Every finding on record at Madonna Towers of Rochester

Based on observation, interview, and record review the facility failed to ensure safety during van transport by ensuring safety straps were appropriately applied for 1 of 1 resident (R1). The failure resulted in actual harm when the van came to a sudden stop throwing R1 from the wheelchair causing fractures to her right and left femurs. The facility had completed corrective measures by 5/26/26 and prior to the start of the survey so citation was issued at past non-compliance (PNC). Findings include: R1's face sheet dated 6/4/26, identified diagnoses of unspecified fracture of shaft of right femur (long bone), unspecified fracture of shaft of left femur, displaced supracondylar fracture without intercondylar extension of lower end of left femur (break just above the knee joint), Alzheimer disease, anemia, unilateral primary osteoarthritis of left knee, muscle wasting and atrophy, and muscle weakness. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment, had clear speech, sometimes understands, and no behaviors. R1 had no impairment to upper or lower extremities, required substantial assistance with dressing, rolling, sitting; staff propelled wheelchair. R1's care plan dated 4/4/25, identified R1 transferred with one assist and mechanical standing lift. R1 did not ambulate. During an interview on 6/4/26 at 10:14 a.m., nursing assistant (NA)-A stated prior to 5/22/26, R1 used a standing mechanical lift with one person assist. R1 had a really big fancy wheelchair that was easy to tilt back and forward. R1 did not slide in the wheelchair once positioned. R1's Nursing Home Incident Report NHIR) dated 5/22/26, identified around 1:00 p.m. on 5/22/26, R1 slid out of her wheelchair while being transported back to the facility. R1 was assessed by nursing staff and around 3:00 p.m. was transferred to the emergency department due to increased pain. R1's Emergency Department provider notes dated 5/22/26, identified R1 had went to an appointment accompanied by family member (FM)-A via wheelchair van. Upon return from the appointment, FM-A stated R1 was improperly fastened in her wheelchair during transport. When the vehicle came to an abrupt stop from approximately 15 miles per hour at a stoplight, R1's wheelchair moved one to two feet forward causing her to slide out the wheelchair onto the floor of the vehicle landing with right lower extremity flexed with right foot positioned beneath buttocks. R1 was lifted by bilateral axillae (armpits) and placed back in wheelchair before returning to facility. On physical exam R1 had left lower extremity pain with no obvious deformity or other areas of tenderness. R1 was diagnosed with fracture femur shaft closed initial right and fracture femur shaft closed initial left. Facility email from van driver (VD)-A to campus wellness director (CW)-A dated 5/23/26 at 2:32 p.m., identified VD-A had resigned due to the driver position being too challenging for him. Facility investigation included a signed letter dated 5/25/26 from FM-A. The letter identified on 5/22/26 around 12:30 p.m., VD-A transported FM-A and R1 from a medical appointment. FM-A identified VD-A appeared to be struggling with securing the wheelchair tie downs. FM-A's letter identified VD-A asked FM-A if it was okay to not attach the upper shoulder strap/seat belt piece and FM-A agreed as the trip to facility was less than a mile. When VD-A braked at a stoplight, R1's wheelchair lurched forward six inches to one foot. The front tie downs were still secured but FM-A thought the back ones were not secured and were loose. FM-A watched R1 slide out of the wheelchair onto the floor with her right leg tucked under her body at a 90-degree angle. VD-A and FM-A placed R1 back in the wheelchair by FM-A holding R1's arms and VD-A assisted with lower half of body. R1's Safe Lifting and Movement observation dated 6/1/26, identified R1 was a two-person transfer with full lift as R1 was unable to bear weight. During an interview on 6/4/26 at 1:42 p.m., licensed practical nurse (LPN)-A who was also the case manager stated on 5/22/26, VD-A had not called her or informed her of the situation that occurred with R1. Around 1:15 p.m., LPN-A was made aware of the situation and went to R1's room to assess her while seated in her wheelchair. R1 complained of knee pain, which LPN-A stated was R1's baseline pain. However when staff attempted to transfer R1 using the standing mechanical lift, R1 complained of pain so staff used the full body mechanical lift to move R1 to her bed. FM-A and LPN-A decided to send R1 to the emergency department. During an observation and interview on 6/4/26 at 10:22 a.m., R1 was lying in her bed. R1 stated on 5/22/26, the incident happened fast and she did not think she was buckled in. R1 indicated since the incident she was somewhat afraid to ride in the bus if she had to go out for an appointment. During an observation and interview on 6/4/26 at 10:30 a.m., CW-A stated van driver (VD)-A had been employed at facility since 5/15/26. VD-A was onboarded on 5/15/26, had computer training on 5/19/26 and 5/20/26. VD-A shadowed with other VD's and was cleared to drive on his own. CW-A interviewed VD-A after the incident on 5/22/26, and VD-A stated he did not utilize the seat belt properly when transporting R1. CW-A went outside the facility to the mobility van with an empty wheelchair. CW-A opened the back of the van for the wheelchair to lift to come down. CW-A placed the wheelchair on the lift and then brought the wheelchair into the van. The wheelchair was facing the front of the van. The wheelchair was positioned in front of two Qstraints (wheelchair tie down system) which connect to the front of the wheelchair. CW-A stated the Qstraints are able to secure to any area that is welded on the wheelchair. CW-A locked the wheelchair and placed the Qstraints on the welded underside of the wheelchair. CW-A then went to the back of the wheelchair and took the Qstraint system from the side of the van and placed on the Qstraint track on the floor of the van. CW-A stated the back Qstraints are not automatically set up like the front so the wheelchair can be brought into the van. After the four lower restraints are attached the seat belt is applied around the resident's middle and a shoulder strap is attached at a 45-degree angle appearing like a normal seatbelt. The driver should then perform a wiggle test on the wheelchair and resident to make sure the restraints were connected and secure. CW-A stated immediately after the incident on 5/22/26, he performed a post-incident inspection on the entire vehicle to ensure safety and performance of the system was good prior to allowing any other residents to ride in the van. During a follow-up interview on 6/4/26 at 2:03 p.m., CW-A stated on 5/22/26, he had performed a competency test watching VD-A place a resident in the Qstraint system without difficulties. CW-A stated all drivers were given a transportation guideline binder that has driving policies, instructions for how to secure residents in the van, and what to do in an emergency that they were supposed to keep with them. During a phone interview on 6/4/26 at 11:17 a.m., VD-A stated he had transported R1 and FM-A to an appointment on 5/22/26 and on the return drive to the facility he hit the brakes coming to a stoplight and R1 slid out of her wheelchair. VD-A stated he felt he was not trained properly. I have never secured a resident in a system like that before it is very complicated. VD-A stated if he were to come to the facility now he probably would not be able to secure it properly. VD-A stated the front wheelchair restraints were secured. The two on the back were crisscrossed and the seat belt came from the ceiling with a three-part system. VD-A stated he did the shake test after securing R1 in the Qstraint system. VD-A did not understand how R1 slid down out of the wheelchair under the seatbelt. After R1 slid out of the wheelchair, VD-A immediately put his flashers on and went to assess the situation. R1's rear end was almost on the floor and her legs were still under her like sitting cross legged almost. VD-A had FM-A assist him to get R1 back in the wheelchair by taking an arm and a leg each and hoisting R1 back into the wheelchair. VD-A reconnected the Qstraint system and drove to facility. After arriving at facility VD-A went to CW-A and explained the situation. VD-A stated after the incident he put in his resignation. A phone call was placed to FM-A on 6/4/26 at 12:55 p.m. with no return call. During an interview on 6/4/26 at 1:13 p.m., certified physician assistant (PA)-C stated any fracture that happens when a person is older could lead to death. R1's fractures could lead to increased debility and decline. The facility had completed the following prior to the start of the survey: -In-service with all van drivers completed 5/26/26. - All residents who utilize the facility's transportation system were interviewed, and standardized investigative questions were asked. No additional concerns were identified. - All facility residents identified as being transported by the facility transportation vehicles in the past two weeks time had the following assessments completed with no identified concerns related to transportation services on 5/25/26: Skin Check Pain Assessment Safe Lifting and Movement Observations - All facility transportation vehicles were immediately placed out of service until a thorough safety inspection was completed on 5/26/26. - All facility transportation vehicles had daily inspection logs reviewed for completion for the past two-week period on 5/25/26. - Facility verified that all current transportation drivers had up to date education completed related to transportation services on 5/25/26. -All facility transportation drivers were reeducated on the following information on 5/26/26: Daily Vehicle Inspection Checklist Transportation Safety Transportation Competency Checklist Offsite Emergency Response (POL_IP100 Transportation & POL_AO020 Offsite Emergency Response Policy) Cornerstone Education Modules Vehicle Inspections and Driver Safety Wheelchair Transportation Safety -AP no longer employed at facility on 5/23/26.

Based on observation, interview, and record review, the facility failed to ensure proper personal protective equipment (PPE) was used during high-contact cares for 1 of 1 residents (R20) reviewed for enhanced barrier precautions (EBP) who had an indwelling catheter (R20). Findings include: R20's quarterly Minimum Data Set, dated [DATE] indicated R20 was cognitively intact, required partial assistance for activities of daily living (hygiene, toileting, transfers, ambulation), and had a urinary catheter. R20's diagnoses list included: neuromuscular dysfunction of bladder, need for assistance with personal care, unsteadiness on feet, muscle weakness, arthritis of knee, and a history of falling. R20's careplan indicated R20 had a urinary catheter that required catheter care per facility protocol. R20 required extensive assistance from 1 staff member for transfers, bed mobility and activities of daily living. An infection careplan indicated R20 required enhanced barrier precautions related to the presence of an indwelling catheter and to post clear signage on the door or wall outside the resident room indicating the type of precautions and requirement of PPE. The careplan also indicated staff must apply gloves and gowns prior to facility-identified high-contact care activities, discard PPE in designated location following activities, and sanitize hands after PPE removal. R20's April medication administration record printed 4/22/26 indicated foley catheter change monthly, flush catheter with 30 mililiters normal saline or sterile water as needed, record catheter output and complete catheter care every shift. During observation on 4/21/26 at 10:11 a.m., R20 was lying in bed. Catheter tubing was observed extending from under the blankets to a drainage bag located below the bed. An orange sign titled enhanced barrier precautions was attached to the door of R20's room. A plastic cabinet containing PPE was located just outside R20's room.During an observation and interview on 4/22/26 at 9:29 a.m., nursing assistant (NA)-B entered R20's room and applied gloves. R20 independently pivot transferred from her wheelchair to the edge of the bed. Without donning a gown, NA-B removed R20's catheter bag from the dignity bag under R20's wheelchair and placed it on a towel located under R20's bed. NA-B then lifted R20's legs onto the bed and placed a pillow under R20's legs. NA-B then reached over and used both hands to cover R20 with a sheet. NA-B then removed gloves and performed hand hygiene. During an interview, NA-B stated they receive have monthly trainings regarding infection control practices and have routine meetings routinely to go over anything new. NA-B stated they would wear gloves and a gown if they are performing direct cares for a resident of if they are draining a catheter bag. NA-B stated they do not have to wear gowns when assisting a resident for transfers or adjusting linens. During an interview on 4/23/26 at 9:07 a.m., the facility infection preventionist (IP) stated residents who have chronic wounds, MDROs (multidrug resistant organisms), and indwelling medical devices, such as urinary catheters, require enhanced barrier precautions. If it is determined a resident requires enhanced barrier precautions, a sign is posted on the door of the resident's room, a cart containing PPE is placed outside the room, the careplan is updated, and a flag is placed on the electronic medical record indicating EBP is required. The IP confirmed staff are expected to wear PPE during personal contact, transferring, toileting, wound care, and any care involving the indwelling medical device. During an interview on 4/23/26 at 9:39 a.m., the director of nursing confirmed staff are required to wear gowns and gloves when having direct contact with a resident who has a foley catheter in place. A policy titled enhanced barrier Precautions revised 4/1/24, indicated the purposed of EBP is to decrease transmission of CDC-target and other epidemiologically important multidrug-resistant organisms. EBP will be used for residents actively infected or colonized with CDC-targeted and other epidemiolocally important MDROs. Additionally, residents at risk for MDROs, specifically those with an indwelling medical device and/or chronic wounds requiring a dressing will be required to use EBP. The procedure describes the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated. It also refers to the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The policy indicated EBP is required for residents with chronic wounds (e.g. pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers), regardless of MDRO colonization status. It is also required for residents who have indwelling medical devices (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator) regardless of MDRO colonization status. High-contact resident care activities are defined as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs/assisting with toileting needs, indwelling medical device care or use, chronic wound care. PPE is described as gloves and gowns prior to the high-contact care activity.

Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators were labeled, dated and discarded properly. This deficient practice had the potential to affect all 55 residents, staff and visitors who received food from facility kitchen. Findings include: During the initial kitchen tour on 6/9/25 at 1:42 p.m., dietary manager (DM) stated the dates listed on the food was the date of opening or when it was prepped and should be tossed after one week. The following items were observed in the fridge expired or undated food: -Mushrooms dated 5/30/25 -Undated, opened celery appearing soft and browning -Undated, opened lettuce -Undated, opened chopped celery appearing with browning spots -Undated, opened carrots During interview on 6/9/25 at 1:42 p.m., culinary director (CD) stated the normal practice they follow is once foods are opened, the opened date is written on the container. The dated food is good for one week; the staff on evening shift will throw undated and expired foods every evening. CD confirmed the mushrooms, celery, lettuce, and carrots should have been thrown out previously, due to being expired or undated. During interview on 6/11/25 at 11:02 a.m., cook (C)-A stated the practice for dating stored foods is to put the date on the container when it was opened, the food is then thrown out in one week. C-A stated the evening shift is responsible for going through the refrigerators and toss undated or expired foods. Per facility Food Storage policy dated August 2019, sanitary procedures will be maintained in perishable food storage to keep foods safe.

Based on observation, interview, and document review, the facility failed to comprehensively monitor and assess for edema (swelling) so intervention effectiveness could be determined, and new interventions developed if needed for 1 of 1 residents (R43) assessed for edema management. Findings include: R43's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R43 had intact cognition and was diagnosed with heart failure and debility. R43's care plan dated 5/23/25, indicated R43 was receiving a diuretic, which placed her at a high risk for adverse reactions staff were to monitor for an infective dose such as an increase in edema. The care plan indicated R43 was at risk for skin alteration related to a history of lymphedema (swelling from an accumulation of protein-rich fluid usually drained by the body's lymphatic system). The care plan indicated staff were to apply R43's left upper extremity edema wraps in the morning, leave them on until the next morning, take off and assess the skin, and then re-apply. The care plan indicated that compression devices were to be applied to R43's bilateral lower extremities in the morning and taken off at nighttime. R43's Weekly Skin Checks dated: 4/9/25, 4/16/25, 4/23/25, 5/7/25, 5/14/25, 5/21/25, 5/29/25, and 6/4/25 were reviewed and indicated R43 had no edema at the time of assessment. R43's medical record dated 4/9/25 to 6/9/25 was reviewed and did not include further assessment of R43's left upper extremity edema. During an interview and observation on 6/9/25 at 4:14 p.m., R43 was observed sitting in her wheelchair in her room. R43's arm was observed with significant swelling to her left upper extremity, with her left hand puffy. R43 was observed attempting to use her left hand and did not appear to be able to fully bend her fingers towards her palms. R43 was observed wearing long pants and her lower extremities were unable to be fully visualized. R43 stated she has had the edema in her left hand for a long time, but it has overall improved since being at the facility, although never fully goes away. R43 stated the edema in her left hand had been worse the past couple of weeks. During an interview on 6/10/25 at 12:54 p.m., registered nurse (RN)-C confirmed she was the nurse for R43 for the shift and was familiar with the resident. RN-C stated R43 had a history of edema and shortness of breath, had gotten better since being at the facility but had never gone away. RN-C stated R43 no longer has edema in her lower extremities, so she has not been documenting R43 has any edema. RN-C stated R43 had chronic edema in her left upper extremity and a compression device was used. RN-C stated R43's left upper extremity was pretty edematous and thought it had been to this degree almost a month but RN-C stated she was unable to find this was being documented. During an interview on 6/11/25 at 10:13 a.m., RN-B confirmed she was the nurse for R43 for the shift and was familiar with the resident. RN-B stated R43 had left upper extremity lymphedema for a while and always had some edema in that extremity. RN-B stated the edema R43 had in her upper extremity was normal for her but was unsure where they documented assessing this edema in her arm. RN-B stated R43's edema to her lower extremities had diminished and R43 usually only had trace edema or did not have any at all there. During an interview on 6/11/25 at 10:54 a.m., RN-A, stated R43's edema to her left upper extremity was a chronic issue for her and would have expected staff to document that in the weekly skin check form. RN-A stated it was important this edema was documented so staff and the provider could see if changes in her edema level had occurred and if the current interventions were still effective. The facility's Resident Examination and Assessment policy dated 10/2/23, indicated that a resident assessment would be completed on admission, with a change in physical function, or with an acute change in condition and documented in the electronic health record (EHR).

Based on interview and document review, the facility failed to ensure 3 of 5 residents (R43, R14, R22) reviewed for immunizations were offered and/or provided the pneumococcal conjugate vaccine (PCV)20 as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infections. Findings include: A CDC Shared Clinical decision-making document titled PCV20 or PCV21 Vaccination for Adults 65 years or older dated 9/11/24 indicated: Adults [AGE] years of age or older have the option to receive supplemental PCV20 or PCV21 (not both) if they previously completed the pneumococcal vaccine series with both PCV13 and PPSV23 [pneumococcal polysaccharide vaccine] and meet the following criteria: -Previously received one dose of PCV13 (but not PCV15, PCV20, or PCV21) at any age, and -Previously received all recommended doses of PPSV23 (including 1 dose of PPSV23 at or after [AGE] years of age) The determination to administer PCV20 or PCV21 is based on a shared clinical decision-making (SCDM) process between a patient and their healthcare provider. SCDM recommendations are optional and informed by the characteristics, values, and preferences of the patient, and the clinical discretion of the health care provider. It continues, Increased risk of exposure to PCV20 or PCV21 serotypes may occur among people who are living in: nursing homes or other long-term care facilities. If exposed, people with one or more of the following health issues are at increased risk of developing severe pneumococcal disease: -immunocompromising condition, one or more of these chronic medical conditions: alcoholism, chronic heart, liver, or lung disease; cigarette smoking; or diabetes. Protection against disease from both PCV13 and PPSV23 is expected to decrease over time. It continues, If you and your patient decide PCV20 or PCV21 is appropriate, give one dose of PCV20 or PCV21 at least 5 years after the patient's last pneumococcal vaccine dose. R43 R43's face sheet indicated she was [AGE] years of age. R43's facility preventative healthcare report dated 6/10/25 indicated R43 received the following vaccinations: -PPSV23 on 12/28/2012 -PCV13 on 12/19/16 R43's Minnesota Immunization Information Connection (MIIC) report indicated R43 received PCV13 on 12/19/2016 and PPSV23 on 10/24/2005 and 12/28/2012. R43's facility immunization review form dated 5/27/25 indicated R43's pneumococcal vaccinations were not up to date and the pneumococcal vaccines were not offered. R43's medical record lacked documentation of shared decision making with provider and resident/responsible agent regarding administration of PCV20 vaccination. R14 R14's face sheet indicated R14 was [AGE] years of age. R43's facility preventative health care report printed 6/10/25 indicated the following vaccinations: -PPSV23 on 12/13/2004 and 6/9/2015 -PCV13 on12/11/2014 R14's MIIC report indicated R14 received PCV-3 on 12/22/14, PPSV23 on 6/9/15 and 12/13/2004. R14's immunization review form, dated 2/6/25, indicated R14's pneumococcal vaccinations were up to date. A facility immunization consent or refusal form dated and signed on 7/12/24, indicated consent to administration of pneumonia immunizations. Date of pneumonia vaccinations was left blank. R14's medical record lacked documentation of shared decision making with provider and resident/responsible agent regarding administration of PCV20 vaccination. R22 R22's face sheet indicated age of 77. R22's facility preventative health care report dated 6/10/25 indicated: -PPSV23 on 12/5/2012 and 1/19/2018 -PCV13 on 2/11/2015 R22's MIIC report indicated R22 received PCV13 on 2/11/2015, PPSV23 on 12/5/2012 and1/19/2018. R22's facility vaccination review form dated 3/28/25, indicated R22's pneumococcal vaccinations were up to date. R22's facility immunization consent or refusal form dated and signed by R22 on 7/12/24, indicated consent to administration of the pneumonia immunizations. Date of pneumonia vaccinations was left blank. R22's medical record lacked documentation of shared decision making with provider and resident/responsible agent regarding administration of PCV20 vaccination. During interview on 6/11/25 at 12:57 p.m., the regional nurse consultant confirmed there was no documentation of shared decision making or offer/administration of PCV20 vaccination for R14, R43, or R22. The infection preventionist stated residents were offered the PPSV23 vaccinations and confirmed the PCV20 vaccinations had not been offered to residents. A facility policy titled Pneumococcal Vaccines for residents dated 3/18/22, indicated the policy purpose was: To reduce the mortality and morbidity from pneumococcal disease by vaccinating all residents who meet criteria established by the CDC. It is the policy of [corporate owner] to provide education and administration of the PPSV23 and PCV13 to the residents of the facility according to CDC recommendations. CDC now recommends pneumococcal conjugate vaccine PCV15 or PCV20 for adults who have NEVER received a prior pneumococcal conjugate vaccine PCV13 if they are 65 years or older and have certain chronic medical conditions or other risk factors. For adults who have only received PCV13 but not PPSV 23, CDC recommends vaccine providers give PPSV23 as previously recommended. Line 6 under Procedure indicated the type pf pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV) offered will depend upon the recipients age and susceptibility to pneumonia in accordance with current CDC guidelines and recommendations. Line 10 indicated A pneumococcal vaccination is recommended for all adults 65 years and older and based on the following recommendations: A. For adults 65 years or older who have not previously received any pneumococcal vaccine, give 1 dose of PCV15 or PCV20. B. For adults 65 years or older who have only received a PPSV23 give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23.

