. The aunt was standing by the bed, on the side of the window, holding the resident's hand. You could clearly see the resident suffering, he was groaning non-stop and begging for help. The NA said she heard the aunt ask RN #10 to send the resident to the hospital. The NA said the RN was on the opposite side of the bed leaning over the resident with one hand on the resident's stomach, and with the other hand pointing her finger at the aunt and loudly said, No! He knows he is dying, you have to accept it. He is dying. The interviewee said RN #10 was getting louder and louder as she told the aunt. The entire time the resident was non-stop begging for help. When asked whether she saw the RN do anything for the resident's pain, the interviewee stated, I think she put a pain patch on him. I know when I went back by the nurse's station (RN #10) had called (doctor's name), because I heard (RN #10's name) say, I am covering myself. When asked if she reported the situation to anyone, she said the next morning I asked to talk to the DON, but he said he was too busy right then. The DON said he was aware of the situation, and if he needed a statement he would get one from her. The interviewee did not give a statement. At the time she witnessed RN #10 talking to the aunt, another resident and a resident's wife were in the room. The interviewee was crying during the entire interview concerning Resident #51, and at times sobbing. After composing herself, the interviewee said, It was the most horrible thing I have ever seen, to see someone die suffering like that. During a confidential interview, Interviewee #2 said they had one nurse that got loud when she was upset and if you did not know her it would seem she was inappropriate - she is not a people person -its more her demeanor. During the interview, the interviewee said, I heard a loud commotion coming from his room, but I could not make out what was being said I was down at the other end of a hall. [DATE] at 8:20 a.m., during an interview, the resident's doctor said, I talked to him that morning and he agreed he wanted to stay here .if I had known he was in that kind of pain I would have either increased his medication or sent him to the hospital . (Resident's name) had capacity. We had a discussion earlier in the day that unless his pain was unable to be control, he agreed stayed in facility - I only became aware of how much pain he was in since this survey investigation. (Resident's name) had an inoperable kidney abscess and history of [MEDICAL CONDITION] [MEDICAL CONDITION] in the past. (Resident #51) had capacity could have changed his mind to be sent to the hospital or if he was in enough pain, he could have changed his mind. The doctor expressed surprised that no one had notified him about the amount of pain the resident was in. On [DATE] at 11:30 a.m. surveyors met and discussed identified pain management issues concerning Resident #51 with the Administrator, Clinical Nurse Executive (CNE) (formerly called Director of Nursing (DON)), the Assistant Director of Nursing (ADON), the Clinical Quality Specialist, and the Clinical Education Specialist. Identified issues and concerns included the resident's pain management the evening prior to the resident's death at 4:45 a.m. on [DATE]. It appeared the resident had worsening pain. It was determined the physician ordered a [MEDICATION NAME] for pain. The Physician was contacted at 3:00 a.m. and the resident's 0.5 milligram (mg) of [MEDICATION NAME] solution was increased to one (1) mg at 4:00 a.m. on [DATE], and the resident died at 4:45 a.m. on [DATE]. The resident's pain worsened and he was not given his pain medication on an hourly basis as ordered, starting at 7:30 p.m. on [DATE] until 4:00 a.m. on [DATE]. The opportunities to give the medication have gaps in when he could have had pain medication, there was 1½ hour gap between 7:30 p.m. and 9:00 p.m., 1½ hour gap between 9:00 p.m. and 10:30 p.m., 2 hour gap between 10:30 p.m. and 12:40 a.m., and then between 1:45 a.m. and 4:00 a.m. another 2 hour gap. There was documentation at 2:30 a.m. the resident was unable to describe his pain and at 3:30 a.m. the Physician was notified. When asked, Is it your expectation staff administer medication according to orders? The DON nodded his head in affirmation. The administrator replied, Yes, it is. The expectation would have been if the resident would have continued in pain the staff would have called the physician. We will check on that. The surveyors informed the facility that they had spoken with the physician, and were told he was unaware of the level of the resident's pain, that if he had been aware, he may have done more or something different. c.) Resident #86 Clinical record review revealed Resident #86 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The [DATE] physician determined the resident had