Based on observation, interview, and document review, the facility failed to ensure the required nurse staffing information was posted daily and contained the facility name. This had the potential to affect all 55 residents residing in the facility and/or visitors who may wish to view the information. Findings include: During observation, document review, and interview on 6/11/25 at 8:32 a.m., the nursing staff posting was observed in the main lobby near the entrance and was dated 6/9/25 with a resident population of 55 and did not have the facility name on it. The staff posting indicated the morning shift began at 6:00 a.m. The administrator confirmed the staff posting had not been updated since 6/9/25 as the staffing coordinator (SC) was on paid time off (PTO). The administrator stated she thought the health unit coordinator (HUC)-A would be the staff member in charge of updating the staff posting while the staffing coordinator was away. During an interview on 6/11/25 at 9:06 a.m., HUC-A stated the SC oversaw posting the staff posting and was not sure who oversaw completing this task while she was on PTO. During an interview on 6/12/25 at 8:54 a.m., the SC stated that she was unsure who oversaw posting the nurse staffing information while she was on PTO. The SC confirmed the staff posting did not have the facility name on it and stated after reviewing the staff postings that it had been like this since September of 2024. The SC stated she had not noticed the change in the form and would have to call cooperate to see why the form no longer had the facility name on it. The facility's Posting of Nursing Hours policy dated 9/20/22, indicated the nurse staffing information would be posted daily at the beginning of each shift and would include the facility name.

Based on observations, interview, and document review, the facility failed to provide the opportunity to make choices related to toileting for 2 of 3 residents (R1, R2) reviewed for choices. Findings include: R1's face sheet dated 2/12/25, identified diagnoses of stress fracture of left tibia (hairline crack in the shin bone) and fracture of middle phalanx of left finger. R1's admission minimum data set (MDS) dated [DATE], identified resident to be cognitively intact. R1 was dependent for all transfers and frequently incontinent of bowel. R1's care plan dated 2/12/25, identified R1 was dependent for all transfers with a total mechanical lift. During an interview on 2/11/25 at 3:50 p.m., R1 stated it had been two days since she has been able to have a bowel movement due to having to use the bedpan instead of using the toilet. R1 stated, I don't feel like I have any power over anything anymore, they tell me when to eat, when to bathe, and when to get up. R1 stated when she puts her call light on to bathroom to have a bowel movement, staff just put her on a bedpan and do not give her an option to sit on the toilet. During an interview on 12/12/25 at 2:08 p.m., R1's family member (FM)-A stated it is a point of dignity she should not have to ask to go to the bathroom laying in bed if it does not work for her. R2's face sheet dated 2/12/24, identified diagnosis of multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves) and neurogenic bladder (condition where a person has lack of bladder control). R2's quarterly MDS dated [DATE], identified R2 was cognitively intact and occasionally incontinent of bowel and bladder. R2's care plan dated 12/12/24, identified R2 was assist of two for toileting with a total mechanical lift. During an interview on 2/11/25 at 1:48 p.m., R2 stated staff were using a ceiling lift in her room previously to allow her to sit on the toilet to have a bowel movement, but since the ceiling lift has been out of use the only way she can have a bowel movement was to sit on a bedpan or go in her incontinent garment. R2 explained when she asked to use the toilet to have a bowel movement, staff told her she had to use the bedpan instead of the toilet. Using the bedpan made made R2 feel not good . During an interview on 12/12/25 at 8:47 a.m., regional director registered nurse (RDRN)-B stated if a resident requests to use the toilet it should be care planned to do so and staff should be honoring their request. During an interview on 12/12/25 at 2:50 p.m., director of nursing (DON) stated if a resident's preference to use the toilet to have a bowel movement this should reflect on their care plan, along with their request to not use the bedpan. The staff should be treating the resident in a dignified manner and staff should follow the resident wishes. Review of the facility's Activities of Daily Living policy dated 6/21, identified interventions to improve and or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.

Based on observation, interview and document review the facility failed to ensure a comprehensive care plan was developed to implement care and services for catheter care and bowel continence for 1 of 1 resident (R1) reviewed for bowel and bladder incontinence/catheter. Findings include: R1's face sheet dated 2/12/25, identified diagnoses of diabetes mellitus, stress fracture of left tibia, chronic kidney disease. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and had an indwelling urinary catheter and frequent bowel incontinence. R1's care area assessment (CAA) dated 12/19/24, identified R1 needed assistance for toileting due to indwelling catheter. R1's physician progress note dated 12/18/24, identified R1 had an indwelling urinary catheter placed during a hospitalization for urinary retention. R1's nursing assistant care guide updated 2/5/25, directed staff that R1 had a catheter. However, did not give any direction to staff to provide catheter care or toileting plan. R1's care plan infection focus dated 12/13/24, identified R1 required enhanced barrier precautions (EBP) due to presence of indwelling catheter. Intervention for staff to apply gloves and gowns prior to high-contact activities. R1's care plan did not identify interventions to manage or care for the indwelling catheter or a toileting plan for bowel continence. During an interview on 2/12/25 at 2:08 p.m., family member (FM)-A stated R1 would have a bowel movement every day like clockwork at home. During an interview on 2/12/25 at 2:13 p.m., R1 stated she was able to hold her bowel when she was at home and did not have any episodes of incontinence. R1 stated the facility did not discuss the risks of having a catheter or inquire about my bowel pattern at home. During an interview on 2/12/25 at 2:33 p.m., nursing assistant (NA)-J stated R1's nursing assistant care sheet did reflect she has a catheter, however, did not reflect how to care for it or have a toileting schedule on it. During an interview on 2/12/25 at 2:50 p.m., director of nursing (DON) stated R1's comprehensive care plan did not address interventions for catheter care or toileting plan for bowel continence. Facility's Comprehensive Assessment and Care Planning policy dated 9/27/23, identified the facility must assess continence to develop, review and revise the resident's person-centered comprehensive care plan and all person-centered care plan interventions will be implemented by qualified personnel, and may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication. Residents and resident representatives will be involved in the comprehensive person-centered care planning.

Based on observation, interview, and record review the facility failed to comprehensively reassess and demonstrate adequate justification for the continued use of indwelling catheter for 1 of 1 resident (R1) reviewed for falls. In addition the facility failed to ensure a resident who was continent of bowel received services to maintain bowel continence for 1 of 1 resident (R1) reviewed for resident safety. Findings include: Catheter justification: R1's care plan dated 12/13/24, identified R1 required Enhanced Barrier Precautions (EBP) related to presence of indwelling catheter device .R1's care plan was reviewed and identified no indication for a foley catheter with no interventions to monitor for signs and symptoms of infection. R1's Care Area Assessment (CAA) dated 12/14/24, section 6 urinary incontinence identified CAA triggered due to use of an indwelling catheter and need for assistance with toileting. R1 has a catheter in for skin care management, due to history of incontinence and reduced mobility with current fracture. The CAA did not address plan for urinary indwelling catheter removal. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1's cognition was intact and had the use of indwelling catheter. R1's Physical Therapy (PT) progress note dated 12/21/24, identified R1 complained of catheter pain. R1's PT progress note dated 1/22/24, identified R1 complained of catheter pain. R1's Occupational Therapy (OT) progress note dated 12/22/24, identified R1 complained of burning in her catheter site. R1's OT progress note dated 12/27/24, identified R1 complained of pain in her catheter. R1's MD progress note dated 12/27/24, identified during R1's hospitalization from [DATE] to 12/23/24, R1 developed urinary retention and hence Foley catheter was placed .R1 was recommended to follow-up with urology to undergo voiding trial (a procedure used to assess a patient's ability to urinate without the assistance of a urinary catheter). R1 has an upcoming appointment on 1/24/2024 with urology. R1's MD Progress note dated 1/24/25, identified .R1 had developed urinary retention while hospitalized in December 2024 and has had an indwelling urinary catheter since. She will be seeing urology today and anticipates a voiding trial will be done . R1's Urology Appointment dated 1/24/25, identified R1 experienced urinary retention in the hospital with over a liter in her bladder with moderate hydronephrosis (a condition where urine builds up in the kidney, causing it to swell). This was in the setting orthopedic injury and surgery with narcotics. R1 has an indwelling Foley catheter that has been in place for the last month. This was really helpful to her because she still is not mobile. New orders identified that a catheter change will be completed, will keep catheter in and do monthly catheter changes until R1 is mobile enough so she would be able to go to the bathroom if the catheter was removed, at that time a voiding trial will be done. R1's progress note dated 2/4/25 at 10:28 p.m., identified a nursing assistant reported that R1 was uneasy and complained of discomfort. R1 stated that she feels the urge to pee. Abdomen noted to be tender and has low urine output in the catheter bag, 100 cc. On-call provider notified and obtained verbal order to flush the urinary catheter with 60 mL of sterile normal saline. Urinary catheter was flushed as per order. Catheter was draining with urine output of 1000 milliliters (ML) in the catheter bag. During an observation and interview on 2/11/25 at 4:05 p.m., R1 was seated in her wheelchair in her room and was noted to have a catheter bag. R1 stated she has had the catheter for convenience because since she fractured her leg she can't get to the bathroom easily. At 4:38 p.m., nursing assistant (NA)-J and NA-K assisted R1 to the toilet. NA-J stated she needed to change R1's brief because it was wet from R1's leaking urine from her catheter. During a phone interview on 2/12/25 at 2:08 p.m., family member (FM)-A stated she brought R1 to the urology appointment on 1/24/25, where they changed R1's catheter. FM-A further stated R1 has her catheter for convenience every time she would have to urinate, she would need a full body mechanical lift to go to the commode. The facility has a hard time getting her to the toilet now. FM-A stated prior to R1's hospitalization R1 was completely continent of bladder. FM-A stated last week the facility called her about a blockage in R1's catheter they had to call the doctor to take care of it. During an interview on 2/12/25at 2:13 p.m., R1 stated she did not remember anyone in the facility talking to her about the risks of having the catheter. R1 further stated, they never talked to her about it and did not have a doctor here tell me about the risks. During an interview on 2/12/25 at 2:50 p.m., director of nursing (DON) indicated she was aware that R1 did not have a clinical diagnosis for her catheter use. DON stated she was not aware that R1 had an appointment with urology on 1/24/25, that indicated R1 had new orders to have her catheter changed once a month. DON would follow up with urology to ensure if the facility would be doing the catheter change or if R1 would have to go to an outside appointment for it. DON was unable to find documentation of education of risks and benefits of catheter use were given to R1. During an interview on 2/12/25 at 3:37 p.m., medical director (MD)-A stated R1 currently has a catheter for convenience and does not have a diagnosis for justification of use. Facility policy, Prevention of Catheter-Associated Urinary Tract Infections (CAUTI), revised 8/30/23, identified Purpose: Though prevalence of indwelling urinary catheter use in the long-term care setting is lower than in the acute care setting, catheter-associated UTI (CAUTI) can lead to such complications as cystitis, pyelonephritis, bacteremia, and septic shock. These complications associated with CAUTI can result in a decline in resident function and mobility, acute care hospitalization s, and increased mortality. Prevention is key. Policy: It is the policy of Benedictine communities that indwelling urinary catheters are eliminated whenever possible. A resident who admits to the community without an indwelling catheter is not catheterized unless the resident's clinical condition indicates categorization is necessary for their well-being. General Considerations: 1. When a resident is admitted to the facility with a catheter in place, a thorough physical assessment, as well as history review will be completed. 2. Once reviewed, primary physician will be notified for catheter removal, if there is not a medical reason for use of catheter. 3. Intermittent catheterization will be used whenever possible rather than indwelling catheter. 4. An indwelling catheter is used only after alternative methods have failed . Bowel Continence: R1's Bowel Observation dated 12/18/24, identified R1 was always continent of bowel and to monitor R1 for constipation due to opiate use. Section 6 treatment/management for program placement was not assessed. Section 7 Bowel summary was left blank. R1's care plan dated 12/18/24 identified a problem with ADL's functional status. R1 had a self-deficit with bowel and bladder. Interventions dated 2/4/25, identified do not use the belted mesh hygiene (toileting) sling. R1's care plan was reviewed and did not identify person centered interventions to resident preference with toileting such as bed pan, commode or toilet, and did not identify toileting plan interventions to maintain bowel continence. R1's Care Area Assessment (CAA) dated 12/19/24, section 5: Activities of Daily Living (ADL's) identified R1's CAA triggered due to left tibial fracture, with non-surgical treatment, was in a long cast and non-weight bearing for at least 6 weeks and being followed by orthopedics and medical doctor. Care plan will be developed due to mobility and cares. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1's cognition was intact and R1 was frequently incontinent of bowel. Further identified R1 was dependent with toileting transfers and required substantial to maximal assist with toileting hygiene. R1's care sheet dated 2/3/25, identified R1's toileting to transfer to/from bed, to pull down pants before/after toileting for clothing management. R1 required assist of 1 with adl's and transferred with ez-way mechanical lift x 2. R1's care sheet lacked information how to transfer R1 to the toilet what type of sling to use and also lacked toileting plan to maintain bowel continence. During an observation and interview on 2/11/25 at 4:05 p.m., R1 was seated in her wheelchair in her room and was noted to have her call light on. R1 stated she had her call light on to try and get on the toilet because she had not had a bowel movement for two days since the staff have been making her use the bed pan. R1 further stated, I used to go every day like clockwork between 1 and 3 pm and it would take me less than 5 minutes. R1 stated now that she hadn't had a bowel movement in two days. R1 had felt gassy earlier and felt full. R1 stated she was going to ask for a laxative if nothing happens. At 4:08 p.m., nursing assistant (NA)-J came in the room, R1 asked NA-J if she could get on the toilet, NA-J stated she was unable to find another staff to help with that. R1 asked NA-J if she would be here tomorrow to try and help her with that? NA-J stated to R1, ok I will see you tomorrow and left the room. R1 stated she did not get the option to use the toilet only the bed pan. R1 stated, I just can't have a bowel movement laying down on a bed pan, I have to be sitting up to go. At 4:14 p.m., RN-D walked in the room and offered R1 some Miralax, R1 asked when she would be able to be able to get to the toilet if she took the Miralax. R1 then asked when it would be a good time for her to go to the bathroom. Registered nurse (RN)-D did not answer R1 and R1 declined the Miralax and RN-D left the room. During a continuous observation on 2/11/25 from 4:18 p.m. to 4:40 p.m., NA-J and NA-K positioned a sling under R1 in the wheelchair and were attempting to transfer R1 to the toilet with the ez-way lift (mechanical lift). NA-J and NA-K struggled to get R1's pants down, but were able to get her pants down and pull R1's brief to the side, R1 then was lowered onto the toilet that had a toilet riser on it. When R1 was seated on the toilet her legs were dangling about a foot above the ground. R1 stated she had a bowel movement and was done. NA-J and NA-K transferred R1 with the use of the ez-way lift from the toilet in her bathroom to her bed and performed toileting hygiene. R1 stated you can't imagine how much better I feel. NA-J stated R1 had a medium formed bowel movement and stated they had not been offering R1 the toilet only the bed pan because it took a lot of time to transfer R1 to the toilet with the ez-way lift. During an interview on 2/12/25 at 8:47 a.m., regional director registered nurse (RDRN)-B stated if a resident requested to use the toilet versus the bed pan it should be care planned to do so and the staff should be honoring her request. During a phone interview on 2/12/25 at 2:08 p.m., family member (FM)-A stated prior to R1's stay here she was completely continent of bowel. FM-A stated the staff have not been offering R1 the toilet instead had been offering a bed pan. FM-A stated R1 had shared the struggles of not being able to have a bowel movement with a bed pan. During an interview on 2/12/25 at 2:13 p.m., R1 stated she was able to hold her bowel when she was at home and did not have any episodes of incontinence. During an interview on 2/12/25 at 2:50 p.m., director of nursing (DON) stated R1's bowel assessment did not identify patterns of incontinence to determine a toileting schedule and stated the care plan did not identify a preference for how R1 preferred to use the bathroom. Facility bowel assessment policy was requested and not received. Facility policy, Activities of Daily Living (ADL), dated June 2021, identified the Purpose: To provide residents with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Policy: Residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility. Implementation: 1. Care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care), b. Mobility (transfer and ambulation, including walking) c. Elimination (toileting) .4. Interventions to improve and/or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 5. The resident's response to interventions will be documented, monitored, evaluated and revised as appropriate. 51576

Based on interview and record review the facility failed to provide adequate supervision for R2. This resulted in an immediate jeopardy (IJ) for R2 who was identified as an elopement risk and was able to leave the facility through a fire door without staff knowledge. R2 was last seen on August 14 at 9:15 p.m. and found approximately two blocks away from the facility and brought back to the facility by police at 11:13 p.m. Staff was unaware that R2 had eloped due to the the door alarm not sounding. The IJ began on 8/14/24 when R2 eloped from the facility. The IJ was identified on 8/23/24. The Director of Nursing was notified of the IJ on 8/23/24 at 3:10 p.m. The IJ was removed on 8/15/24 and deficient practice was corrected on 8/16/24, prior to the start of the survey and was therefore past noncompliance. Findings include: R2's observation for elopement risk dated 7/30/24, indicated R2 recently had changes in medications and recently moved to the facility. R2 was disoriented. His elopement risk was low. R2's care plan dated 8/1/24, indicated R2 exhibited wandering (moves with no rational purpose, seeming oblivious to need or safety). Wander guard (an arm bracelet which notifies staff if resident leaves the premises) placed to wrist to alert staff to exit seeking behavior. R2's physician order sheets dated 8/5/24, indicated R2 had placement of a wander alert system. R2's progress note dated 8/14/24 at 12:23 p.m. indicated R2 walked to the fire door and set off the alarm. Staff responded and let him back in. R2's observation of elopement event dated 8/15/24, indicated R2 had successful and unsuccessful elopement attempts in the past. R2 wandered with no rational purpose and attempted to open the door. R2 was found in a parking lot of a large retail store. R2 had dementia and Covid-19. R2's interventions were 15-minute checks with a paper log. A progress narrative note indicated on 8/14/24 at 12:23 p.m. R2 walked to the door and set off the alarm. Staff responded and escorted him back in. On 8/14/24 at 11:56 p.m. documentation indicated at around 11:13 p.m. a police officer arrived at the facility at the main entrance using the nursing doorbell. The writer and another nurse approached the officer and asked if they knew R2. The officer stated he found him around 11:04 p.m. at a large retail store. R2 wasn't able to explain how he left the building or which door he used. Skin assessment was completed with no concerns. R2 was placed on 15-minute checks. R2's wander alert on his right wrist was checked at 12:00 a.m. and was not working. The writer had last seen R2 from 7:30-7:50 p.m. giving medication. R2's family was left a voicemail. No alarm was heard by the staff to notify them there was an elopement. Maintenance was called after R2 returned and writer expressed concerns of the doors not being properly secured. Maintenance came out and checked the door. The director of nursing (DON) and the on-call nurse were notified of the incident. Staff were educated on resident being on 15-minute checks and a paper log was provided to the staff. R2's admission Minimum Data Set (MDS) indicated R2 had a Brief Interview for Mental status (BIMS) score of 9 indicating R2 was cognitively impaired. The MDS indicated R2 had wandering behavior 4 to 6 days, but less than daily. R2 required supervisor or touching assistance for transfers and walking. R2's pertinent diagnoses were Parkinson's disease, radiculopathy of the lumbar region (injured nerve roots in the lower back), and bradycardia (slow heart rate). Upon interview on 8/22/24 at 5:10 p.m. nursing assistant (NA)-B stated she had assisted R2 to get ready for bed on 8/14/24 at around 7:30 and did not see him after that. She stated she was aware of his elopement and was retrained on how to reset the door alarm. Upon interview on 8/23/24 at 8:45 a.m. the director of nursing (DON) stated he was called regarding the elopement on 8/14/24. The registered nurse (RN)-C told him R2 was returned to the facility by the police at around 11:13 p.m. He had returned safely with no injuries. RN-C stated the staff did not hear an alarm sound. RN-C placed R2 on 15-minute safety checks and requested the on-call maintenance staff to go onsite and assess the doors. The DON stated the root cause of the elopement was after R2 sounded the alarm on 8/14/24 at 12:30 p.m. the door was not reset. He stated the alarm has to be reset or the door alarm will not work. He stated the maintenance staff found that the door in R2's hallway, the same door he used for his attempted elopement, was not armed when he checked the doors during the night on 8/14/24. The following morning, 8/15/24 the DON reviewed video footage and the footage did not show R2 leaving the building. The DON collaborated with the camera company and found out the camera system had a 10 second delay. The DON further stated R2 had been given medications at approximately 7:30 p.m. by nursing and a nursing assisted viewed him around 9:15 p.m. R2's physician and family were notified. The facility provided an in-service/education on the elopement policy, wander guard system, egress door alarm system, temporary magnetic alarm, and the Wimplisafe alarm system on 8/16/24. Upon interview on 8/23/24 at 9:30 a.m. R2 stated it was a dark night and it was [NAME] outside. He stated he used a doorway and rode in the backseat of a car. He did not know what the wander guard around his was or what it was for and he couldn't recall why or how he left the facility. Upon interview on 8/23/24 at 12:11 p.m., the maintenance director stated one of his staff was on-call when the elopement occurred and went to the facility at approximately 1:00 a.m. He stated the following day he found out that R2 had sounded the fire door alarm on 8/14/24 around 12:30 p.m. and the maintenance department was not notified to reset the door alarm. He stated if the alarm is not reset it will not work. He stated since the elopement incident all staff were trained on how to reset the door. The facility also increased security so staff can see if a door was ajar on the television screens mounted in the hallways the same television that shows the staff which call lights are on. Upon interview on 8/23/24 at 12:33 p.m., registered nurse (RN)-A stated she was the nurse on call on 8/14/24 when R2 eloped. She stated R2 was a wanderer and had a wander guard placed on his wrist. She stated on 8/14/24 she heard R2 sound the fire door alarm at around 12:30 p.m. and saw that a nursing assistant was redirecting R2 back to his room. RN-A stated she was aware of how to reset the door when the alarm sounded, however found out following the elopement that nursing assistant staff had not been trained to reset the doors. Upon interview on 8/23/24 at 12:48 p.m. a maintenance staff worker stated on 8/14/24, he had worked in the facility until 9:00 p.m. At 11:45 p.m. he received a call from RN-C who told him a resident had eloped from the facility, was found about two blocks west of the facility and the door alarms did not sound. The maintenance staff member stated he arrived at the facility at approximately 1:00 a.m. He checked all the doors at the facility and found that door 6 was not alarmed. He stated he reset the alarm, checked it, and went home. The next day, through the facility investigation, he found out that R2 had sounded that alarm earlier on 8/14 and the alarm had not been reset. The NA who assisted R2 back to his room following the elopement attempt on 8/14/24 at 12:30, did not return a call during the survey. Upon interview on 8/23/24 at 4:19 p.m., nursing assistant (NA)-A stated R2 was a wanderer. She stated the evening he eloped from the facility she had walked past his room at approximately 9:15 p.m. and R2 was seated in the chair in the corner of his room looking out into the hallway. A facility policy titled Elopement dated 2018 indicated the facility was to provide a safe and least restrictive environment for resident. To maintain the safety of residents who are at risk of wandering and/or active elopement. This IJ was called at past non compliance due to action the facility took prior to survey entrance. Actions taken included, all staff were educated on how to reset all the doors at the facility, the door alarm company was onsite the following day and checked all the tags for the all the doors, equipment was added that allowed the staff to see any door that an alarm had gone off on the televisions, the facility updated their camera system post motion on the video from the default of 3 seconds to 10 seconds.

Based on observation, interview, and record review the facility failed to conduct regular inspections of all bed frames, mattresses, and bedrails as a part of the regular maintenance program to identify areas of possible entrapment. All of the residents at the facility have the same beds. The facility census was 55 and 50 of those residents had the same quarter siderails on the beds. The bed manufacturer guidelines indicated to visually inspect the bed and accessories monthly. This failure had the potential to affect 50 residents in the facility. Findings include: A side rails safety environment inspection form dated 9/20/22 indicated one resident with bedrails was assessed with revisions made and again on 5/24/24 one resident with siderails was inspected with revisions made. Upon observation on 8/23/24 at 10:10 a.m. all residents' rooms at the facility were observed for bedrails. Fifty residents had beds with quarter sized bedrails attached by the head of the bed and five residents did not have any bedrails. The bed manufacturer guidelines indicated maintenance/inspection information: Visually inspect the bed and accessories for broken welds or cracks and check for loose hardware on a monthly basis. If any broken welds or cracks are found remove bed from service immediately and replace affected parts or contact technical support and tighten any loose hardware. Upon interview on 8/23/24 at 11:15 a.m. the regional nurse stated she believed maintenance inspects the bedrails quarterly. She stated she would provide documentation. She provided a log of a bedrail assessment dated [DATE] completed during the survey process for one resident. Upon interview on 8/26/24 at 9:09 a.m. registered nurse (RN)-B, nurse manager stated the nursing department does not inspect the bedrails. If the nursing staff noticed a concern with any bedrails the staff would notify the maintenance department. She was not aware how often maintenance inspected the rails. Upon interview on 8/26/24 at 9:29 a.m. the director of maintenance stated the beds are inspected yearly. He stated the facility is only required to check one of the beds because all the beds are the same and bedrails to all of the beds are the same as well. Upon interview on 8/26/24 at 11:33 a.m. the director of nursing (DON) stated he did not consider the rails on beds to be bedrails. He stated he considered them to be grab bars. Defining a grab bar as a small bar attached to the bed and a bedrail would be taking up a quarter of a bed. He stated the appliance the facility used is only about a foot above the mattress and does not restrict residents therefor they are not bedrails. A facility policy titled Bed Safety and Bedrails dated 2022 indicated bedrails are adjustable metal or rigid plastic bars that are attached to the bed. They are available in a variety of types, shapes, and sizes. Bedrails included: side rails, safety rails, and grab/assist bars. The policy indicated siderails and mattresses are checked for entrapment concerns annually. Findings are documented. Maintenance will routinely inspect beds and related equipment to ensure proper function, identify risk and problems including potential entrapment risks.

Based on observation, interview, and record review the facility failed to attempt to try alternative devices before using bedrails on resident's beds for 7 of 7 resident (R1, R2, R3, R4, R5, R6, R7) when the facility failed to accurately assess the resident for risk of entrapment by assessing residents medical diagnoses, size and weight, cognition, communication, mobility, and risk of falling. In addition, the facility failed to provide ongoing assessments to assure the bedrail is used to meet the resident's needs. Findings include: Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023 indicated a physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily and that restricts freedom of movement or normal access to one's body. The important consideration is the effect of the device on the resident, and not the purpose for which the device was placed on the resident. Residents who are cognitively impaired are at a higher risk of entrapment and injury or death caused by physical restraints. It is vital that physical restraints used on this population be carefully considered and monitored. Any manual method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition. This can only be determined on a case-by-case basis by individually assessing each and every manual method or physical or mechanical device, material, or equipment (whether or not it is listed specifically on the MDS) attached or adjacent to the resident's body, and the effect it has on the resident. R1's annual Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact. R1 did not have any behaviors. R1 was dependent in rolling left to right, transferring, dressing and personal hygiene. R1 was frequently incontinent of bowel and bladder. R1's pertinent diagnoses were Parkinson's disease, osteoarthritis, and chronic congestive heart failure. R1 was taking an anticoagulant and a diuretic. R1's MDS did not indicate she had a bedrail in place. R1's restraint/adaptive equipment use observation form dated 9/18/23 indicated R1 had side rails. R1 was taking diuretics and sedative/hypnotics. R1 was to use the quarter assist bars for bed mobility in bed. The form indicated the siderails were not a restraint. No alternative devices were attempted. No other Restraint/Adaptive Equipment observations were completed in R1's medical record. Upon interview on 8/22/24 9:15 nursing assistant (NA)-C stated he had worked at the facility for about a year and R1 was never able to move herself in bed with or without the bedrails. He stated it took two staff to hold her on her sides. Upon interview on 8/22/24 at 11:29 a.m. NA-D stated R1 did not use the bedrails when the NA's were caring for her. She was a heavy total assistance of two, she could not reposition herself. Upon interview on 8/22/24 at 3:18 p.m. family member (FM)-A stated R1 did not use the bedrails. Upon interview on 8/26/24 at 9:09 a.m. registered nurse (RN)-B stated R1 was dependent on two staff members to assist her with bed mobility. She was not certain if R1 could assist with any mobility. She stated R1 had not had an observation for the side rails since 9/18/23 and she stated R1 had declined since that date. RN-B did not believe R1 could physically remove the bedrails by herself. She was unaware of any devices attempted and failed for R1. R2's admission Minimum Data Set (MDS) indicated R2 had a Brief Interview for Mental status (BIMS) score of 9 indicating R2 was cognitively impaired. The MDS indicated R2 had a wandering behavior of 4 to 6 days of the 7-day assessment periods, but less than daily. R2 required supervisor or touching assistance for transfers and walking R2's pertinent diagnoses were Parkinson's disease, radiculopathy of the lumbar region (injured nerve roots in the lower back), and bradycardia (slow heart rate). R2's MDS did not indicate if he had bedrails on his bed or not. R2's care plan dated 8/8/24 indicated R1 had cognitive loss/dementia. R1 exhibited cognitive loss, no diagnosis of dementia, has Parkinson's disease, delirium in hospital. BIMs score of 5 on admit. R2's care plan dated 8/15/24 did not indicate R2 had quarter bedrails on his bed. R2's Restraint/Adaptive Equipment Use Observation document dated 7/30/24 indicated R1 had siderails and grab bars. The observation did not indicate R2 had behavior symptoms, which included wandering and wore a wander guard (a bracelet which alerts staff when residents have attempted elopement). The form indicated that no alternative to the bedrails or grab bars were tried in the past. The form indicated the device met the definition of a physical restraint with no further documentation. The siderails were to be used for decreased mobility when R2 was in bed to assist with transfers, bed mobility and boundary limitations. Upon observation and interview on 10:20 a.m. R2 had quarter side rails in his room. R2 was unable to state what the siderails were and what they were to be used for. Upon interview on 8/26/24 at 10:55 a.m. RN-A stated she was not certain of R2's cognition since had a different BIMs score on his MDS versus his care plan. R2's MDS dated [DATE] indicated his BIMS scare was a nine and his care plan dated 8/8/24 indicated his admission BIMs was a five. She stated she believed R2 used the bedrails to transfer in and out of bed. RN-A denied trying any alternative devices for R2 and did not believe that PT tried any other methods as well. She stated R2 was a wanderer and he had wandered into other residents' bedroom. R2 sounded the fire door alarm on 8/14/24 and later that same day of 8/14/24 eloped without recollection. RN-A was not certain if R2 understood the bedrails or if he could remove then easily. R3's care plan dated 9/6/23 indicated R3 displayed the following behaviors related to yelling out and verbally abusive toward others. Staff was to distract resident when an upsetting situation develops. If R3 became aggressive staff was to leave room and return later. If resident became delusional staff was not to challenge the situation. If resident became verbally aggressive staff was to respond calmly and not raise their voice. Staff was to remove objects that might be used to harm resident or others. R3's quarterly MDS dated [DATE] indicated R3 had a BIMS score of 3 indicating severe cognitive impairment. R3 was not identified as having any behaviors. R3 required maximum assistance to roll from left to right in bed. R3 was dependent with all transfers. R3 was always incontinent of bladder and frequently incontinent of bowel. R3's pertinent diagnoses were chronic kidney disease, spastic hemiplegia affecting right dominant side (muscles on one side of the boy being in a constant state of contraction and dementia. The MDS indicated R3 did not have a bedrail in use. R3's Restraint/Adaptive Equipment observation form dated 8/23/24 (completed the during the survey process) indicated R3 had bilateral grab bars. The form indicated R3 had no behaviors. R3 was taking antidepressant and diuretics. The device would be used while R3 was in bed. The form did not indicate if any alternatives to the current device had been tried in the past, if based on the findings if the use of the device supported by appropriate reason for use or if based on the findings the device was safe for the resident. The form did not classify the grab bars as side rails, they were classified as adaptive equipment. The form did not include any behaviors for R3. Upon interview on 8/26/24 at 9:09 a.m. RN-B stated maybe R3 could hold one of the bedrails with his left hand only during a repositioning with staff if staff asked him to. When R3 was on his own in bed cognitively he would not have been able use the bedrail to reposition. R3 could not remove the bedrail himself. No other alternative devices were attempted. R4's Restraint/Adaptive Equipment observation form dated 8/13/24 indicated an admission assessment for bed rails was completed. No other information was documented on the form. Including the type of device, behaviors, alternative methods attempted, falls, when and why a device was used, falls and if the device was a restraint. R4's quarterly MDS dated [DATE] indicated R4 had a BIMS score of 15 meaning she was cognitively intact. R4 had no behaviors. R4 required moderate assistance to roll in bed and with all transfers. R4's pertinent diagnoses were congestive heart failure, Type 2 Diabetes, and osteoarthritis. R4 did not have a bed rail. R4's Restraint/Adaptive Equipment observation form dated 8/23/24 (during the survey process) indicated R4 had bilateral grab bars. The form did not identify R4 as having any behaviors. R4 preferred to have the grab bars to aid in repositioning when she was in bed always. The grab bars were not classified as siderails, they were classified as adaptive equipment. No alternative devices were tried in the past. Upon interview on 8/26/24 at 9:09 a.m. RN-B stated she did not believe that R4 could physically remove the bedrails. She denied any alternative devices attempted. R5's Restraint/Adaptive Equipment observation dated 7/25/23 indicated R5 had siderails. No alternative devices were attempted. The type of side rail was a top half used for assistance with transfers and bed mobility. R5's quarterly MDS dated [DATE] indicated R5's BIMS score was a five indicating she had severe cognitive impairment. R5 had no behaviors. R5 required extensive staff assistance with bed mobility. R5 had a pressure relieving mattress. The MDS did not indicate if R5 had a bedrail. R5 had no concerns with skin conditions. Upon interview on 8/26/24 at 9:09 a.m. RN-B stated R5 would be able to follow directions if staff guided her to use the siderail during her cares, but not on her own. She stated R5 cognitively would not be able to remove the bedrails on her own. An alternative device was not attempted for R5. R5's last Restraint/Adaptive Equipment observation was over a year ago. RN-B stated she believed assessments were to be done quarterly by the MDS nurse. R6's care plan dated 7/17/23 indicated R6 was on the turning and reposition program due to decreased mobility with assistance and grab bars in bed and one staff member. R6 could not always verbally ask for assistance. R6's care plan dated 8/2/23 indicated R6 required the assistance of two staff members while in bed. R6's care plan dated 6/20/24 indicated R6 was admitted to Hospice for a terminal diagnosis. R6 was taking antidepressant and antianxiety medications. R6's quarterly MDS dated [DATE] indicated R6 had a BIMS score of 0 indicating severe cognitive impairment. R6 had no behaviors. R6 required extensive assistance with bed mobility and transfers. R6 had a pressure relieving mattress on her bed. The MDS did not indicate if R6 had a bedrail. R6's care plan dated 8/17/24 indicated R6 had a perimeter mattress to define edges and prevent falls. R6's Restraint/Adaptive Equipment observation form dated 8/22/24 (completed during the survey process) indicated. R6 had side rails. R6 had no behaviors, she was taking narcotics. She had a resident decline in medical condition. She used the bed rail for bed mobility. No alternatives to the current device had been tried in the past. The form did not indicate whether the device was safe for R6 at this time, or the side rails were a restraint. Upon interview on 8/26/24 at 9:09 A.M. RN-B stated R6 was on hospice and would not be able to remove the bedrail by herself cognitively or physically. She did not believe that R6 was using the bedrail, but maybe she was holding onto it when the nursing assistants, (NA) were providing care. R6 did not have a Restraint/Adaptive Equipment observation prior to 8/22/24 during the survey process. R7's admission MDS dated [DATE] indicated R7 had a BIMs score of 3 indicating she had severe cognitive impairment. R7 did not have any behaviors. R7 was dependent with rolling in bed and with all transfers. R7's pertinent diagnoses were dementia, chronic obstructive pulmonary disease, Kienbock's disease (a disease of the wrists where the bone deteriorates and causes pain and swelling), and osteoporosis. R7's MDSH did not indicate R7 had bedrails on her bed. R7's care plan dated 8/1/24 indicated R7 used a Hoyer lift for all transfers. R7 required the assistance of two staff for bed mobility. R7 could not verbally ask for assistance. R7 was on the turning and repositioning program due to decreased mobility every 2-3 hours. R7 had a floor mat while she was in bed and frequent checks in bed due to a history of falls. Care plan did not indicate R7 had bedrails. Upon interview on 8/26/24 at 10:55 a.m. RN-A clarified that R7 was a newer admission and did have siderails. She stated with a BIMs of 3 R7 was not able to remove the bedrails on her own. She stated no other devices were attempted. Upon interview on 8/23/24 at 11:15 a.m. the regional nurse stated the nursing managers are to be assessing the bedrails quarterly per the facilities policy. She was not aware that alternative device methods were required prior to the use of bedrails. Upon interview on 8/26/24 at 11:55 a.m. physical therapist (PT)-A stated she look at mobility when she is assessing a resident, whether they can get out of bed or not. She stated there was only a handful of residents at the facility who did not have bedrails. PT-A stated the therapy department does not try alternatives. She stated bedrails and siderails are defined as rails placed on a bed for mobility and grab bars silver bars that are mainly hung in the bathrooms to assist with mobility. A facility policy titled Bedrails dated 2018 indicated prior to installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include verbal cuing, PT/OT evaluation, strengthening exercises, over-bed trapeze and other mobility and positioning strategies. If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes: -An evaluation of the alternatives to bedrails that were attempted and how these alternatives failed to meet the resident's needs. -The residents risk associated with the use of bedrails, input from the resident and/or representative and consultation with the attending physician. -Before using bedrails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with the bedrails and obtain informed consent. The following information will be included in the consent: -The assessed medical needs. -The residents' risks from the use of bed rails and how those will be mitigated. -The alternatives that were attempted but failed to meet the resident's needs -The alternatives that were considered but not attempted and the reasons. Any use of side rails will meet the FDA guidelines to reduce entrapment risk.