capacity to make health care decisions. The [DATE] nursing admission assessment revealed he was alert and oriented. During an interview, on [DATE] at 1:45 PM, NA #23 had told her on [DATE], during the evening shift, that NA #26 had told him you should just use your fingers then we wouldn't have to feed you. NA #23 considered this comment to be abusive since the resident couldn't use his arms and had to be fed by staff. NA #23 stated she reported the incident to RN #80 during that same shift. During a phone interview, on [DATE] at 2:10 PM, RN #80 stated Resident #86 is totally dependent for eating due to problems with both his arms. RN #80 stated the resident is in the facility for therapy. RN #80 denied being informed of any incident of verbal abuse or Resident being told to use his fingers to eat. During an interview, on [DATE] at 3:42 PM, Resident #86 stated he was at the facility for rehab. He stated he had [MEDICAL CONDITION] arthritis and was unable to use his arms. Resident #86 stated that 2 days ago NA #26 had an attitude problem. She told me If I would use my fingers, they wouldn't have to feed me. It upset me at the time He stated I don't want anyone to loose their job. Resident #86 stated he reported the statements to NA #23 when he was upset. During an interview with Administrator, DON #35, ADON #2 and CQS #94, at [DATE] at 3:50 PM, the Administrator stated she would consider the comments made to Resident #86 to be verbal abuse. The Administrator stated she had not been informed about the incident. d.) Review of facility's policy and procedure entitled Abuse Prohibition revised [DATE] was conducted on [DATE] at 6:00 PM. The policy stated .Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin or misappropriation of property .report the incident to his/her supervisor immediately. The policy also states initiate an investigation within 24 hours of an allegation of abuse that focuses on: whether abuse or neglect occurred and to what extent, clinical examination for signs of injuries, if indicated . The policy also states the investigation will be thoroughly documented The Center will protect patients from further harm during the investigation.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three (3) of sixteen (16) sample residents. The facility failed to ensure adequate pain management for Resident #51 resulting in actual harm to the resident. Resident #74 experienced periods of unresponsiveness. The facility failed to identify Resident #74's pacemaker settings and failed to monitor the resident's heart rate as ordered by the physician. Resident identifiers: #51 and #74. Facility census: 48. Findings include: a) Resident #51 On 09/23/17 at 9:27 a.m. review of Resident #1's medical records found he first entered the facility on 01/18/16. The resident had multiple health issues, including but not limited to [MEDICAL CONDITIONS] (stroke), [MEDICAL CONDITION] (impairment of language), dysphagia (difficulty in swallowing), occlusion and stenosis of bilateral carotid artery, [MEDICAL CONDITIONS], perineal abscess, recovering from opiod [MEDICAL CONDITION], and convulsions. The resident's perineal abscess and become septic and he was hosptalized on [DATE] and returned to the facility on [DATE]. Death occurred in the facility on 09/13/17. On 09/23/17 at 9:36 a.m., review of physician's orders [REDACTED].>-- an order dated 09/13/17 was for [MEDICATION NAME] (Concentrate) Solution 20 mg/ml Give 20 mg - 1 ml by mouth every one (1) hour as needed for pain. On 09/25/17 at 9:36 a.m., review of the physician's orders [REDACTED]. Review of physician orders [REDACTED].>-- An order dated 09/08/17 for [MEDICATION NAME] HCl Tablet 10 milligrams (mg) give one (1) tablet by mouth every six (6) hours as needed for pain. -- orders dated 09/12/17 included orders for do not resuscitate (DNR) status, and Do not re-hospitalize - unless unable to keep comfortable in house. -- An order dated 09/12/17 was noted for [MEDICATION NAME] 72 hour 12 MCG/hr (micrograms/hour) apply one (1) patch [MEDICATION NAME] one (1) time a day every three (3) days for pain and remove per schedule. -- a subsequent order also dated 09/12/17 was for [MEDICATION NAME] (Concentrate) Solution 20 mg/ml (milligram per milliliter) Give 10 mg - 0.5 ml by mouth every one (1) hour as needed for pain -- On 09/13/17, the [MEDICATION NAME] (Concentrate) Solution 20 mg/ml was increased from 10 mg/0.5 ml to 20 mg/1 ml by mouth every one (1) hour as needed for pain. Review of Medication Administration Record [REDACTED] - [MEDICATION NAME] HCl Tablet 10 mg at 3:09 a.m. and 11:03 a.m., the resident could have one (1) tablet by mouth every six (6) hours as needed for pain. - [MEDICATION NAME] (Concentrate) Solution 0.5 ml (10 mg) at 3:47 p.m., 7:20 p.m., 9:02 p.m.,10:30 p.m., the resident could have this every hour as needed for pain. Review of