Based on observation, interview and document review the facility failed to ensure process's were followed for safe mechanical lift transfers for 3 of 18 residents (R1, R2, R3) reviewed for safety with mechanical lift transfers. Findings include: R1: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment. R1 had impaired range of motion (ROM) on one side of lower extremity and was completely dependent on staff for all transfers. R1's undated Facesheet identified diagnoses of right leg above the knee amputation, history of falling, and dementia. R1's care plan dated 12/8/23, identified R1 had a self-care deficit with transfers. An intervention on 12/22/23, identified R1 required assist of two staff for transfers with a ceiling lift for all transfers. Must use gold full body sling for all transfers; however, did not identify the size of gold sling to be used. R1's physical therapy (PT) treatment encounter note dated 12/22/23, identified R1 utilized a ceiling lift with an assist of two staff. Educated nursing assistant on appropriate sling to use with ceiling lift a motorized device that lifts and transfers a person from point to point along an overhead track) which was gold full body sling; the sling size was not identified. R1's progress note dated 12/22/23, identified R1 required assist of two staff for transfers with a ceiling lift for all transfers. Must use gold full body sling for all transfers; however the lift sling size not identified. R1's Fall Event Report dated 1/20/24 at 11:45 a.m., identified R1 was transferred with a full body mechanical lift from the wheelchair to the bed when R1 slipped out of the sling and onto the floor. R1 was transferred back to bed with full body mechanical lift and assist of three staff. R1 complained of right shoulder pain with no ROM concerns. A facility reported incident dated 1/21/24, identified on 1/20/24 at 11:45 a.m. R1 experienced a fall out of the full body lift mechanical sling during cares. The provider and family were notified. R1 was sent to the emergency room (ER) for evaluation returned the same day with no injury. R1's PT treatment encounter note dated 1/23/24, identified safety assessment for use of full body mechanical sling for an amputee. Multiple trials performed with two different style slings; bucket style sling and single limb wrap sling and was determined the bucket style sling with black loops was most appropriate option due to size of R1's right residual limb. PT trained two different aides with return demonstration competency. Discussed making care plan to have sling stay underneath R1 to ensure proper positioning of sling when R1 needed to be transferred out of wheelchair, staff instructed to not use this sling with toileting, only transfers to bed; however, R1's care plan did not identify to not transfer R1 to toilet with this type of sling. During an interview on 1/29/24 at 8:54 a.m., certified occupational therapy assistant (OTA)-A stated that all mechanical lift transfers would be assisted by two people. The therapy department would help to determine what sling to use on a resident. R1's record lacked evidence a sling size was determined, as part of the assessment process, for a safe transfer with the use of a ceiling lift or a full body mechanical lift; and there was no evidence staff were directed on what sling to use with the full body mechanical lift while the ceiling lift was not available for use. During an interview on 1/29/24, at 8:59 a.m. regional director of clinical services (DOCS)-A identified R1 fell from a full body mechanical lift on 1/20/24, at 11:45 a.m. R1 fell when R1 was transferred with only one staff. The facility policy was to always use two staff with mechanical lift transfers. Also a ceiling repositioning sling was used to try and transfer R1 from the wheelchair to the bed with a full body mechanical lift. Prior to R1's fall on 1/20/24, residents that utilized mechanical lifts were not being assessed for sling sizes. DOCS-A- identified all residents who required a mechanical lift were weighed and the EZ-Way (brand of standing mechanical lift) sling guide was used to determine safe sling size for each resident and each care plan and care guide was updated. DOCS-A identified all nursing and therapy staff were educated and competency tested with the EZ-Way lift, care plan and care guide updated. In addition, audits of resident transfers were being performed to ensure education was effective. On 1/29/24 at 11:37 a.m., R1 laid in bed covered by a sheet. R1 stated that on 1/20/24, NA-A attempted to transfer R1 from wheelchair to bed when the fall happened. R1 identified the ceiling lift was not used. During an interview on 1/29/24 at 1:50 p.m., NA-A stated that on 1/20/24, R1 needed to use the bathroom. NA-A stated the ceiling lift was not working and staff had to use the EZ-Way smart lift (a name brand full body mechanical lift) to get R1 into bed. NA-A identified the top of the gold sling was placed at the base of R1's neck and tried to shimmy the bottom of the sling to cover the bottom of R1's feet while in the wheelchair. NA-A stated, the gold sling was huge and covered R1 like a cocoon. NA-A identified the EZ Way smart lift was hooked to the four-point harness sling and R1 was lifted approximately two inches above the wheelchair and NA-A pulled on the sling for adjustment while lifting R2 in the full body mechanical lift. R1 slid out of the sling hitting her right shoulder on the wheelchair cushion and R2's bottom landed on the floor. NA-A stated a picture was taped to the closet that identified only the gold sling could be used for transfers because of R1's right leg amputation. NA-A confirmed the gold sling was supposed to go over R1's head not at the base of the neck. NA-A realized now that was the wrong type of sling to use with the EZ-Way smart lift. During a phone interview on 1/30/24 at 9:22 a.m., LPN-A stated they worked the day shift on 1/20/24. At 11:45 a.m. NA-A was standing outside R1's room requesting help as R1 had slid out of the sling onto the floor. LPN-A identified a gold body sling was used for the transfer of R1 and was the only sling available for staff to use. R1 should have been transferred with two staff and one staff was used for the transfer with R1's fall. R2: R2's quarterly MDS dated [DATE], identified R2 had moderate cognitive impairment and a diagnosis of Parkinson's disease. R2 was dependent with transfers from bed to chair to toilet and required substantial to maximal assist with wheelchair for mobility with no falls identified. R2's care plan updated 1/23/24, with an intervention that included R2 required two staff to assist with use of mechanical lift for toileting and transfers with the use of a beige medium sized sling. R2's care guide updated 1/26/24, identified R2 required two staff assist with use of mechanical lift for toileting and transfers with the use of a beige medium sized sling. During an observation on 1/29/24, at 10:21 a.m. R2 was suspended from a full body mechanical lift being transferred by NA-D and NA-F from the toilet to the wheelchair. R2's sling that had burgundy-colored tubing and a size large tag was identified. During an interview on 1/29/24 at 10:25 a.m. NA-D identified they recently had education on all of the care guides being updated to include the right sized sling to be used for each resident. NA-D stated, I always use the large toileting sling for R2. NA-D identified the size the care guide directed would be a size medium and beige in color. During an interview on 1/29/24 at 10:54 a.m. NA-E walked to R2's room and identified the large size toileting sling was the one they always used to transfer R2 with. NA-E identified the size on R2's care guide should be a medium. NA-E stated, this is the wrong size sling in here, I will take it out and go get a medium sized one. Each resident should have their own sling in their room for infection control purposes. During an interview on 1/29/24 at 11:35 a.m. NA-F verified R2's care plan was not being followed as R2 was transferred to and from the toilet using the wrong size sling, as a large sling was used instead of the medium sized one. R3: R3's quarterly MDS dated [DATE], identified R2's had intact cognition and diagnoses included left knee pain and adjustment disorder with depressed mood. R2 was dependent with transfers from bed to chair to toilet and required substantial to maximal assist with wheelchair for mobility with no falls identified. R3's care plan updated 1/23/24, with direction that R3 required two staff assist with use of mechanical lift for toileting and transfers with the use of a beige medium sized sling. On 1/29/24 at 11:20 a.m., R3 was seated in a recliner in her room with her legs extended. R3 stated, I am on a schedule and prefer to be transferred to the bathroom at 9:00 am and won't need to be transferred again until 6:00 p.m. R3 identified two staff always assist to transfer with the sling and R3 identified the lift sling staff used on R3 by pointing to the sling with burgundy colored tubing and was a size large that was the chair, and it was the same one staff used earlier in the day when they toileted R3 During an interview on 1/29/24 at 11:42 a.m. clinical manager (CM)-B walked to R3's room and identified the sling in R3's chair was a large sling and R3 was care planned to use a medium size sling. CM-B removed the large sized sling from R3's room. During an interview on 1/29/24 at 12:05 p.m., DOCS-A identified R2 was transferred with a large sized sling instead of the care planned medium sized sling. The aides should always look at their care guides to ensure they are using the right sized sling for transfers. Our policy was for each resident to have their own sling in their room to avoid confusion and for infection control purposes. DOCS-A identified an unawareness of the wrong sized sling being in R3's room and verified R3 should be transferred with a medium sling per care plan and resident safety to reduce the risk of falls. The facility policy Mechanical Lift dated 12/02, identified the mechanical lift was used to lift/transfer a heavy and/or dependent resident and included the following direction: A minimum of two (2) staff will operate/be present during transfer. PROCEDURE 1. Identify the resident by reading the wristband or other method. 2. Explain what you would like to do to the resident. 3. Wash hands. 4. Gather supplies 5. Mechanical lift with sling a. Wheelchair/Chair b. Blanket/lap robe 6. Obtain assistance of another staff member to assist with transfer procedure. 7. Provide privacy. 8. Position the wheelchair/chair near the bed. 9. Raise the bed to working level. 10. Lock the brakes of the bed. 11. Inspect the lift sling for possible tears or weak areas. 12. Roll the resident to one side and place the sling halfway under the resident. 13. Rolls the resident to the other side and pull the sling through, smoothing while checking for correct placement. 14. Roll the resident back onto the center of the sling. 15. Raise the head of the bed slightly. 16. Position lift over the bed. 17. Guide the lift to the proper position. 18. Attach the sling to the lift according to manufacturer's instructions. 19. Instruct the resident to fold hands over his/her chest or hold on to the frame of the lift. Monitor all tubing, i.e., catheters, IV tubing, etc. to prevent displacement. 20. Lower the level of the bed as the lift raises the resident off the bed, until the resident's buttocks have cleared the bed. 20. Steady the resident while in the sling while positioning the lift/sling over the chair. 21. Lock wheelchair legs. 22. Stand behind the chair and place arms around the resident's waist or use the handle that may be on the back of the sling to guide the resident until he/she is lowered into a sitting position in the chair. 23. Disconnect the sling according to manufacturer's instructions. 24. Move the lift away from the chair. 25. Position the resident's feet on chair rests as appropriate, Cover legs and lap with blanket. 26. Leave the resident comfortable, Place call light within reach. 27. Return mechanical lift to storage area; DO NOT leave the lift in the resident's room. 28. Wash hands. 29. Report/record resident position, reaction to procedure and tolerance. 30. To transfer resident to bed, reverse the process, washing hands before and after transfer. The EZ Way Smart lift operator's instructions revised 6/14/23, identified The EZ Way Smart Lift' was designed primarily to lift patients from the bed, chair, toilet, and floor. The maximum lifting capacity is located by the model and serial number of your lift. For safe operation of the EZ Way Smart Lift', operators should watch the training video, read through this manual, complete the competency checklist, and practice on fell ow staff members before use with patients. Do not modify the sling design in any way. Please make sure the accessories used with each lift are appropriate for both the patient and the transferring situation. EZ Way slings are made specifically for EZ Way Smart Lift's. For the safety of the patient and caregiver, only EZ Way slings should be used with EZ Way lifts. Warning: For safe operation of the EZ Way Smart Lift, the lift must be used by trained personnel in accordance with the operator's manual, video, and training checklist to avoid injury to the patient. Multipurpose slings these slings are used primarily for above the knee amputees and people with large thighs and delicate skin. EZ Way Sling Sizing Chart revised 7/31/18, identified sling color coding system was used on the binding of slings, not used with specialty slings. It is important that the base of the sling be positioned two inches below the tailbone and the top of the sling is parallel with the top of the shoulder line (base of the neck). Note: The size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of the patient. A proper fit will involve the judgement of the care giver. Applied to washable and disposable slings: -size small: 70 - 100 pounds (lbs.) and height from patients tailbone to base of neck 21 inches, gray color -size medium: 90 - 220 lbs., height 24 inches, beige color -size large: 190 - 320 lbs., height 26 inches, burgundy color -size extra-large: 280 - 450 lbs., height 29 inches, green color -size XXL: 400 - 600 lbs., height 36 inches, black color -size XXXL: 600 + lbs., height 37 inches, brown color The Guldmann Ceiling Hoist manufacturer instructions dated 12/11, identified a Purpose and use: the GH2 is a ceiling-mounted hoist that covers the need for lifting and moving people in hospitals, at nursing homes, institutions, swimming pools, riding schools and in private homes. The preconditions for using the GH2 hoist are that: the staff who operate this aid facility have received training, the instruction offered by Guldmann to all customer groups in connection with the purchase of a ceiling-mounted hoist has been received, the caregiver pays close attention to the well-being of the person being lifted, the hoist is used in rail systems approved and tested in acc. with Guldmann' s stipulations, installation and testing of rail systems should only be performed by Guldmann-approved engineers. the hoist is used with a Guldmann lifting hanger or with another suitable lifting hanger. The hoist is used with a Guldmann lifting sling. Slings made by other manufacturers Guldmann shall not be liable for faults or accidents that occur as a result of using lifting slings made by other manufacturers. If you are in doubt regarding the choice or use of the lifting sling: please contact your supplier. Guldmann shall not be liable for faults or accidents due to incorrect use of the lifting sling, or for reasons of inadequate attention on the part of the carer or user. The Guldmann repositioning sling manual dated 8/23, identified the intended purpose was for lifting or supporting a person or body parts of a person. Area of use the sling was suited for use in hospitals, nursing homes, institutions, rehabilitation centers and in private homes. Conditions of use was designed for use with ceiling hoist systems and was suitable for placing users in lateral position, repositioning in a bed, lift of head and trunk to half-sitting position, supine lateral transfers to other surfaces such as beds and stretchers, or in connection with change of linen. The use of the sling is subject to the following: The sling is used by trained staff or persons who have been instructed in the use of the sling in question. The sling is used for lifting or repositioning a person in a lying position. The helper pays attention to the well-being of the user when using the sling. The sling is used with the Guldmann lifting hanger. Important! Plan the move. Never leaving the user in the lifting sling unattended. Do not start to lift until it has been checked that the user cannot get trapped and that the sling does not catch on the bed, wheelchair, or other obstacles. The user's head, arms, hands, and feet must not be in danger of becoming trapped. Be careful with any tubes and wires that are attached to the user and/or equipment. Check that the hand control and hand control cable is free of hanger, patient and other object before the hoist is activated up. Guldmann shall not be liable for faults or accidents due to incorrect use of the lifting sling, or for reasons of inadequate attention on the part of the carer or user. If the sling is used in combination with products that are not manufactured by Guldmann, a risk assessment must be made by qualified staff. Guldmann shall not be liable for faults or accidents due to incorrect use of the lifting sling, or for reasons of inadequate attention on the part of the carer or user. If the sling is used in combination with products that are not manufactured by Guldmann, a risk assessment must be made by qualified staff.

Based on observation, interview, and document review the facility failed to complete neurological assessments and comprehensively assess and monitor skin injuries following falls for 4 of 4 residents (R1, R2, R3, R4) who had unwitnessed falls or unwitnessed falls with injuries. Findings include: R4's face sheet included diagnoses of trochanteric bursitis, left hip, type 2 diabetes mellitus with diabetic nephropathy, age related osteoporosis without current pathological fracture, mild neurocognitive disorder, history of falling. R4's admission Minimum Data Set (MDS) dated [DATE], indicated R4 was cognitively intact, was dependent on staff for lower body dressing, was substantial to max assistance from staff for hygiene, and was partial to moderate assist from staff for toileting, mobility, and transfers. MDS also indicated R4 had a fall in the last month and another in the last 2-6 months. R4's Safety Events report-Falls dated 10/26/23, indicated R4 had an unwitnessed fall at 7:05 p.m., that resulted in a bump on the head (no location of bump on the head was identified) and was sent to the emergency room (ER). Treatment included monitor for 72hours for bruising, change in mental status/condition, pain or other injuries related to fall. Neuro checks for every 15 minutes-times 4, then every hour- times 2, then every 2 hours- times 2, then every 4 hours- times 2, then every shift- times 3. Post fall observation every shift- times 9 to equal 72 hours. R4's progress note dated 10/26/23, at 10:55 p.m. indicated R4 arrived back at the facility. R4's physician visit note dated 10/27/23, indicated R4 was seen by the physician for post fall follow-up. The note did not address R4's injury to her head. Note directed staff to continue with neuro and vital sign monitoring. R4's follow up vital signs and neuro checks sheet initiated on 10/26/23, indicated R4 was at the hospital till 8:00 p.m., on 10/26/23. R4's neuro checks did not resume until midnight on 10/27/23 then checked again on 10/27/23 at 4:00 a.m. On 10/27/23, 10/28/23, and 10/29/23, there were two other entries marked as AM and PM but no time was specified when the neuro assessments were completed. In review of R4's record it was not evident vital signs were monitored in conjunction with neuro assessments, nor a comprehensive assessment of head bump was completed, nor evident R4's head injury was continuously monitored following the incident on 10/26/23. R4's progress note dated 12/5/23 at 11:49 p.m., indicated R4 was found on the floor at 11:35 p.m. bleeding from left forehead. Resident was sent to ER. R4 returned to the facility at 4:28 a.m. with a visible wound on the left eyebrow and lump on her forehead. No further description of the head wound was included. R4's progress note from 12/6/23, at 8:03 a.m. indicated R4 was in her recliner and had a dressing on her forehead, no active bleeding. No further description was included. R4's skin assessment dated [DATE], included a diagram of a body. The front (face) had a circle drawn on the forehead with the words Bump on forehead written next to the circle. On the back of the diagram there was a circle on the middle of the back of the head with words Bumps on head written next to the circle. No other description of wound was included. Subsequent skin assessments were completed on 12/14/23 and 12/19/23, however, did not address R4's head wound. In review of R4's record it was not evident the injury to R4's head was comprehensively assessed and continuously monitored falling the fall on 12/5/23. R4's progress note dated 12/20/23 at 8:33 a.m. indicated R4 had an unwitnessed fall and was found on the floor hitting left forehead, L [left] forehead has a big bump with actively bleeding. R4 stated my head is very sore and pian The note indicated R4 was sent to the ER for further evaluation. No further description of the injury was included. Subsequent progress note at 2:18 p.m. included, she [R4] continues to have bruising on her face and bandage on her forward [sic] The progress note had no further description of the bruising or injury the bandage covered. Skin assessment dated [DATE] and 12/27/23, did not identify the injury to R4's head. In review of R4's record it was not evident the injury to R4's head was comprehensively assessed and continuously monitored falling the fall on 12/20/23. During an observation on 12/28/23 at 10:51 a.m., R4 sitting in her wheelchair participating in an activity. R4 had a large bandage on her forehead. R2's face sheet included diagnoses of Parkinson's disease without dyskinesia, Alzheimer's disease, history of falling, and abnormalities of gait and mobility. R2's quarterly MDS dated [DATE], indicated R2 had moderate cognitive impairment. R2 required partial to moderate assistance with dressing, bathing, toilet hygiene, and transfers. MDS identified no fall since re-admission on 7/24/23. R2's Event report dated 11/5/23 at 1:50 p.m., indicated R2 was lowered to the floor while toileting by NA. R2 sustained a skin tear to each wrist. On the left wrist skin tear measured 5.5 centimeter (cm) by 3.0 cm and on right wrist skin tear measured 2.0 cm by 2.0 cm. Area cleaned and covered with non-stick gauze. New treatment initiated to cleanse wound with soap and apply clean dressing change as needed. Xeroform gauze to be applied over the entire lacerated area then covered with 4 by 4 gauze and secured in place with roller gauze. In review of R2's record between 11/5/23 and 12/28/23, it was not evident the wrist wounds were assessed weekly and continuously monitored. R2's record included the following; R2's weekly skin checks completed on 11/9/23, 11/17/23, 11/20/23 did not address R2's injuries to her wrists. R2's event report dated 11/22/23 at 6:31 p.m., indicated left arm wound sustained from fall is not healed and sanguineous drainage noted in the old dressing. No further description of the wound was included. R2's skin audit dated 11/24/23, included no new skin changes and did not address injuries to R2's wrist. R2's skin audit dated 12/4/23, identified R2 had sore on left wrist, redness on her right shoulder and small bruises on both arms. The note did not include any further descriptions of impaired skin integrity. R2's progress note dated 12/8/23, indicated weekly skin assessment completed with no new injuries. The note did not identify the injuries to R2's wrist. R2's skin audit dated 12/14/23, indicated R4 refused to take shower skin check not completed. R2's skin audit dated 12/15/23 and 12/25/23, did not address R2's wrist injuries. During on observation on 12/27/23, at 3:51 p.m. R2's left wrist had a thin reddish/pink line with no open areas and had minimal bruising to both arms in various stages of healing. During an interview on 12/28/23, at 10:02 a.m., case manager (CM)-A reviewed R2's record and stated R2's wrist skin tears should have been documented on in the providers notes and in the progress notes. If it wasn't in the progress notes, it wasn't done. R3's face sheet included diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus with diabetic chronic kidney disease, history of falling, unsteadiness on feet, and difficulty in walking. R3's quarterly MDS dated [DATE], indicated R3 had severe cognitive impairment. R3 was dependent on staff for bathing and bathing transfers, R3 did not walk, R3 required substantial to maximal assistance for transfers and dressing. R3's Safety Events Falls dated 10/27/23, identified R3 had an unwitnessed fall at 4:31 p.m. and was unable to explain why she fell . The report did not identify if R3 sustained injuries as a result of the fall. In review of R3's record it was not evident neurological assessments were completed and not evident skin assessment was completed immediately following the fall. R3's skin audit dated 11/1/23, identified R3 had bruises to his legs and arms, however, did not include any further description and did not identify causation of the bruises. R3's Safety Events Falls dated 11/25/23, identified R3 had an unwitnessed fall at 9:30 a.m. She was found sitting on the floor between bed and wheelchair. In review of R3's record it was not evident neurological assessments were completed after the unwitnessed fall and not evident a skin assessment was completed immediately following the fall. R3's Safety Events Falls dated 12/19/23 at 6:52 a.m., identified R3 had an unwitnessed fall, she was found outside her room in a seated position. R3 reported she had lost her balance, fell , and did not hit her head. A skin check was done, and no injury was noted. Neuro checks started. R3's follow-up vital signs and neuro checks document included neuro checks on 12/19/23. The first recorded neurological check was recorded at 10:00 a.m. and had multiple missing entries when neurological assessments were supposed to be completed. The last entry was recorded on 12/22/23 at 1:00 p.m. R3's skin assessments were reviewed between 11/8/23 and 12/27/23. Skin assessment dated [DATE], indicated R3 had old skin bruises and a scab on left leg. However, the skin evaluations dated 11/8/23, 11/15/23, 11/21/23, 11/22/23, 11/29/23, and 12/13/23 did not identify R3 had any bruising and/or a scab on left leg. Additionally, the record did not identify when or how R3 sustained bruises that were described as old on the 12/27/23 assessment. R1's face sheet included diagnoses of fracture of neck of left femur, chronic systolic heart failure, vascular dementia, muscle weakness, difficulty walking, long term use of anticoagulants, and cognitive communication deficit. R1's progress note dated 12/15/23 at 6:33 p.m., indicated R1 had an unwitnessed fall and was found on the floor laying on his right side around 12:30 p.m. R1 stated she fell forward out of his recliner. R1 was sent to ER related to being on anticoagulant and returned at 6:45 p.m. R1's progress note dated 12/16/23, at 5:23 a.m., indicated R1 had an unwitnessed fall at 5:00 a.m. R1 was found sitting on the floor beside his bed. R1 denied hitting his head and had pain in right leg. R1's progress note dated 12/16/23, 6:38 a.m., indicated R1 wanted to go to the hospital and was transferred to the hospital at 6:34 a.m. In review of R1's record it was not evident neurological assessments were initiated and completed after R1's falls on 12/15/23 and 12/16/23. During an interview on 12/27/23 at 11:02 a.m., registered nurse (RN)-B stated after resident falls the floor nurse assigned to the resident gathered all the information. The nurse then provided the information to the clinical managers. RN-B indicated nurses were supposed to complete and document skin inspections after each fall. Floor nurses completed weekly skin audits and would only report new or worsening skin problems to the clinical managers. RN-B stated she has never measured or documented wound assessments and when she did wound dressing changes she would not document wound descriptions or measurements. During an interview on 12/28/23, at 11:04 a.m. RN-C stated if a fall was unwitnessed, the floor nurse should initiate neuro checks and assess for injury. Facility fall protocol directed staff take vital signs every shift for 72- hours. If a wound was found RN-C would inform the wound nurse or providers. Measuring of all wounds should be done during wound rounds by the team or wound nurse. RN-C had only completed comprehensive wound assessments and measurements on new wounds and did not complete weekly assessments and measurements for existing wounds. During an interview on 12/27/23 at 9:48 a.m., clinical manager (CM)-B stated neuro checks were supposed to be completed after any unwitnessed fall or a fall with head injury. CM-B indicated there was a fall check list that needed to be initiated after a fall and turned into the clinical managers once completed. During an interview on 12/28/23, at 10:02 a.m., CM-A explained when a wound was found, the floor nurse would document the wound on the wound sheet and in a progress note. Existing skin tears were supposed to be monitored and documented on weekly on the wound assessments and in a progress note. The documentation should also include if the wound was new, worsened, or if resolved. If the wound was diabetic, venous, arterial, pressure, or surgical the wound nurse and provider would follow them until resolution, but they did not follow other types of impaired skin integrity. During an interview on 12/28/23 at 11:40 a.m., director of nursing (DON) stated, expectations for new wounds following a fall would be to monitor the wound after and chart on it every shift for 3 days. The case managers were responsible for ensuring this was completed by the floor nurses. Any wound even if a bruise should be assessed and measured at a minimum weekly, then monitored until it was gone. DON indicated the facility policy was for neuro checks to be completed for every unwitnessed fall or if there was a bump to the head. DON stated, I can see there are holes in the facilities documentation and will be discussing it with the IDT [interdisciplinary team]. During an interview on 12/28/23 at 11:53 a.m., [NAME] director of clinical services (RDCS) stated with all falls the facility should have falls check list to follow. The policy directs if a resident sustains a new wound from a fall, the wound should be monitored weekly at a minimum. On all residents the skin was observed daily by nursing assistants (NAs); if anything new was noted the NAs should notify the nurse. Floor nurses monitored skin weekly and documented either on the paper evaluation or in a progress note. A proper wound assessment would include looking at and documenting on redness/pinkness, swelling, edema, pain, drainage, measurements, smell, and surrounding tissue. The documentation should also identify if the wound was getting better or worse. RDCS explained the skin assessments/evaluations and monitoring were not getting done right now. Facility document Fall Event Checklist dated 7/18/18, included proactive interventions placed to decrease risk of repeat falls. Monitor vital signs every shift for 72 hours this is to be put in the electronic medication administration record/electronic treatment administration record (eMAR/eTAR). Neurological checks initiated for all un-witnessed falls and /or falls in which a resident hits their head. Charge of building or DON to make sure follow-up assessment done within 24-48 hours.

Based on interview and document review, the facility failed to provide the resident and/or resident representative (RR) with a written notice of facility initiated transfer for 1 of 1 resident (R1) reviewed for hospitalization . Findings include: R1's face sheet included diagnoses of fracture of neck of left femur, chronic systolic heart failure, vascular dementia, muscle weakness, difficulty walking, long term use of anticoagulants, cognitive communication deficit. R1's progress note dated 12/15/23 at 6:33 p.m. indicated R1 had a fall and was on anticoagulation medication. He was transferred to the hospital for further evaluation. R1 returned to the facility at 6:45 p.m. In review of R1's record, it was not evident R1 and/or R1's resident representative was provided with a written transfer notice. During an interview on 12/28/2023, 2:40 p.m. regional director of clinical services (RDCS) reviewed R1's record and stated the facility completed the bed hold notice but did not complete a transfer notice. RDCS stated she was not aware of the regulation or requirement of transfer forms in the nursing home. During an interview on 12/28/23 at 2:45 p.m., the director of nursing (DON) stated the nurses were expected to notify the resident or representative verbally about the reason for emergent transfers and was unsure of a process for written notice. The facility policy titled Emergency Transfer and discharge date d 02/19, identified should it be necessary to make an emergency transfer or discharge to a hospital or other related institution, the facility will prepare a transfer form to send with the resident.

Based on observation and interview the facility failed to perform appropriate hand hygiene during a clean dressing change to prevent or mitigate risk of wound infection for 1 of 2 residents (R3) who had physician ordered wound treatments. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3's cognition was intact, and required extensive assist of two staff for bed mobility, transfers, hygiene, and dressing. In addition, R3's diagnoses included congestive heart failure, emphysema, and failure to thrive. During an observation and interview on 6/21/23, at 11:05 a.m. registered nurse (RN)-A was in R3's room to do multiple dressing changes to R3's pressure ulcers. RN-A put gloves on without performing hand hygiene, took the dressing off R3's left heel, disposed the dressing in the garbage, then took gloves off. RN-A put a new pair of gloves on without performing hand hygiene, touched the pressure ulcer on the bottom of R3's left heel, then put a new dressing on the wound. RN-A then removed gloves, put a new pair of gloves without performing hand hygiene, removed dressing from the right heel, took gloves off, and applied new gloves without hand hygiene. RN-A then put a new dressing on R3's right heel. With the same gloves on RN-A removed R3's grippy socks that were lying on the bed, put the socks into the dirty linen bag lying on the floor, and then put R3's ordered pressure reduction boots on bilateral feet and floated R3's heels with a pillow. Without washing her hands, RN-A then put new gloves on, removed R3's sacral dressing, took off gloves, put on new gloves, did not perform hand hygiene prior to putting the new dressing on. RN-A then removed her gloves, no hand hygiene, put new gloves on and removed R3's right buttock dressing, RN-A then took bandage scissors that were lying on the table and cut a slit into the bottom of R3's sacral dressing and laid the scissors back on R3's tray table. RN-A did not perform hand hygiene or remove gloves and proceeded to remove R3's dressing on his right upper back. Old dressing had 3 area of scant amount of serous drainage. RN-A then removed gloves and did not perform hand hygiene and applied new gloves, then cleaned R3's three wounds on his right upper back. RN-A applied a dressing to R3's right upper back and removed her gloves and used hand sanitizer. RN-A stated, I usually wash my hands in between glove use and verified she had not. During an interview on 6/21/23, at 12:22 p.m. interim director of nursing (IDON) indicated she would expect staff to use appropriate hand hygiene to include hand hygiene in between glove use during a dressing change especially when a resident had multiple wounds. Facility policy, Hand Hygiene, dated June 2017, indicated a purpose that Infection Prevention begins with the basic hand hygiene. By following proper hand hygiene practices, associates will reduce the spread of potentially deadly germs, as well as reduce the risk of healthcare provider colonization caused by germs acquired from the residents. Hand hygiene simply means cleaning hands using either handwashing (washing hands with soap and water), or antiseptic hand rub (i.e., alcohol-based hand sanitizer, including foam or gel). Times to Perform Hand Hygiene are, but not limited to: Before and after changing a dressing, after contact with a resident's mucous membranes and body fluids or excretions, after handling soiled or used linens, dressing, bedpans, catheters, and urinals, after handling soiled equipment or utensils, and after removing gloves or aprons. Hand Hygiene using Alcohol-Based Hand Sanitizer: Use Alcohol-Based Hand Sanitizer: o Anytime hands are not visibly dirty o When not dealing with Clostridium difficile.

Based on observation, interview and document review, the facility failed to ensure personal privacy was maintained for 1 of 1 resident (R2) while using the bathroom and during personal cares. Findings include: R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R2 had intact cognition and required moderate assistance with most activities of daily living (ADLs). Diagnoses included depression, muscle weakness, hypertension (high blood pressure), thyroid disorder, and lymphedema (localized swelling of the body). R2's care plan dated 1/27/22, indicated staff would always leave her room door open and bathroom door ajar however lacked interventions for staff to use to ensure personal privacy. During an observation on 5/22/23, at 6:39 p.m., R2 was in her bathroom, with the door opened, disrobed while seated on the toilet. R2 was visible to other residents and visitors from the hallway. At 6:45 p.m., nursing assistant (NA)-E asked R2 if she needed more time or if R2 was done using the bathroom. R2 stated she needed more time and would place on her call light when she was ready. NA-E left R2's bathroom and the doors remained open. During an interview on 5/22/23, at 6:50 p.m., NA-E confirmed R2 was in her bathroom undressed, seated on the toilet and was visible to other residents, family and visitors from the hallway. NA-E stated R2 requested the doors be left open. NA-E confirmed R2 was visible to all staff, residents, and family from the hallway when she was in the bathroom with the doors left open. During an interview on 5/23/23, at 2:55 p.m., trained medication aide (TMA)-D stated staff did not close R2's doors because she would become angry with staff when they closed the doors. TMA-D confirmed that R2's doors remained open during personal cares and toileting. TMA-D stated she attempted to stand in front of R2 to block others from seeing her however sometimes R2 requested to be left alone in the bathroom for a few minutes. During those times, she was exposed and visible to others who walked past her room. During an interview on 5/24/23, at 8:30 a.m., registered nurse (RN)-A stated all residents should be provided privacy during cares. RN-A indicated R2 did not want her doors closed so they were left open when R2 used the bathroom and during personal cares. RN-A was not aware of any interventions the facility could implement that would allow R2's doors to remain open while still being provided privacy. During an interview on 5/24/23, at 9:10 a.m., NA-F stated R2 refused to have her doors closed during personal cares and while she used the bathroom. NA-F stated anyone in the hallway could see R2 seated on the toilet or see staff assisting her with personal cares. NA-F stated he attempted to position himself in front of R2 to prevent others from seeing her exposed. NA-F indicated R2 usually requested a few minutes alone when using the bathroom and stated again anyone who walked past her room could see her exposed. NA-F stated he would like to be informed of other ways he could provide privacy while respecting R2's wishes to have her doors remain open. During an interview on 5/24/23, at 10:07 a.m., R2 stated she wanted her bathroom and room doors left open because she is claustrophobic. R2 stated she was aware when she was receiving cares in her bathroom she could be exposed to anyone who walked past her room. R2 indicated she would prefer to have privacy while in her bathroom however closing the doors caused her anxiety. R2 stated the facility had not attempted any alternative options that would allow her personal privacy in her bathroom while continuing to leave the doors open. During an interview on 5/24/23, at 10:56 a.m., licensed social worker (LSW)-A stated R2 refused to have her doors closed and would scream at staff if they attempted to shut them. LSW-A confirmed when R2 was in her bathroom she was visible to other residents and visitors from the hallway. During an interview on 5/25/23, at 9:41 a.m., NA-G stated she assisted R2 with her baths twice a week. NA-G indicated she would pull the curtain to provide privacy if R2 refused to have the door closed however stated R2 allowed her to close the door with each bath. During an interview on 5/25/23, at 10:30 a.m., the director of nursing (DON) stated she expected staff would provide privacy when providing personal cares to R2. DON stated privacy could be achieved in various ways by closing doors, pulling the privacy curtain, closing the window blinds, keeping resident's private areas covered and only expose what was necessary at the time. DON stated when a resident's door could not be closed, she would still expect personal privacy to be a priority and staff would offer alternative choices to provide privacy. DON stated she was unaware R2 had not been provided privacy when using the bathroom and during personal cares and indicated it was unacceptable. A facility policy titled Resident rights and notification of resident rights, dated 11/28/17, indicated the facility acted to protect and ensure the rights of the residents.

Based on observation, interview and document review, the facility failed to identify triggers to avoid potential re-traumatization and failed to develop the care plan to include individualized trauma-informed approaches for 1 of 1 resident (R17) who had post-traumatic stress disorder (PTSD). Findings include: R17's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R17 had intact cognition and required assistance with most activities of daily living (ADLs). Diagnoses included: PTSD, anxiety, paraplegia, and major depressive disorder. R17's care plan dated 4/4/23, lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization related to PTSD. R17's hospital discharge summary dated 8/27/20, identified diagnosis of PTSD resulting from being a victim of abuse. During an interview on 5/22/23, at 3:37 p.m., R17 indicated she had a diagnosis of PTSD however stated she did not wish to discuss it as it was personal to her and hard to discuss with someone she was not familiar with. During an interview on 5/23/23, at 4:42 p.m., nursing assistant (NA)-B stated he was not aware R17 had PTSD. NA-B indicated he was not sure if he had received training regarding trauma informed care. During an interview on 5/23/23, at 4:45 p.m., registered nurse (RN)-B stated she would discover a resident had PTSD upon admission after she reviewed the hospital discharge summary. RN-B stated she was not aware of specific requirements of care planning for a resident with PTSD. RN-B indicated R17 had a diagnosis of PTSD and verified she was not aware of any specific triggers or interventions in place for R17. RN-B confirmed R17's care plan lacked evidence of trauma triggers and interventions for her diagnosis of PTSD. During an interview on 5/23/23, at 4:57 p.m., licensed social worker (LSW)-A stated she completed a trauma informed care observation for every resident upon admission. LSW-A indicated when a resident had a diagnosis of PTSD, the nursing staff would add the trauma triggers and interventions to the resident's care plan. LSW-A stated the care plan was shared with all staff through their electronic health records (EHR) behavior monitoring documentation. LSW-A confirmed R17 had a diagnosis of PTSD. During an interview on 5/23/23, at 5:05 p.m., the director of nursing (DON) and regional director (RD), DON stated each resident was assessed for trauma upon admission. If a resident had a diagnosis of PTSD, the staff were expected to find out what the trauma was associated with, identify the triggers, care plan how to avoid the triggers, and identify the specific interventions to be used if the resident's triggers were activated. Both DON and RD stated R17 had a diagnosis of PTSD and confirmed R17's care plan lacked specific triggers and interventions related to PTSD and past trauma. A facility policy titled Trauma-Informed Care, dated 8/2022, identified residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. If the trauma survivor was reluctant to share history, the facility was still responsible to try to identify triggers which may cause re-traumatization and develop care plan interventions which minimize or eliminate the effect of the trigger.