Medication Administration Record [REDACTED] - No [MEDICATION NAME] was given to the resident on 09/13/17 according to the MAR. - According to the MAR [MEDICATION NAME] (Concentrate) Solution 0.5 ml (10 mg) was given at 12:41 a.m. and 1:45 a.m. on 09/13/17. The resident could have 0.5 ml (10 mg) every hour as needed for pain. - [MEDICATION NAME] (Concentrate) Solution 1 ml (20 mg) was given at 4:02 a.m., the resident may have every hour as needed for pain. - The MAR indicated [REDACTED]. On 09/25/17 at 11:17 a.m., review of nurse's progress note (written by RN #10) dated 09/12/17 at 18:47 (6:47 p.m.), revealed it included, (typed as written), At about 540 pm (Aunt's name) resident's Aunt came to the nurses station demanding he be sent to the ER (emergency room ) now, Explained to her that (Resident) has capacity and his wishes were to be kept in the facility and be made comfortable .I walked out of the room and called (Doctor's name) at 550 pm, (Doctor's name) said he spoke with the resident this morning about 8 am himself and the resident did not wish to be sent to the Hospital unless we can not keep him comfortable in house. Also given a verbal order to start D5 1/2 NSS at 75 ml/hr again for 3 days for hydration. This morning (LPN #19's name) LPN received scripts from (Doctor's name) for [MEDICATION NAME] and Fent(anyl) Patch and (Resident's name) was aware of the medication prescribed Review of nurse's progress note dated 09/13/17 at 2:28 a.m. (written by LPN #14), on 09/25/17 at 10:06 a.m., revealed the resident was showing signs and symptoms of shortness of breath, gasping for air, upper quad lungs sound gurgling .trying to cough but unable. MPOA agreed to take him off fluids, got verbal order ok from (doctor's name) and disconnected intravenous fluids per request. Resident showing signs and symptoms of pain such as wincing, blinking and saying yes when asked if he is in pain, resident unable to verbally say what is hurting him or verbalize a numbered pain scale, [MEDICATION NAME] as ordered every hour .continuing to monitor. When asked whether Confidential Interviewee #1 knew Resident #51, the interviewee started crying and became very emotional. The interviewee said, When I came into work that day I went in to check on him because they said he was dying. I have been a (staff position and how long in that position) and have never seen anyone die like that, suffering in that way. He was begging for help. The resident was groaning, and kept saying over and over, 'Please help me. Please help me' and groaning 'Oh God.' When asked whether RN #10 was aware of the situation and the resident's suffering, the interviewee said, Yes, and added RN was aware, because I saw her go into the resident's room and saw it herself. The aunt was standing by the bed, on the side of the window, holding the resident's hand. You could clearly see the resident suffering, he was groaning non-stop and begging for help. The NA said she heard the aunt ask RN #10 to send the resident to the hospital .The entire time the resident was non-stop begging for help .The interviewee was crying, sobbing at times, during the entire interview concerning Resident #51. After composing herself, the interviewee said, It was the most horrible thing I have ever seen, to see someone die suffering like that. On 09/23/17 at 9:12 a.m., review of the resident's care plan revealed a focus area Resident exhibits or is at risk for alterations in comfort, date initiated was 08/31/17. An intervention included Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated (date initiated - 08/31/17). The resident's pain worsened and he was not given his pain medication on an hourly basis as ordered, starting at 7:30 p.m. on 09/12/17 until 4:00 a.m. on 09/13/17. The opportunities to give the medication had gaps in when he could have had pain medication - there was 1½ hour gap between 7:30 p.m. and 9:00 p.m., 1½ hour gap between 9:00 p.m. and 10:30 p.m., 2 hour gap between 10:30 p.m. and 12:40 a.m., and then between 1:45 a.m. and 4:00 a.m. another 2 hour gap. There was documentation at 2:30 a.m. the resident was unable to describe his pain and at 3:30 a.m. the physician was notified. When asked, Is it your expectation staff administer medication according to orders? The DON nodded his head in affirmation. The administrator replied, Yes, it is. The expectation would have been if the resident continued to have pain, the staff would have called the physician. We will check on that. The surveyors informed the facility they had spoken with the physician, and were told he was unaware of the level of the resident's pain, that if he had been aware, he may have done more or something different. During an interview with the resident's medical doctor (MD #87) on 10/03/17 at 8:20 a.m., he said he had talked to the resident the morning of 09/12/17 and the resident