Based on observation, interview and document review, the facility failed to comprehensively assess falls and identify causative factors to determine the reason for falls and identify potential effective interventions to decrease the risk for future falls for 2 of 3 residents (R1, R2) reviewed for accidents. R1 who had 11 falls, nine falls from a Broda chair with six falls unwitnessed. On 7/10/22 R1 was left alone in her room after placed in her Broda chair, fell and sustained a fracture. On 5/18/22, R2 fell during the night after she got up unattended to go to the bathroom resulting in a fracture. R2 has fallen an additional 14 times; each of the 14 falls occurred in R2 ' s room when alone and unsupervised. These deficient practices resulted in immediate jeopardy. An immediate jeopardy began on 7/11/22 when it was discovered, R1 fell from the Broda chair and sustained a left acetabulum and pubic fracture and was admitted to the hospital. The facility administrator and director of nursing (DON) were notified of the IJ on 7/29/22 at 10:33 a.m. The IJ was removed effective 7/30/22 when the facility revised residents care plan, completed therapy evaluation and provided staff training, but noncompliance remained at the lower scope and severity level 2- D - isolated, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had more than two falls and one resulted in a major injury, R1 is severely cognitively impaired and needs extensive assist of 2 persons for bed mobility and transfers and did not walk during the assessment period. The MDS indicated use of a wheelchair for mobility and transfers. R1's MDS further indicated R1 was incontinent of bowel and bladder and currently on hospice. R1's care plan interventions dated 4/11/21, include: keep call light in reach, provide assist of 2 with lift for toileting. R1's care plan dated 3/10/21 indicates R1 cannot verbally ask for assistance and requires 2 assist to use the bathroom. In addition, R1's care plan included, R1 to remain in common area until ready for bed. R1 also has a history of falls related to muscle weakness, dementia with Lewy bodies and behaviors. R1's care plan goal was not to sustain a fall with injury through the review date. Furthermore, R1's care plan also included frequently check in room at least 1-2 hours or as needed, instruct staff to follow the same routine each day and to analyze resident's falls and follow fall policy. During an observation on 7/28/22, at 9:40 a.m. R1 was seated in the Broda chair by the nurses station, no table and no activities provided. R1 staring blankly at the wall or window. R1's record review indicated previous falls: R1 had 2 falls on 1/11/22. First fall- R1 was found after she had fallen from her recliner and the second fall that day R1 fell from her Broda in the common area. R1's fall documentation for incidents occurring on 3/25/22, 3/28/22 and 3/31/22, indicated R1 fell from the Broda chair because she was unfamiliar with the Broda chair. R1 since received her personal Broda chair and no further falls from the Broda chair had occurred. The facility documentation lacked an identification of causative factor, an analysis of why R1 continued to get up from the Broda and had not placed effective interventions to prevent future falls. R1's fall event report dated 5/16/22 includes, Housekeeping staff notified writer resident was sitting on the floor at 3:20 p.m. Writer noted resident to be sitting on the floor at the nurse station by a table, she was sitting with her legs tucked under her, trying to stand herself up. Resident was wearing shoes at the time, but noted a pair of shoes to be under the table that it seemed resident was reaching for and either stood herself up or bent forward and slid out. Immediate intervention: staff will remove any items (shoes, etc) from the floor around resident to prevent her from reaching for them. She was toileted about 35 minutes prior to this. R1 was screened by therapy three days later (5/19/22) with no services indicated. R1's fall event report dated 5/19/22 includes, Resident attempted to stand up on her own and ended up falling on the floor on her bottom. Fall was witnessed. Resident was in common area by nursing station after lunch. Had been given activities and seen 30 seconds prior by multiple staff. R1 was screened by therapy 14 days later (6/2/22) with no services indicated. R1's fall event report dated 6/5/22 includes, Resident had an unwitnessed fall in room late this afternoon. Resident had just been toileted and had her clothes changed by aides. Resident was left in room watching TV in her Broda chair. Aides stated she left room to assist with something and came back and resident was on the floor. Resident had one sock on and one sock off. Resident took out a drawer from a cabinet and sat in it. Resident was lifted with Hoyer back into her Broda chair with the assistance of two aides and brought out to common area. Events 5/16/22, 5/19/22 and 6/5/22, were reviewed and closed on 7/7/22 by facility interdisciplinary team (IDT). The review note includes, On 5/16 resident had an unwitnessed fall by the nurses station. She was attempting to pick up shoes off the floor. No injuries noted. On 5/19, resident had a witnessed fall by the nurses station. No injuries noted. On 6/5, resident had an unwitnessed fall in her room while sitting in her Broda chair. Resident is at risk for falls d/t [due to] prescribed antidepressant medication with dx [diagnosis] of depression, [MEDICATION(S)] with a dx of [CONDITION(S)], [CONDITION(S)] [hypertension] with prescribed antihypertensive medication and most recent BIMS [brief interview for mental status] of 0 indicating severe cognitive impairment. RCA[root cause analysis]: poor safety awareness. Interventions include: Ensure floor is free from clutter in residents surroundings, Offer the toilet resident upon arising, before and/or after meals at HS[bedtime] and prn[as needed] and do [sic] leave resident unattended in Broda chair in her room. R1's care plan lacked the interventions discussed in the IDT meeting. During an interview on 7/27/22, at 1:56 p.m. trained medication assistant (TMA)-A stated he felt everyone knew R1 should be brought to the common area and should not be left alone in R1's room. TMA-A stated he looks in the care guide for fall interventions for all residents in the facility. During an interview on 7/27/22, at 2:06 p.m. TMA-B stated she worked on 7/11/22, the day after R1's fall with major injury. TMA-B stated staff usually toilet R1 after getting her up and then R1 is brought to common room. TMA-B stated R1 should not have been alone in her room on 7/10/22. During an interview on 7/27/22, at 2:20 p.m. nursing assistant (NA)-B stated he observed R1 on the floor in her room on 7/10/22 and called to the nurse. NA-B stated he had seen her previously in her Broda chair after breakfast . NA-B stated, Everybody knows not to leave her in her room because she will get up. I was surprised to see her alone in her room. During an interview on 7/27/22, at 2:26 p.m. registered nurse (RN)-B who is familiar with R1 and takes care of her one or two times a week. RN-B was aware of R1's fall with injury. RN-B added the reason for the fall was because R1 was left alone in her room. RN-B stated she believed a night shift staff had gotten her up and left R1 in her room alone. RN-B stated she would not leave R1 alone in her room if she is awake unless requested to do so by hospice or a visitor. During an interview on 7/27/22, at 2:38 p.m. director of nursing (DON) stated the expectation is all staff are to know the interventions and ways of caring for the residents. Resident interventions for falls are in the care plan. During an interview on 7/27/22, at 3:20 p.m. licensed practical nurse (LPN)-A stated she was R1's nurse at the time of the fall on 7/10/22. LPN-A stated she was not aware of R1 being alone in her room in the chair prior to the fall. LPN-A stated if R1 is in her chair she keeps her up near the nurses station. LPN-A stated she was not aware of the intervention indicating R1 is not to be left alone in her room. LPN-A said she was aware there was a sign above R1's bed that read she should not be left in her room alone. LPN-A was not aware when the sign was hung in R1's room. LPN-A said she was not aware of any interventions added to the care plan after R1's fall on 7/10/22. During an interview on 7/28/22, at 1:55 p.m. certified nurse practitioner (CNP)-A stated facility staff contacts her after a fall. CNP-A stated R1 is a challenge and feels the facility is attempting to prevent further falls. CNP-A even has prevented R1 from falling when walking by the nurses station. CNP-A stated she did feel the Broda chair is appropriate and the best seating option for R1. During an interview on 7/28/22, at 2:41 p.m. occupational therapy (OT) verified R1 was last on caseload April 15 th to May 6th, 2022 related to impairments in transfers. OT had last seen her January 13th of 2021. OT indicated R1 had not evaluated a wheelchair or Broda chair. During an interview on 7/28/22, at 4:08 p.m. DON stated the facility does not have a current audit process in place to monitor the effectiveness of interventions placed in the care plan. DON indicated the facility uses general observations exampled by; if a resident moves to a new room and it is observed the resident had non skid strips on the floor and or grab bars on the bed, they are moved or installed in the new room. Interventions in the computer are monitored by audits such as the tasks the nurses complete. DON stated if the interventions are not on the care plan he said, it doesn't matter how good it is. Once the IDT are completed with the review and interventions they should be placed in the care plan right away. DON verified if the interventions are not in the care plan staff are not aware of any new interventions developed. The DON's expectation after the IDT meeting would have been for the nurse manager to place the discussed interventions in the care plan related to R1's falls. During an interview on 7/29/22, at 8:24 p.m. regional director clinical services (RDCS) stated she had met with quality assurance performance improvement (QAPI) and talked about fall management program and was currently working with a consultant from Pathways. She stated they are working on falls and working on investigations. RDCS indicated quality assurance improvement program meeting had lots of falls discussed and improving the IDT process including investigations. RDCS added her expectations would be to have falls brought to quality assurance and audits should continue to be addressed until compliance is met. Adding, falls are one of the biggest risks. When asked about the closing of the event reports after an incident she said, The closing of the falls event needs to look at closer as a process, there are currently no standard in this building. The goal is with in one week I would say is reasonably. R2's significant change MDS assessment dated [DATE] indicated R2 had cognitive impairment, [CONDITION(S)] with dementia, and suffered from anxiety. The MDS indicated R2 required the regular use of an anti-psychotic and anti-depressant medication. The MDS also indicated R2 required the extensive assistance of 1-2 persons with bed mobility, transfers and ambulation, as well as with dressing, grooming and toileting. MDS also indicated R2 suffered from falls and was recovering from a fracture related to a fall. R2's progress notes indicated R2 had been admitted to the facility in April of 2022 for rehabilitation services with the goal of returning to assisted living after a fall that required hospitalization . R2's care plan included a problem list initiated 5/5/22 and updated 7/11/22 indicating, Resident is at high risk for falling due to multiple pelvic fx, h/o [history of] falling, [CONDITION(S)], weakness, poor vision, frequency of micturition [urination], altered mental status, impaired mobility. Fall risk evaluation score indicates high risk for falls. Interventions included, fall prevention/reduction precautions per facility protocol, and toileting per urinary/bowel section of this care plan. The intervention in that section of the care plan indicated, offer toileting in AM upon arising, before and after meals, at HS [bedtime] and with nightly rounds. R2's medical record indicated R2 suffered 14 incidents where she fell or ended up on the floor. On 5/18/22, R2 was found on the floor in her bathroom at around 2:30 a.m. According to a progress note, R2 stated she wanted to go to the emergency department (ED). Subsequently, the facility received a call from the hospital to let them know R2 would be returning to the facility later in the day, and R2 had suffered a left femur fracture subsequent to the fall, but would not require surgical intervention. R2 had reported hitting her head when she fell and suffered a hematoma (collection of blood outside of the blood vessels) injury. R2's medical record events (incident reports) and progress notes lacked evidence showing analysis was done to identify the root cause of R2's falls. R2's care plan fall interventions lacked fall prevention interventions. In addition, despite the 5/18/22 fall having occurred in the bathroom, the facility failed to add new intervention timely. The next update to R2's fall care plan was placed on 5/23/22 and indicated the room had been rearranged to R2's preference. In relations to subsequent falls, interventions were added including, 5/27/22, bed in low position with fall mat at bedside, 5/31/22, have resident in commons area when awake as she will allow, 6/27/22, bring resident to the nurses' station after meals until staff can toilet resident-do not bring her to her room after meals unless she can be toileted right away, 6/27/22, assist resident with toileting every 2-3 hours and as needed per her request and on 7/7/22, staff will complete 30 minute safety checks on resident any time she is in her room without family present. Continue to encourage her to sit at station between meals as she is willing. During an observation and interview 7/27/22, at 12:55 p.m. R2 was observed in her room seated in a reclining Broda chair. R2 had a family member (FM)-A visiting. FM-A stated he was aware R2 fell frequently. FM-A stated he felt R2 was likely to continue to fall due to her [CONDITION(S)] and the length of facility halls and the time it would take any person to walk to R2's room. During an interview on 7/27/22, at 2:39 p.m. R2 was not oriented to the time of day. R2 stated she was aware she was prone to fall, but was unable to state anything about the falls, when or why she had fallen. During an interview on 7/27/22, at 2:44 p.m. a NA-B stated staff knew how to take care of any resident by looking at their care plan. NA-B stated fall prevention interventions in general included making sure residents are always left in a safe place, and were positioned appropriately. During an interview on 7/27/22, at 2:46 p.m. NA-C stated staff would know how to care for residents by checking the care plan or asking a nurse. NA-C stated she was familiar with R2 and it was important to check on her every 30-60 minutes if she was left in her room alone. NA-C stated R2 seldom would take a nap due to her agitation. NA-C stated R2 would sometimes ask to lay down for a while, but said R2 would not usually stay laying down for long. During an interview on 7/27/22, at 2:52 p.m. a RN-B stated R2 was confused and would forget to call for help, and would often get up on her own. RN-B stated staff were to encourage R2 to be in the commons area rather than be alone in her room, but stated her family likes her to be in her room. R2 stated she felt R2 would be more confused if she had been napping and would often believe she needed to go to the toilet each time she would awake. In response to this, RN-B stated staff would try to keep the door to the room open so they could see R2 when they walked by. RN-B stated a belief that the best thing for R2 was frequent supervision, but said, family requests her to be in the room so we can't do much about that. During an interview on 7/27/22, at 3:27 p.m. the DON stated new interventions were always added to resident care plans after a fall. DON also stated that was how staff knew how to care for residents was by reading the care plan, but no other mechanism was currently in place to notify staff of changes in the care plan. DON stated families that may be resistant to having residents brought to an area where they can be more easily supervised should receive safety education from the nurses. On 7/28/22, at 9:24 a.m. R2 was not in any facility common area and could not be seen in her room. RN-A was notified and went to seek out R2's location. After a few minutes, RN-A was observed to find R2 seated on the toilet in her bathroom with a piece of lift equipment parked in front of her with the brakes on. R2 stated she was finished in the bathroom, but the call-light was not observed to have been turned on. RN-A turned on the call-light and then used a walkie-talkie to call NA-A to assist R2 from the toilet. During an interview on 7/28/22, at 9:33 a.m. NA-A stated R2 was able to transfer with a stand-aid and minimal assist. NA-A said R2 was able to pull herself up with the equipment, but staff locked the brakes and supervised. NA-A also stated R2 could be left on the toilet unsupervised, and she would pull the cord to the call-light when she was done. During an interview on 7/28/22, at 9:37 a.m. R2 stated she did not remember much about her falls except that, everyone tells me I fall. R2 was unable to provide any insight into the reasons for her falls, and stated she was not concerned about falling despite having suffered fractures. R2 was unable to identify anything that could be done to reduce her risk of falls. R2 did say she did not really care to be out in the commons area, but was not able to say why. R2 did not recall ever having gotten up unattended since moving to the facility. R2 was not able to demonstrate how to turn on her call-light without prompting during that interview. During an interview on 7/28/22, at 10:54 a.m. RN-A stated nursing staff and aides would know if a resident was a fall risk by looking at a resident's care plan, but did not know if there was any other means of identifying high risk fall individuals. RN-A stated she was aware R2 had a history of falls, but did not find information in the care plan regarding whether R2 could be left alone on the toilet. RN-A stated she did not think it was safe to leave R2 unattended on the toilet, but understood that NA-A had received a call to assist another NA with another resident. RN-A stated NA-A could not know how long he might be away when going to help someone else and said she had not yet gone to talk to NA-A about leaving R2 on the toilet, but was planning to do so. RN-A also stated she was unaware of any facility fall prevention protocols, but as a nurse knew it was important to do frequent checks on residents, make sure they were left with water within reach, make sure they were comfortable or did not have to go to the bathroom prior to leaving them. During an interview on 7/28/22, at 12:29 p.m. the facility administrator stated the IDT met every morning, Monday through Friday to discuss patient care, new admissions, upcoming discharges and any falls that might have occurred. Administrator stated a discussion of a fall was to include a root cause analysis to try to determine what had caused a fall so they could attempt to mitigate any similar risks in the future. Administrator stated some persons were habitual fallers, but IDT should review all interventions put in place after the fall to see if they were helpful, if those interventions should continue or be eliminated and replaced with new and different interventions. Administrator stated an expectation for the nurse manager to take notes at the meetings and then document on the IDT discussion and plan. Administrator stated the facility used an event record in the electronic medical record for documentation of falls, and stated there was a section in the event where the IDT notes could be documented, but stated an expectation for IDT notes to at least be written in the resident progress notes for continuity of care. Administrator stated they did not have a system by which they formally closed an event after an IDT discussion and he was unsure of how quickly fall event records were to be reviewed, but stated an expectation of documentation to occur immediately after an IDT discussion. During an interview on 7/28/22, at 1:33 p.m. DON stated IDT met each Wednesday and that was when falls were reviewed. DON stated they could discuss falls on any day, but Wednesday IDT was when they went through the falls in depth and did a thorough analysis of the event. DON stated the IDT meeting was to be documented in a progress note following the meeting. DON stated this documentation was an expectation of the nurse managers job, and had been communicated to the nurse managers upon hire and during IDT meetings. DON stated on that week both nurse managers were gone and he was responsible to cover their work. DON stated the facility had not been fully utilizing the medical record event form and did not currently have a procedure in place for that. A nurse, the RDCS entered the conversation at that time and stated they were making plans for this, and had identified that the process of identifying the root cause of incidents was in need of improvement. During an interview on 7/28/22, at 1:54 p.m. a CNP-A stated she was notified of falls, but did not attend IDT. CNP-A stated discussions regarding fall preventions were more informal. CNP-A stated R2 had advanced [CONDITION(S)] and was prone to falls. CNP-A stated R2 was quite alert and might be oriented enough to perform well on a mental status assessment, but R2 did not have recognition of her limitations or demonstrate knowledge of safety measures that might prevent falls or harm. CNP-A stated a FM had asked if R2 could have a mat on the floor of her room and just allow her to crawl around on it, but CNP-A was not sure if this could be done. CNP-A said statements that the family wanted R2 to be in her room rather than brought to the commons area should be taken in context as they had expressed concerns to CNP-A that R2 was sometimes up in her chair near the nurses' station at night for extended periods and they thought this might actually worsen her sleep cycle. CNP-A stated R2 should not be left unattended in the bathroom, and a mechanical lift should not be left in place in lieu of supervision as it could cause an entanglement risk should R2 attempt to get up on her own. During an interview on 7/28/22, at 3:48 p.m. FM-B was visiting R2. FM-B stated she had been involved in a care conference for R2, and was surprised to be told no side rails or alarms were allowed due to state law. FM-B also stated she was told by the facility they were unable to provide a lip mattress or a Broda chair for the same reason, but FM-B said R2's hospice provider had made arrangements for these items to be supplied. FM-B stated she was a nurse and had expressed to the facility her concerns with R2 being left in the common area because R2 would not have a call-light or anyway to obtain assistance if staff were not readily available. FM-B stated understanding of R2's need to be supervised as much as possible to prevent falls. An undated facility policy titled, Integrated Fall Management indicated a fall risk assessment form was to be completed within 48 hours of admission, quarterly and upon significant change of condition. The policy indicated those persons at risk for falls were to have an individualized resident centered care plan developed and the interventions were to be based on the findings of the fall risk assessment. Additional professionals were to be contacted as needed including medical providers, pharmacist and/or therapists. The policy indicated an assessment of the resident was to be made after the fall and appropriate notifications made to family and providers, as well as facility administration. The environment was to be evaluated for contributing factors. The policy indicated the IDT was to review the fall and care plan and initiate additional interventions as needed and document this; however, no further information or guidance was listed on how to accomplish this or as to the frequency or expected time line for completion. No further protocols for fall prevention were outlined in the policy. The IJ was removed on 7/30/22, when the facility removal plan was approved and showed resident assessment had been completed, care plans had been revised, therapy evaluation had been completed for R1 on 7/29/22, with recommendation and majority of staff training/education had been completed. On 8/3/22, at 11:00 a.m. during an on site visit it was verified by observation, interview, and record review that the facility took the following steps: · R1 order for therapy evaluation for Broda chair seating and positioning was ordered 7/29/22. Therapist completed evaluation on 7/29/22, with a recommendation for trial wedge cushion to assist in proper seating while allowing resident to continue self-propel ability when up in chair and decrease risk of un-purposeful transfer attempts to promote increased safety and lower risk of mechanical ground fall. Resident responsible party was informed of evaluation and recommendation. R1 care plan was updated on 7/29/22 with education provided to staff on unit. · R2 staff was re-educated on 7/29/22 and care plan revised to include resident was not to be left unattended on the toilet. ·

Based on interview and document review the facility failed to ensure the quality assessment and assurance committee (QAA) developed and/or maintained an appropriate systemic action plan for safety and fall prevention as previously cited in surveys exited 1/7/22 and 2/19/20. This failure to operationalize the facility Quality Program Plan had the potential to affect all 55 resident who currently reside at the facility Findings include: When interviewed on 7/28/22, 12:29 p.m. the facility administrator stated an awareness of discussions related to falls occurring in the QAPI meetings, but stated he had not been the person responsible for quality assurance or designing performance improvement projects (PIP's) in the facility. The administrator stated there had been an individual hired specifically to handle QAPI and PIP's, however, that person had recently taken on a new role in the company and they did not have anyone to replace her. Administrator stated he would have to take on that role himself, but the change was recent and he had not done so yet. In relation to falls in the facility, the administrator stated that was the director of nursing's (DON) responsibility. Administrator stated he thought they might have a new PIP related to falls, but was unsure. During an interview on 7/29/22, 7:28 a.m. the DON stated the facility had developed a falls PIP, but said it had not been fully implemented due to changes in staffing. DON stated a person hired to support the QAPI process had been pulled in multiple directions, and now had moved to a totally different position. Additionally, clinical support from the regional office had changed multiple times over the past two years. In relation to QAPI and the implementation of PIP's in the facility, DON said turn over in leadership resulted in the team having to keep going back to square one. DON expressed an understand that a PIP was to be put in place with the express purpose of creating a systemic improvement. DON stated the front line staff were often the main players in providing for safety and preventing falls, but because many of them were contract staff and busy providing resident cares, they did not attend QAPI meetings, and thus were not able to provide much input of what might work best for the residents. DON stated the QAPI group met monthly, but did not have any subcommittees working on PIP activities between meetings. DON said he had received training to perform his position, but felt he needed further information on the QAPI processes and how to develop and maintain a PIP. When interviewed on 7/29/22, 8:23 a.m. a registered nurse hired as the regional director of clinical services (RDCS) stated she had just started in her position in June of 2022 and was just getting to know the facility. RDCS stated she was planning to spend at least one day per week at the facility and planned to provide more education and support to the DON. RDCS stated she had attended a facility QAPI meeting a few weeks before, and the topic of falls was discussed. RDCS stated falls were of the biggest risk. RDCS said they had discussed doing rounds in the facility and doing spot checks on persons who are of falls risk, and stated an additional nurse manager was expected to help provide coverage. RDCS stated sustained compliance cannot occur unless the items were repeatedly brought back to QAPI for evaluation until the committee agrees the PIP was met and sustainable. A policy on QAPI was not located.