had wanted to stay at the facility. The physician added that the resident had capacity and they had discussed earlier in the day that unless the resident's pain could not be controlled, the resident would stay in the facility. MD #87 said he had been unaware of the kind of pain he was in until this survey investigation. MD #87 said, If I had been aware I would have changed interventions. If I had known he was in that kind of pain, I would have either increased his medication or sent him to the hospital. The doctor stated Resident #51 had an inoperable kidney abscess and history of [MEDICAL CONDITION], which had [MEDICAL CONDITION] in the past. MD #87 acknowledged Resident #51 had capacity and had agreed if he was in enough pain, he could have changed his mind about going to the hospital. MD #87 voiced surprise that no one had notified him about the amount of pain the resident was in. The failure of staff to ensure the resident received all pain medications as ordered by the physician and failure to notify the physician when the resident begged for help resulted in actual harm to the resident. b) Resident #74 Clinical record review revealed Resident #74 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. At 10:30 p.m. on 06/19/17, Licensed Practical Nurse #14 wrote a progress note stating, Had an episode form her A-fib this evening. I was across the hall in another residents room giving meds, and was called in to check on (name of resident) by a residents spouse who was in the room with her. Resident was found lying flat on her bed, supine position, eyes dilated and was unresponsive for approximately 30 seconds, I was unable to get a pulse for about 10 seconds, then pulse became weak and thready and slowed to 20 for approximately 2 minutes. Resident then started to respond to my voice, her pulse wen back up to 60 and resident said she was ok, but very tired. Checked vitals BP (blood pressure) was 118/52, pulse was 63, R (respiratory rate) 16, oxygen was 92% via nasal cannula at 2 liters/minute. Resident is now responsive and alert at this time. Will continue to monitor. On 06/20/17 at 8:35 a.m., a nurse noted, Spoke with (name of physician) this AM (morning) to alert him to episode with patient. Instructions to continue to monitor. A 06/29/17 at 4:54 p.m. an outpatient cardiology physician visited and noted, She states she has been having periods of unresponsiveness. She states that she will usually have these when she is lying or sitting down. They come on after some exercise or movement. She states that she does not recall what happens. Her eyes rolled back in her head, and what she has been told is she becomes unresponsive for 5-6 minutes. The physician stated she was in [MEDICAL CONDITION] and had failed an ablation (procedure used to remove or terminate a faulty electrical pathway from sections of the hearts of those who are prone to developing cardiac arrhythmias) in 2010. The physician planned to do a 30 day cardiac monitor and continue Eliquis (an anticoagulant) and [MEDICATION NAME] 50 mg twice daily (a medication to control heart rate). The 07/08/17 hospital discharge summary indicated Resident #74 was hospitalized from [DATE] to 07/08/17 for Bradyarrhythmia (slow heart rate) and single chamber pacemaker insertion on 07/07/17. A 07/17/17 outpatient cardiology physician progress notes [REDACTED]. The pacemaker programmed heart rate was 60 beats/minute. A 07/31/17 12:45 p.m., a LPN #83 noted, resident had 3 episodes of unresponsiveness. Resident found lying across bed. Eyes were open at time, but did not respond to staff. After several minutes during these episodes resident would awaken, but be very drowsy and lethargic. Unable to keep eyes open. Stated, 'I'm just so tired' vitals: blood pressure 120/84, T (temperature) 97.2, Pulse 82, Respiratory rate 18 Saturation 82% on room air. Resident placed on 2 liters oxygen via nasal cannula. Saturations increased to 95%. Resident was transported to emergency room . The 08/11/17 hospital discharge summary listed primary [DIAGNOSES REDACTED]. The 07/31/17 cardiology physician's note in the emergency room stated the pacemaker was functioning at base heart rate of 60 with the pacemaker being intermittently used at 59% of the time. A 08/12/17 physician's orders [REDACTED].