Based on observation, interview, and document review the facility failed to protect 1 of 1 residents (R2) from physical abuse and aggressive behaviors from R1 who demonstrated an escalation in aggressive abusive behaviors after admission to the facility. In addition, the facility failed to determine the possible causes of the behavior and put interventions in place to mitigate the risk of physical agression toward others. The immediate jeopardy began on 6/24/22, when R1 demonstrated verbal and physical behaviors towards staff in R2's room, R1 dug her nail into R2 and staff then left the room, leaving R1 alone with R2. R1 then barricaded the door so that staff could not enter. The administrator and director of nursing (DON) were notified of the IJ on 7/1/22, at 12:15 p.m. and was removed on 7/2/22 at 4:00 p.m. but non-compliance remained at scope and severity of D, isolated which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include R1's Face Sheet indicated R1 was admitted to the facility on [DATE], with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospital discharge summary dated 6/21/22, identified R1 was disorientated to place and time, poor judgement, impulsive, and had poor safety awareness. R1's Minimum Data Set (MDS) dated [DATE], identified R1 had fluctuating cognition, delusions, physical and verbal behavioral symptoms directed toward others, rejection of care, and wandering that occurred one to three days per week. The MDS indicated R1 was administered one antipsychotic medication and R1 was independent with locomotion in wheelchair. Although R1's hospital discharge summary and MDS identified R1 had behaviors between 6/21/22, and 6/24/22, R1's baseline care plan did not identify any behavioral concerns and/or behavioral interventions nor cognitive impairment/dementia concerns or interventions. R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (anti-[CONDITION(S)] medication) 25-100 milligrams (mg) every 2 hours (start date 6/21/22). -[MEDICATION(S)] (antipsychotic medication) 25 mg now for agitation and aggressive behavior and 12.5 mg twice per -day as needed for agitation that is not responsive to non-pharmacological interventions (start date 6/23/22). -May transfer patient to the ED (emergency department) for agitation, aggression, attempts to leave facility, or unsafe behavior that is unresponsive to [MEDICATION(S)] and non-pharmacological interventions (start date 6/23/22). R1's record identified after facility admission, that R1 had delusions and demonstrated increased verbal and physical behaviors directed towards staff and a visitor. Although the facility was monitoring R1's behaviors, R1's record lacked evidence of a comprehensive assessment for causal factors and implementation of non-pharmacological behavioral management interventions. When R1's behaviors escalated on 6/23/22, the facility obtained an antipsychotic medication for medical management, however the record lacked an evaluation of the effectiveness and on 6/24/22, R1 physically abused R2 and was subsequently admitted to the hospital. Upon R1's return although there were behavioral management medication changes and the care plan was revised, the care plan continued to lack identification of target behaviors and individualized non-pharmacological interventions (associated with target behaviors) and strategies to protect other residents, visitors, and staff. R1's physical therapy (PT) note dated 6/22/22, indicated R1 was disorientated, impulsive and thought she was at [NAME]. R1's progress notes dated 6/23/22, identified: -At 8:23 a.m., R1 yelled at nursing assistant (NA)-A when NA-A attempted to help her get dressed. NA-A alerted registered nurse (RN)-A of R1's refusal of care. R1 yelled about NA-A stating she was rifling through her drawers to look for daytime clothes. -At 1:06 p.m., R1 was exit seeking. When a NA attempted to redirect R1, R1 started yelling, hitting, and kicking at the NA. -At 4:06 p.m., R1 became aggressive with staff, a visitor, and was exit seeking. The note identified RN-A called nurse practitioner (NP) who gave an order to give [MEDICATION(S)] and send R1 to the ER if she continued to display aggressive behaviors. The note indicated pharmacy was not able to dispense the [MEDICATION(S)]. The note indicated emergency medical services (EMS) was called; however, EMS did not transport because R1 was medically stable. -At 6:27 p.m., R1 took dose of [MEDICATION(S)] but continued to yell at staff occasionally. R1's nurse practitioner visit note dated 6/24/22, included patient was seen yesterday morning (6/23/22), for medication reconciliation visit. She was noted to be slightly confused at that time but remained calm. Over the course of the day R1 became more disoriented and agitated, attempting to leave [NAME] Towers and being physically aggressive towards staff. Orders were given for a one-time dose of [MEDICATION(S)] with additional twice daily PRN dosing. Due to concern for her safety and inability to redirect, EMS was called, but upon arrival, declined to transport patient to ED. This morning nursing contacted me reporting that R1 was extremely agitated and paranoid. Therapy was attempting to work with R2 and she became verbally aggressive and physically assaultive towards the therapist. The therapist attempted to move R2 gently away from R1 who grabbed R2 forcefully digging fingernails into his arm. When therapist left to call for nursing staff to assist, R1 shut the door of her husband's room and refused to allow entry to anyone (both inside). R1's progress note dated 6/24/22, at 10:11 a.m. indicated R1 was aggressive with physical therapy team when they attempted to work with R2 in R2's room. R1 tried to hit and kick staff, grabbed R2's arm, then R1 slammed the door on staff and barricaded R1 and R2 in room. Staff unable to be sure of either resident safety. NP notified and 911 called for change in mental status and admitted to the hospital. RN-B who was acting as DON in their absence was notified of transfer. R1's baseline care plan identified revision while R1 was hospitalized to include the following, however did not address level of supervision: -On 6/25/22, R1's care plan was revised to indicate R1 had behavioral symptoms and was at risk to harm others related and at risk for elopement due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -When my behaviors occur, I would like to be left alone. -Report and investigate any allegations of abuse. -If became physically aggressive implement interventions to minimize risk to myself and others. -To keep me safe observe and document changes in mood or behaviors that may increase risk for abuse. On 6/27/22, R1 care plan was revised to include the following interventions: -Avoid over stimulation. -Maintain a calm, slow, understandable approach. -When resident becomes physically abusive, keep distance between resident and others. -When resident becomes physically abusive, move to quiet environment. Although interventions were later identified in the care plan, upon interview faciltiy staff were not able to locate them nor articulate R1's behavioral interventions or safety measures. R1's hospital discharge summary dated 6/30/22, identified R1's principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary indicated R1 did not have any behavioral issues during hospitalization but endorsed she was having a hard time coping at that facility. Medication changes included [MEDICATION(S)] 12.5 mg twice a day; separate doses by at least 6 hours. R1's progress note dated 6/30/22, at 11:00 a.m. R1 returned to the facility from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews with staff on 6/30/22, and 7/1/22, identified an ongoing unfamiliarity with R1's behaviors and appropriate interventions for behavioral management. In addition, staff were not able to articulate the need to immediately remove vulnerable adults from a dangerous situation to prevent abuse and serious harm or injury. During an observation on 6/30/22, at 2:20 p.m. R1 was lying in bed after physical therapy. R1 was disoriented, abrupt with answers, and told surveyor to get the hell out of my room. During an interview on 6/30/22, at 11:34 a.m. social worker (SW)-A stated on 6/24/22, director of physical therapy (DPT) notified her when PT and OT had attempted to enter R2's room for therapy, R1 barricaded her wheelchair behind the door and would not let them in so they left R1 alone with R2 and reported R1's behavior to DPT. SW-A stated DPT went back to R2's room and R1 was seated on foot R2's bed and R2 was seated in his wheelchair. DPT explained to R1 she was taking R2 to the physical therapy room. R2 repeatedly yelled at DPT to get out of room. R2 stated she was going to call the cops; however, was unable to do so as the phone was upside down and was unable to dial out. DPT attempted to wheel R2 out of room when R1 grabbed R2's left upper arm and dug her fingernails into skin. DPT backed up and directed R1 to release the arm of R2 and she released it immediately. DPT left R1 and R2 in room behind closed doors and notified RN-A. DPT and RN-A went to notify NP in the physician's work room. During an interview on 6/30/22, at 12:04 p.m. physical therapist (PT) stated R1 was left alone with R2 when they went to go get assistance from facility staff. During an interview on 6/30/22, at 12:04 p.m. occupational therapist (OT) stated on 6/23/22, R1 had entered the therapy room and wanted to be in there with R2 and demanded the key and for everyone else to get out. OT wheeled R1 out of therapy room and R1 became more agitated and used profanities. OT stated we schedule R1 and R2's therapy apart so they are not together at the same time because R1 tried to control R2. OT stated on 6/24/22, at 9:15 a.m. PT and OT stated they opened R2's room roughly an inch and R1 slammed the door yelling, get out, get out! OT stated NA-A was located at nurses' station, NA-A told them she was unable to do morning cares for R1 due to behavioral concerns. PT and OT stated they did not attempt again as they had been warned already by R1 and went to get assistance from DPT. During an interview on 6/30/22, at 12:36 p.m. NA-A indicated she was familiar with R1. NA-A indicated R1 was independent with locomotion around the unit in her wheelchair and R1 had history of being aggressive which included hitting and yelling at staff. NA-A was uncertain if behavioral or safety interventions were put into place after R1 demonstrated behaviors and was not aware of any of R1's triggers or current interventions for R1's aggressive behaviors. NA-A stated R2 had mentioned R1 can sometimes be not so nice. NA-A stated she was aware R1 had barricaded the door to R2's room on the morning of 6/24/22 as she was walking down the hallway at the time. NA-A stated facility had concerns R1 would hurt herself or possible injure R2. NA-A indicated R1 returned from the hospital today between 10:00 and 11:00 a.m. NA-A indicated R1 did not like her so she did not attempt to intervene. During an interview on 6/30/22, at 12:45 p.m. RN-A stated she was aware R1 had prior behavioral and aggressive incidents at facility which included both facility staff and a visitor. RN-A stated on 6/23/22, at approximately 12:50 p.m. R1 tried to exit the building and when NA tried to redirect her R1 started hitting and kicking at staff and so she called NP who gave her an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated then at approximately 3:00 p.m. R1 attempted to exit the building again, and she (RN-A) grabbed R1's wheelchair, explained to R1 it was not safe to go out, and as RN-A pushed R1's wheelchair away from the door, R1 planted her feet on the floor to stop, reached out and aggressively grabbed a visitor's thigh. RN-A stated uncertainty knowing if behavioral or safety interventions were put in place after R1 demonstrated aggressive behaviors. On 6/24/22, RN-A stated she was in her office directly across from R2's room when the incident between R1 and R2 took place; however, did not hear the escalation of events happening. RN-A stated DPT came to her office for assistance and tried to reapproach R2's room, was able to get the door open 6 inches, but R1 slammed the door back in RN-A's face. RN-A and DPT left room and walked down to physician's work room to get NP's assistance who was also unable to enter the room. RN-A stated 911 was then called. RN-A explained the police responded first and were able to gain access to the room because R1 had moved away from the closed door, and then the ambulance transported her the hospital for acute change of mental status. RN-A was not aware if R1's care plan had been revised and/or new behavioral/safety interventions after R1 returned from the hospital. During an interview on 6/30/22, at 1:00 p.m. RN-B stated she had been the interim director of nursing between 6/21/22-6/24/22 she had been aware R1 had verbal and physical abusive behaviors towards staff and a visitor however, indicated she had not completed a comprehensive assessment of the behaviors or revised the care plan. RN-B stated she had communicated the behavioral concerns to DON and the administrator, however, indicated no further direction was provided. During an interview on 6/30/22, at 1:25 p.m. DPT stated R1 was disoriented on 6/21/22, and 6/22/22. On 6/23/22, R1 had a significant increase in exit seeking behaviors and started to use verbal profanities against OT. On 6/24/22, at 9:15 a.m. PT and OT came to DPT for assistance due to behavioral and safety concerns occurring between R1 and R2 in R2's room. DPT stated R2 was seated in his wheelchair next to the bed and R1 was seated at the foot of the bed but stood up immediately when DPT entered room on 6/24/22. R1 yelled, get out, get out, this is a set up, and I am going to call the police on you. DPT attempted to wheel R2 away to therapy when R1 clutched her fingernails concerningly into R2's left upper arm. DPT immediately backed away and notified RN-A in her office directly across from R2's room. DPT and RN-A walked down hallway to notify NP in physician's work room; however, no facility staff stayed with R1 and R2 in room or outside of doorway to ensure safety of residents. DPT indicated an unawareness of further behavioral interventions for R1 and/or safety measures to protect other residents in the event R1 demonstrated aggressive behaviors. During an interview on 6/30/22, at 2:00 p.m. DON confirmed he was not at the facility between 6/21/22, and 6/24/22, and had appointed RN-B interim DON. DON stated he was not aware of R1's behaviors between 6/21/22, and 6/23/22, however was aware of the incident that occurred on 6/24/22, however stated he did not recognize R1's behavior as abuse. During an interview on 7/1/22, at 7:20 a.m. licensed practical nurse (LPN)-Z stated she had worked with R1 the day she first admitted to the facility (6/21/22). LPN-Z stated she did have behaviors that day when we tried to encourage her not to self-transfer, she yelled and screamed and wheeled herself out of her room. LPN-Z indicated R1 received [CONDITION(S)] medications every 2 hours at night; R1 was woken up every 2 hours last night for med administration and was yelling at the nurse. LPN-Z stated she was not sure what staff were supposed to do when she had behaviors and would have to look at the care plan. At 7:35 a.m. LPN-Z reviewed R1's care plan and stated, I can't find anything in her care plan for an intervention for her behaviors and will go ask the nurse manager. During an interview on 7/1/22, at 7:44 a.m. NA-A stated R1 became aggressive with cares and had heard she was still aggressive since she was readmitted to the facility. NA-A stated the only interventions that she was aware of was staff are supposed to remain calm, ensure safety, and re-approach. NA-A stated to her knowledge there was no increased supervision implemented to ensure other residents' safety. During a subsequent interview on 7/1/22, at 7:55 a.m. DON again stated he had no idea R1 had been demonstrating behaviors between 6/21/22 and 6/24/22. DON referenced and reviewed R1's record during this interview. DON indicated no behavioral documentation on 6/21/22 or 6/22/22, and there was no comprehensive assessment or revisions made to the care plan after the behaviors were identified by staff. DON then referenced 6/23/22, progress note at 1:06 p.m. and stated an unawareness of which aide R1 had been hitting out at or what interventions were used to de-escalate R1. DON stated in reference to the progress note at 4:06 p.m. he was not sure who the visitor was that R1 grabbed, was not sure why the pharmacy was not able to supply the [MEDICATION(S)], and was not sure if the facility medication emergency kit contained [MEDICATION(S)] and if it did was not sure why staff did not give it. DON indicated that the staff attempted to control R1's behaviors by calling 911; when she was not transferred the record did not identify behavioral interventions or a plan to keep residents safe. DON stated according to progress note at 6:27 p.m. R1 was finally administered the [MEDICATION(S)] but continued to yell at staff occasionally. DON then reviewed the progress note dated 6/24/22, identified the behaviors and indicated he did not think R1's behaviors constituted abuse. DON stated after 4 incidents of R1 being aggressive, we did not update the care plan with any new interventions, no increased monitoring however stated, he would not expect there to be interventions in place because R1 had only been there a couple of days. DON stated on 6/25/22, he had a meeting with RN-A to determine interventions on how to keep residents safe; the care plan was revised to include behavior problem with interventions to report abuse, investigate to minimize risk, an approach to keep me (R1) safe and document. DON stated on 6/27/22, additional interventions were added that included if R1 became aggressive/abusive distance her from others to keep safe space and move R1 to a quiet place. DON indicated the plan did not identify triggers and/or interventions to prevent escalation of abuse behaviors rather interventions after the abusive behaviors were in progress. DON stated R1 was readmitted to the facility on [DATE], and R1 had medication changes in the hospital including an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON also stated R1's medication regimen included [MEDICATION(S)] every two hours, even during the night. DON indicated the facility had not been monitoring sleep patterns to assess for sleep deprivation. DON stated an unawareness that staff had witnessed behaviors since R1's re-admission and indicated R1 had not been placed on increased monitoring and/or supervision. At 9:37 a.m. DON reported he had initiated 1:1 for R1 to keep her and others safe, when we do this we will be monitoring her for what triggers her. When interviewed on 7/1/22, at 2:34 p.m. NP stated RN-A and DPT notified her in the physician work room on 6/24/22, that R1 became physically aggressive with therapy team and R2. R1 grasped the arm of R2 and dug her fingernails into his skin. NP did not assess for injuries. NP stated she believed R1's increased behaviors and aggression were contributed from her being woke up every two hours at night for her [MEDICATION(S)] dose. NP was not aware R1 was refusing medication or of missed doses. When interviewed on 7/1/22, at 3:35 p.m. a visitor stated on 6/24/22, R1 was very agitated with facility staff at the main entrance. Visitor stated R1 was upset, struck out and got a hold of her skin, but didn't cause any injury to her. The immediate jeopardy was removed on 7/2/22, at 4:00 p.m. when it was verified the facility implemented an acceptable plan of correction that included: -1:1 supervision of R1 until staff could comprehensively assess R1's behavioral patterns and determine individualized interventions -Facility contacted psychiatric services for consultation and pharmacist for medication regimen recommendations and schedule changes. -Facility revised R1's care plan to reflect individualized interventions to address potential resident behaviors. -Audits were completed of residents who had aggressive behaviors and care plans reviewed and updated for appropriately. -Facility staff were provided with education with a focus on removing vulnerable adult from a dangerous situation, behavioral management, and documentation standards. In addition the facility's abuse policy was also reviewed with all facility staff. The facility policy titled Abuse Prevention Plan dated 8/14/20, indicated in order to prevent abuse, neglect, misappropriation of resident property, and financial exploitation, the facility shall do the following: -Identify, correct, and intervene in situations where abuse, neglect misappropriation of resident property, and/or financial exploitation occurs. -Assess residents with needs and behaviors that might lead to conflict or neglect through teams meetings, care conferences, and facility reports. -Require staff to report concerns, incidents, and grievances immediately to their supervisor. Concerns, incidents, and grievances are promptly investigated and appropriate steps are taken to minimize the likelihood of re-occurrence. -The facility will develop an individual abuse prevention plan for each vulnerable adult who receives services in the facility. -Specific measures to be taken to minimize the risk of abuse, neglect, and financial exploitation of residents and other vulnerable adults.