#14) stated to do a pacemaker apical pulse (a pulse obtained using a stethoscope check over the heart on the chest). Check apical pulse for one minute daily. Pulse rate should be the same as pacemaker rate or faster. Notify physician if pulse is more than 5-10 beats lower than pacemaker's setting. The 08/11/17 care plan problem statement was, Resident is at risk of complications related to internal cardiac pacemaker interventions included: monitor for signs/symptoms of pacemaker complications: shortness of breath, weakness, [MEDICAL CONDITION], fatigue, cyanosis, [MEDICAL CONDITION]. Notify the physician as needed. Pacemaker checks as ordered. Review of the August 2017 and September 2017 Treatment Administration Records (TAR) revealed the actual heart was not recorded on 08/17/17, 08/18/17, 08/19/17, 08/20/17, 08/24/17, 08/25/17, 08/28/17, 08/29/17, 08/30/17, 08/31/17, 09/01/17, 09/02/17, 09/04/17, 09/05/17, 09/06/17, 09/16/17, 09/17/17, 09/18/17, 09/22/17, 09/25/17, 09/26/17 and 09/27/17. All 22 of 46 possible entries had only the nurses' initials and a checkmark. The TAR did not reflect the 08/12/17 physician's orders [REDACTED]. and did not reflect the pacemaker's rate was set at 60. During an interview on 09/28/17 at 9:08 a.m., the Director of Nursing (DON) #35 stated based on his initial review of the clinical record he could not determine what type of pacemaker had been implanted and the programmed heart rate. On 09/28/17 at 1:00 p.m., DON #35 said he had to have the physician obtain copies of the 06/29/17 and 07/17/17 outpatient cardiology physician notes and the hospital records for the 07/06/17 to 07/08/17 and 07/31/17 to 08/11/17 hospital admission. During a telephone interview on 09/28/17 at 10:40 a.m., LPN #14 stated on 06/19/17 she worked the evening shift with Resident #74. LPN #14 stated she did not remember notifying the physician of the resident's unresponsiveness, but if she had notified the physician she would have documented it in her note. LPN #14 stated she obtained the order from the physician on 08/12/17 to check the resident's apical heart rate every night and to notify the physician if the pulse was more than 5-10 beats below the pacemaker's setting. LPN #14 stated she did not know what the pacemaker rate was so she did not know when to notify the physician. LPN #14 stated she just documented the performance of the pulse check being done with a checkmark on the TAR. During a telephone interview on 09/28/17 at 11:30 a.m., LPN #83 stated she really did not know what the resident's pacemaker rate was programmed. LPN #83 confirmed she sent Resident #74 to the hospital on [DATE] due to 3 episodes of unresponsiveness. During an interview on 09/28/17 at 3:05 p.m., after reviewing the 06/19/17 at 10:30 p.m. nurse's note, the DON stated the nurse should have notified the physician immediately of the episode of unresponsiveness. DON #35 stated staff should not have waited until the following morning to notify the physician at 8:35 a.m. During an interview on 10/02/17 at 3:41 p.m., LPN #19 stated she did not know what the programmed setting was for Resident #74's pacemaker. LPN #19 stated that nurses were to update the resident's care plan when they obtain new intervention orders from the physician like the order obtained on 08/12/17 for daily apical pulse check of Resident #74. During an interview on 10/02/17 at 3:50 p.m., DON #35 stated when he interviewed the nurses they believed Resident #74's pacemaker was programmed at 60. DON #35 was unable to provide an explanation of LPN #19's interview. Upon review of the August and September 2017 TAR, the DON #35 stated the facility expectation was for nursing staff to document the resident's actual heart rate, not a checkmark.

Based on record review, family interview, and staff interview, the facility failed to provide an environment as free as possible of accident hazards and failed to ensure each resident received interventions as planned to prevent avoidable accidents with injuries for one (1) of thirty-three (33) Stage II sample residents. Resident #48 fell from her bed at 3:05 a.m. on 05/23/10. At the time of the fall, the resident's bed was not in the lowest position as per her physician's orders [REDACTED].) As a result of the fall, the resident sustained [REDACTED]. The facility also failed to fully investigate the circumstances around the fall as evidenced by a failure by staff to complete the facility's "Resident Fall Investigation Form" for this incident. Resident identifier: #48. Facility census: 57. Findings include: a) Resident #48 1. Review of Resident #48's comprehensive admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/18/09, revealed this [AGE] year old was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She transferred to the hospital on [DATE] and returned to the facility on [DATE]. According to the most recent quarterly assessment with an ARD of 03/22/10, she had problems with both short and long term memory; was not oriented to person, place or time; had moderately impaired cognitive skilled for daily decision making; required extensive assistance with bed mobility; was totally dependent with transferring between surfaces (e.g., bed to chair); and had partial loss of voluntary movement on one (1) side of her body. Further record review revealed Resident #48 fell from her bed at 3:05 a.m. on 05/23/10. 2. The incident report related to this fall, when reviewed on 05/28/10, contained the following: - Under "Description of incident" - "Resident found lying on (R) right side on floor beside bed." - Under "Description of injury" - "Bruises to bilateral knees and (R) shoulder." The report was signed by a licensed practical nurse (LPN - Employee #43) on 05/23/10 at 3:30 a.m., by the assistant director of nursing (ADON - Employee #67) on 05/24/10, and by the administrator (Employee #63) on 05/25/10. Attached to the incident report was found a two-page form entitled "Resident Fall Investigation Form". Under Section 1, "Fall Risk Status", in response to the question "What preventive measures are on the care plan?", staff documented, "Low bed when unattended." The section titled "New interventions / preventive measures added to care plan:" was blank, as was the section titled "Signature of person completing Section 1". Review of Section 2 "Unavoidable status" found this was to be completed by the interdisciplinary team (IDT) within seventy-two (72) hours of a fall. Review of Part A titled "A determination that a fall was unavoidable may be made only if routine preventive care is provided including (check if documentation verifies):" found the following items were left blank: - "Care Plan followed?" - "Supervision done as established?" - "Therapy Recommendations followed?" - "Were new interventions implemented (from Section 1)?" - "Additional team recommendations?" - "Care plan updated?" - "Staff aware?" Section 2 was signed by the clinical records coordinator (Employee #65), the assistant rehabilitation program manager (Employee #69), the social services director (Employee #68), and the director of admissions (Employee #57) on 05/24/10. Review of Section 3 "Follow-up to be completed by DON (director of nursing) / designee within five (5) working days of fall" found the following items were left blank: - "Was the resident seen by the interdisciplinary team within 72 hours?" - "What new interventions were implemented" - "Was the care plan updated to reflect the changes?" - "DON signature:" Section 3 was signed by the administrator (Employee #63) on 05/25/10. 3. A review, on 05/27/10, of the care plan in effect for Resident #48 (dated 03/22/10) revealed a focus area of: "Resident is at risk for falls: CVA (cerebrovascular accident) with right hemiparesis and anti-depressant meds." The goals associated with this problem statement were: "Resident will have no falls with injury and will not exhibit any adverse reactions r/t (related to) meds through next review date." The first intervention listed to accomplish the goals was: "Utilize low bed." 4. A review, on 05/27/10, of physician's orders [REDACTED]." Another order (dated 05/24/10 - the day after the fall) stated, "X-ray (L) (left) knee in a.m. (morning) knee pain /c (with) recent fall." (A subsequent review of the medical record, on 05/31/10 at 11:09 a.m., revealed the x-ray was done on 05/25/10 for pain in the left knee from the fall.) When interviewed on 05/27/10 at 9:00 a.m., the sons of Resident #48 stated they both had been informed by facility staff that Resident #48's bed was not in the low position at the time of the fall on 05/23/10. In an interview with the nurse who responded to the fall in Resident #48's room on 05/23/10 (Employee #43), on 05/31/10 at 6:35 a.m., Employee #43 stated that, during the early morning hours of 05/23/10, he responded to Resident #48's room immediately after her fall. He assessed the resident, discovered bruises to both knees and her right shoulder, and assisted her back into bed. When asked if the bed was in the low position prior to the fall, he stated, "No." He clarified that the bed was not up "all the way", but it was not in the low position as ordered. He stated he thought there was some confusion regarding the physician's orders [REDACTED]. An interview was conducted with nursing assistant (Employee #31) at 6:50 a.m. on 05/31/10; she was the nursing assistant who initially went into the room and found Resident #48 on the floor. Employee #31 stated she heard the resident yelling out and went to the room to see what had happened. She found the resident lying on floor and alerted a nurse, who sent Employee #43 into the room. When asked about the position of the bed, she, at first, said she could not recall, but then she said she thought it would have been down (in the low position). The administrator, when interviewed on 05/31/10 at 10:00 a.m., was asked if the bed was in low position. She reported she did not know that information and would have to ask the nursing assistant who responded to the fall. In a follow-up interview conducted with the son of Resident #48 at 9:16 .m. on 06/01/10, he stated that, when he was notified of the fall, he specifically asked Employee #43 what the position of the bed was at the time of the fall, and Employee #43 told him the bed was not in the low position. .

Based on medical record review and staff interview, the facility failed, for one (1) of sixteen (16) sampled residents, to provide adequate supervision and/or assistive devices to prevent an accident with injury. Resident #6 had a [DIAGNOSES REDACTED]. A physical therapy evaluation identified her as being at risk for falling, and staff was aware of her tendency to lean forward in her wheelchair. The only interventions implemented to promote her safety related to falling was staff encouraging and reminding her to sit back in her wheelchair, directives which she was not able to remember and consistently perform on her own due to her impaired cognition. On the afternoon of 04/25/10, Resident #6 fell face first from her wheelchair and sustained a fractured nose. Resident identifiers: #6. Facility census: 61. Findings include: a) Resident #6 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE], for rehabilitation for debility, [DIAGNOSES REDACTED] (LBD), and resolved pneumonia and urinary tract infection. Other [DIAGNOSES REDACTED]. 2. According to information from the Alzheimer's Association (found via the Internet at <http://www.alz.org/alzheimers_disease_dementia_with_lewy_bodies.asp>): "Dementia with Lewy bodies is characterized by abnormal deposits of a protein called alpha-synuclein that form inside the brain's nerve cells. ... "Symptoms of dementia with Lewy bodies (include) - Memory problems, poor judgment, confusion and other cognitive symptoms that overlap with Alzheimer's disease. - Excessive daytime drowsiness. - Visual hallucinations. - Cognitive symptoms and level of alertness may get better or worse (fluctuate) during the day or from one day to another. - Movement symptoms, including stiffness, shuffling walk, shakiness, lack of facial expression, and problems with balance and falls. ..." 3. Review of the resident's admission care plan, dated 04/21/10, noted the resident was exhibiting symptoms of decline in her cognitive function related to the LBD. Interventions were not individualized in relation to the resident, with only broad approaches listed. 4. Review of the physical therapy treatment encounter note, dated 04/22/10, identified the need for precautions related to fall risk. Following this initial evaluation, the facility failed to develop a care plan to address her fall risk with interventions appropriate to her level of cognitive functioning, in order to promote safety and prevent falls with injuries. 5. Documentation in the resident's medical record indicated staff was aware of resident's tendency to lean forward in her wheelchair. The resident had an order for [REDACTED]. Physical therapy notes, dated 04/23/10, stated, "Patient continually leans forward in chair and tries to stand without assistance." Nursing documentation, on 04/23/10 at 2:46 p.m., stated the resident was "frequently encouraged to sit back in wheelchair to prevent possibility of fall. Resident continually leaning forward in wheelchair, unable to redirect." 6. On 04/25/10 at 1:30 p.m., documentation in the resident's medical record noted, "Resident was sitting in the wheelchair within the Madison Canter TV lounge. Resident attempted to stand up without assistance and fell to the floor and suffered a laceration on bridge of nose. Resident sent to the hospital; hospital states nose is broken." Further review of the medical record revealed a nursing progress note, dated 04/25/10 at 14:46 (2:46 p.m.), stating, "Resident was in wheelchair in TV lounge at nurses station. Frequently encouraged to sit back in the wheelchair to prevent possibility of fall. Resident continually leaning forward in wheelchair, unable to redirect. Resident fell face first onto the floor from wheelchair. Laceration noted to bridge of nose with swelling. Resident daughter and doctor notified will transport to (acute care hospital) for eval(uation)." Documentation of the facility ' s investigation into this fall stated, "Resident fell from wheelchair due to her continually leaning forward. Resident was instructed by staff to sit back however due to [DIAGNOSES REDACTED] resident unable to comprehend this. Fall did result in laceration to bridge of nose and bilateral black eyes." 7. On 05/19/10 at 2:00 p.m., the facility's administrator (Employee #59), the regional speech language pathologist (SLP - Employee #65), the director of nursing (DON - Employee #54), and the assistant director of nursing (ADON - Employee #63) were interviewed. The members of this care management team acknowledged the resident's comprehensive plan of care did not include appropriate interventions to prevent falls from the wheelchair and that she was redirected and encouraged to sit back in the chair per staff, directives which were beyond her cognitive ability to understand and consistently follow to promote safety and prevent falls. .