Based on observation, interview, and document review, the facility failed to ensure staff monitored [CONDITION(S)] and reported indicators of increased [CONDITION(S)] to the physician for 2 of 3 residents (R108 and R114) reviewed for [CONDITION(S)]. R108 experienced actual harmed when the facility failed to monitor his [CONDITION(S)], failed to notify the physician of a six-pound weight gain in two days, applied compression stockings without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R108's Face Sheet identified he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R108's Observation Detail List Report dated 12/28/21, indicated he had no open areas on his skin at the time of his admission to the facility, and had, 2 + pitting [CONDITION(S)] (a build-up of excess fluid in the body to the point an indentation remains for up to 15 seconds after pressure is applied) to his lower extremities. R108's electronic medical record (EMR) revealed he had not had a Minimum Data Set (MDS) assessment completed at the time of survey. R108's Order History included, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R108's care plan, included, Resident with CHF, potential for alteration in vital signs, beginning 12/28/21. The approaches included, Monitor for increased [CONDITION(S)] and significant weight changes and report to NP/PA/MD [Nurse Practitioner/Physician's Assistant/Physician] if occurs. Protect resident from injury/trauma, and weights as ordered, beginning on 12/28/21. The care plan did not specify what constituted a significant weight change. R108's Care Guide for Unit B, where R108 resided and provided by the facility on 1/5/22, revealed R108 was, at risk for skin impairment, with no actual impairment. Further review of the Care Guide revealed no mention of R108's [CONDITION(S)] or location of his [CONDITION(S)], or the use of compression stockings. R108's weights, identified he weighed 210.3 pounds on 12/29/21, 213.7 pounds on 12/20/21 (a gain of 3.4 pounds in one day), and 216 pounds on 12/31/21 (a gain of 2.3 pounds since the previous day and 5.7 pounds in 48 hours). Further review of R108's weights revealed no further weights were taken prior to 1/4/22 when his weight was 217 pounds. R108's nursing progress notes, dated 1/2/22, at 5:23 a.m. included, Resident c/o [complained of] left leg pain during the night. Ted [compression] stockings were removed from both legs as they had rolled partially down each leg and the elastic was constricting each leg leaving grooves and causing the fluid to be trapped below the elastic. Both legs and feet have +2 pitting [CONDITION(S)]. Further review did not reveal whether the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R108's progress notes dated 1/3/22, at 3:36 a.m. included, Nurse was assisting resident back to bed during night when resident requested lotion be applied to lower extremities. Nurse then discovered skin breakdown and blistering/weeping of right lower leg. One wound and one major blister with other smaller blisters surrounding, drainage scant and from blister which is mostly intact. Foam dressings applied to these areas. Resident has compression stockings from home he has been wearing while at facility, he does not have current orders for compression stockings or wraps at facility. R108's Nurse Practitioner progress notes dated 1/3/22, included, 2 blisters on the right lateral lower extremity that have burst under draining clear fluid now. The note did not specify what the blisters burst under. R108's general orders dated 1/3/22, included, once daily dressing changes to wo open areas on his right lower extremity. R108's progress note dated 1/5/22, included, Received orders for compression wraps to BLE [bilateral lower extremities] and foam dressings to open areas to RLE [right lower extremity]. Larger open blister area on right shin measured today 5 cm [centimeters] x [by] 2.5 cm, smaller open blister area next to it measures 3 cm x 2 cm. R108's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed, Bilateral lower extremity [CONDITION(S)] up to the knee level. He was weeping from the right lower extremity with 1 new blister anterior . on the right lower extremity. He has others that have burst . he does have bilateral lower extremity [CONDITION(S)] and his weights, although variable over the past 48 hours are certainly up - I suspect most of the weight is in his LEs [lower extremities]. It is possible he is up about 10 lb [pounds] post hospitalization . It is possible he will need IV diuresis if this weight trend continues . We will need to go to twice daily dressing changes, or more frequently if needed to the right lower extremity to control the [CONDITION(S)] soakage . When interviewed on 1/4/22, at 2:07 p.m. R108 stated he had, some blisters or something on the back of his right leg, which he stated were new within the past two days and causing him some discomfort. During interview and observation with R108 in his room on 1/5/22, at 4:46 p.m. revealed R108 sitting in his wheelchair. His lower extremities were visibly swollen and loosely wrapped with a compression bandage. Compression stockings were in the resident's room, draped over the arm rest of a recliner in his room. The resident pointed at the stockings and stated, I don't wear those. I don't know where they came from, but they hurt. They're garbage as far as I'm concerned, and you can take them with you. When interviewed on 1/5/22, at 5:33 p.m. nursing assistant (NA)-F stated, she was assigned to care for R108 that shift. NA-F stated that she worked for a staffing agency, rather than the facility itself, so was not familiar with R108. NA-F stated that she would refer to her Care Guide for information on that resident. NA-F referred to the B Unit Care Guide and stated that R108 was, at risk for skin problems but doesn't have any skin problems right now. NA-F stated the facility provided her with the Care Guide, which she carried with her and used as a reference when providing care, since she did not have access to resident care plans as an agency staff member. Review of the Care Guide revealed columns for resident room numbers and names, transfer status, devices such as dentures or glasses the resident used, toileting status, assistance needed for Activities of Daily Living (ADL's). whether the residents were Skin/Fall Risk, and Important Preferences. When interviewed on 1/6/22, at 11:13 a.m. NA-E stated he had worked with R108 in the past, but was not aware of any [CONDITION(S)] or if he wore compression stockings. NA-E stated that as a facility employee he could access both the care plan in the EMR and the Care Guide used by agency staff, but those two documents did not typically match one another. When interviewed on 1/6/22, at 2:41 p.m. licensed practical nurse (LPN)-D stated R108 did not have any open areas to his skin prior to 1/3/22, at that time it was discovered he was wearing ted stockings without an order and had developed blisters. When interviewed on 1/6/22, at 4:18 p.m. R108's medical doctor (MD)-A stated, it was her expectation that any resident admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD stated that daily weights were the facility's primary mode of monitoring CHF so long as they were taken before breakfast each day and using the same scale for accuracy. The MD stated that the facility had not reported R108's almost 6-pound weight gain in 48 hours between 12/29/21 and 12/31/21 to her office, which she would have expected as part of the CHF Protocol. The MD stated that in R108's case he had been admitted from a different hospital than the facility was accustomed to working with, and she had been on vacation at the time the resident was admitted , so somehow the CHF Protocol did not get initiated. The MD stated that the facility should not have placed compression stockings on the resident without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD stated that R108 would have been unable to don his own compression stockings given the amount of [CONDITION(S)] he had. When interviewed on 1/7/22, at 8:19 a.m. the director of nursing (DON) stated, he was not sure how R108 came to have compression stockings in his room, or who had applied them on 1/2/22 or 1/3/22. The DON stated, the facility was using agency staff to cover many shifts during this time, so it was difficult to tell who had provided care for R108 on those nights. The DON stated he presumed family had brought the compression stockings from home, but the staff should not have placed the stockings on R108 unless it was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked to provide the facility's policy for [CONDITION(S)] Management, as well as the CHF Protocol referenced by R108's MD. At 10:11 a.m. the DON stated, technically agency staff did have access to the care plans in the EMR, but the facility provided the Care Guide as a shortcut so they could provide care with a limited amount of orientation to residents. The DON stated that he updated the Care Guides on a spreadsheet in his computer daily and distributed them to the nurse's stations. When observed on 1/7/22, at 10:11 a.m. with family member (FM)-B, and LPN-D, FM-B stated R108 had used compression stockings at home in the past, but his [CONDITION(S)] became so much the stockings were too tight, for about 2 months prior to hospitalization and nursing home admission. FM-B had been wrapping his legs with compression bandages instead. FM-B stated she had not brought the stockings that were draped over a chair in his room, in for him. R108's wound care progress note dated 1/7/22, at 11:41 a.m. included, Continues to have 2+ pitting [CONDITION(S)] of BLE (bilateral lower extremities) from toes to mid shin. Right lower anterior had one open area and two smaller areas. The measurements were right lower anterior 1.1 cm. x 1.0 cm x 1.0 cm. The Superior anterior shin wound measured 2.2 cm x 1.2 cm x 0.1 c.m. The lateral right lower leg, does not appear to have one large wound but now has area with pin point area within it. Total area 5.0 cm x 3.0 c.m. with pinpoint weeping areas throughout. When interviewed on 1/7/22, at 10:31 a.m. the administrator stated, it was his expectation that the facility would identify CHF as a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator stated it was his expectation that staff would not apply compression stockings without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator deferred these requests to the DON. The Administrator stated it would be his preference that all staff accessed the care plan in the EMR rather than try to keep a second Care Guide document that had to be updated separately, and he would work with his leadership team to, make it happen. When interviewed on 1/7/22, at 12:41 p.m. the DON stated the facility did not have an [CONDITION(S)] management or CHF protocol. R114's Face Sheet, undated, identified an admitted [DATE], and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R114's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician was to be notified for weight gain greater than 2.5 pounds in 48 hours, or 5 pounds over admission weight. Dry weight was noted to be 274 pounds. The physician was also to be notified if weight was over 280 pounds or under 268 pounds. R114's weights since admission were documented as: On 12/22/21, R114 weighed 280.8. On 12/23/21, R114 weighed 282.8 (2.8 pounds over 280, defined as a notification point in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/24/21, R114 weighed 280.8. On 12/25/21, R114 weighed 280.0. On 12/26/21, R114 weighed 248.8 (no explanation for this weight being 31.2 pounds down from the previous days' weight) On 12/27/21, R114 weighed 285.6 (warranting physician notification for being over 280 pounds and a gain of greater than 2.5 pounds in 48 hours) On 12/28/21, R114 weighed 286.3. On 12/29/21, R114 weighed 285.6. Review of R114's EMR, did not contain documentation that R114's physician was notified of weight variances on 12/23/21, 12/26/21, 12/27/21, or 12/28/21. When interviewed on 1/7/22, at 9:07 a.m. the DON stated, the physician should have been notified of R114's weight changes. At 1:26 p.m. the DON provided documentation R114's physician had been notified of weight changes on 12/22/21, 12/29/21 and 1/3/22. However, the physician had not been notified of the weight changes 12/23/21, 12/26/21, 12/27/21, or 12/28/21.

Based on observation, interview, and document review, the facility failed to ensure physician ordered respiratory devices were functioning appropriately, notify the physician with a change in cognition and failed to monitor and identify signs/symptoms of respiratory distress for 2 of 3 residents (R1 and R2). The facility's failures resulted in an immediate jeopardy for R1 who suffered serious harm when she displayed respiratory distress, subsequently transferred to the hospital, and admitted to the intensive care unit. The facility's failures had the potential to effect addition 3 of 3 residents who continued to reside in the facility who required physician ordered respiratory devices. The immediate jeopardy began on 5/20/21, when the facility failed to report and replace necessary components of [CONDITION(S)] (non-invasive ventilator that pushes air in and out of the lungs to help with breathing) machine to ensure adequate respiratory management and was identified on 5/27/21. The director of nursing (DON), administrator, and the director of nursing in training were notified of the immediate jeopardy at 2:25 p.m. on 5/27/21. The immediate jeopardy was removed on 5/28/21, but non-compliance remained at the lower scope and severity of D- isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview on 5/26/21, at 4:59 p.m., R1's family member (FM)-B stated he went up to visit R1 on 5/23/21, between 7:30 a.m. and 8:00 a.m. FM-B stated, R1's [CONDITION(S)] was not on, she had her oxygen on via nasal cannula, however, one of the cannula's was not in her nose and the oxygen was only set to 2.0 L (liters) instead of 3. FM-B stated she did not look good and was barely responsive when he asked her questions. FM-B stated he got the nurse, and shortly thereafter, R1 was sent to the hospital via ambulance where she was in a coma in the intensive care unit. FM-B stated her prognosis was poor. FM-B said he remained hopeful, but the doctors told him she would probably not survive. FM-B stated, R1 absolutely had to have her [CONDITION(S)] on and was very faithful about using it because she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . FM-B stated R1 required 3.0 L of oxygen when the [CONDITION(S)] was on and during the day she required 1.0-2.0 L of oxygen. FM-B stated the [CONDITION(S)] machine R1 used at the facility was her own from home. FM-B stated he was not notified by the facility of any problems or issues with the [CONDITION(S)] including missing parts. R1's hospital discharge summary dated 5/18/21, included diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge summary identified R1 required [CONDITION(S)] to manage sleep apnea. R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 did not have signs and symptoms of [CONDITION(S)] or rejection of care behaviors. The MDS identified R1 required extensive physical assist from one staff member for bed mobility, transfers, and toilet use. R1's progress note dated 5/18/21, indicated R1 was alert and orientated to person, place, and time. R1's face sheet, identified R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Patient to wear [CONDITION(S)] at night time with 3 L of oxygen twice[while sleeping] per day 2:30 p.m. - 11:00 p.m., 11:00 p.m. - 6:00 a.m. (start date 5/18/21) -Patient may use 2L of oxygen as needed during activity (start date 5/18/21). R1's respiratory care plan dated 5/18/21, included: Uses oxygen related to chronic respiratory failure with [CONDITION(S)] (did not identify diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's goal indicated R1 would not have signs/symptoms of respiratory distress and saturations will be maintained within prescribed parameters. Interventions included, 1) oxygen saturations as ordered. Follow up with concerns. 2) oxygen settings as ordered. 3) [CONDITION(S)]/[CONDITION(S)] (is a treatment method for patients who have sleep apnea) as ordered, 4) complete respiratory observations in Matrix (electronic health record) and summary in progress notes of findings. Update care plan to reflect interventions utilized to decrease symptoms of shortness of breath. 5) oxygen bleed [oxygen supply tube is attached to the [CONDITION(S)] machine] as ordered. 6) observe/document/report: mental status changes, cyanosis, excessive paleness, shortness of breath, or level of consciousness, check oxygen saturation. Notify physician for concerns. R1's Progress Notes from 5/21/21 to 5/23/21 revealed the following: -5/21/21, at 6:25 a.m. Resident is missing a piece of her [CONDITION(S)] [sic], clip for mask to connect to head piece, unable to locate. 02 (oxygen) administered via nasal cannula at 3 L/min per overnight order. R1's record lacked evidence the physician was notified R1 had not used her [CONDITION(S)] and or evidence the facility had obtained a replacement part. -5/21/21, at 9:50 p.m. indicated R1 did not have the [CONDITION(S)] on because strip on right side broken. Although R1's treatment administration record (TAR) identified registered nurse (RN)-A checked the box indicating the [CONDITION(S)] was on R1. -5/23/21, at 11:38 a.m. Resident was found to be mostly unresponsive this am by CNA [certified nursing assistant] and nurse was alerted. When I arrived at the resident's bedside, she appeared to be in respiratory distress with labored breathing and gasping. Resident was on 3 L 02 via NC [nasal cannula]. Vitals were taken (see eMAR [electronic medication administration record]) and it was discovered that 02 sats were in the 80's. Writer determined that EMS [emergency medical system] should be called and resident was taken by ambulance to [name of hospital] for further care. During an interview on 5/27/21, at 9:09 a.m. RN-B stated he worked the morning of 5/23/21. RN-B stated NA-B called him around 8:00 a.m. requesting he go to R1's room right away. RN-B stated he had not previously been in R1's room that morning. RN-B stated when he arrived to R1's room, R1 had not had her [CONDITION(S)] on and only 3 L of oxygen. RN-B indicated the [CONDITION(S)] was not on because there was a piece missing. RN-B stated R1 was minimally responsive, only able to answer simple questions, and R1 was not able to report her symptoms. RN-B stated he took her vital signs and called the ambulance. RN-B indicated when he started his shift that morning nothing had been reported about R1. RN-B indicated he became aware of the [CONDITION(S)] broken piece either on 5/21 or evening of 5/22/21. During an interview on 5/27/21, at 9:21 a.m. NA-B stated she had worked the morning of 5/23/21. NA-B stated FM-B had arrived at the facility between 7:30 a.m. and 8:00 a.m. NA-B stated FM-B notified her that R1 needed to be checked. NA-B stated she went into R1's room, R1 did not have her [CONDITION(S)] on, 3 L of oxygen was on, and she called for RN-B using her walkie talkie. NA-B stated she had not been in R1's room prior. During an interview on 5/27/21, at 9:47 a.m. director of nursing (DON) stated she was not aware R1 was missing a piece to her [CONDITION(S)] mask and had not been used. DON stated staff should have notified the physician and contacted a supplier for replacement parts. DON also indicated if [CONDITION(S)]/[CONDITION(S)]'s were not used related to missing parts/rejections it was an expectation respiratory status be monitored and documented. DON also indicated the physician should have been notified of R1's new onset of confusion as it is a symptom of respiratory distress. DON stated staff had not been provided with education pertaining to [CONDITION(S)]/[CONDITION(S)] machines within the last year. During an interview on 5/27/21, at 9:59 a.m. RN-A stated she worked the overnight shifts on 5/21 and 5/22/21. RN-A stated R1 did not wear her [CONDITION(S)] mask on 5/21 or 5/22/21, because the mask was broken so she applied the 3 L of oxygen via nasal cannula. RN-A verified the documentation on the TAR was incorrect. RN-A stated during her shift on 5/22/21, R1 was really confused, she had thought it maybe was because of low 02 saturations, although R1's levels were 95%. RN-A stated she had obtained R1's 02 saturations a couple of times and they were stable at 95%; RN-A stated since R1's oxygen saturations were good, she thought that R1 must have a urinary tract infection. RN-A stated she did not document the vital signs or the new onset of the confusion and indicated she did not notify the physician. RN-A indicated she had reported the broken [CONDITION(S)] machine to RN-B but could not recall if it was the morning of the 5/21/21 or 5/22/21. R1's record lacked evidence the physician was notified of the new onset of confusion and documentation of the change in cognition as well as the vital signs were not documented by RN-A. During an interview on 5/27/21, at 10:09 a.m. certified nurse practitioner (CNP) indicated if a resident did not have their [CONDITION(S)] on, [CONDITION(S)] (absence of enough oxygen in the tissues to sustain bodily functions) could occur and confusion. CNP stated R1 had sleep apnea so that is why she was on [CONDITION(S)] at night, without the [CONDITION(S)] she became hypoxic, this would affect her mental status and lead to decreased respiratory drive. During an interview on 5/27/21, at 11:50 a.m. sleep medicine registered nurse (SM-RN) said the indication for R1's [CONDITION(S)] use was for chronic respiratory failure with hypercapnia. SM-RN stated R1 had an overnight oximetry in February 2021, oximetry was good so no changes were needed to the therapy. SM-RN stated there had been no communications since February. SM-RN stated it would be very much concerning if R1 was not wearing the [CONDITION(S)] for 2 nights, and if R1 was not able to wear the [CONDITION(S)] because it was broken or missing pieces, the expectation would be to get it fixed or get a loaner. SM-RN stated R1 should be wearing the device whenever she was sleeping (daytime hours included), in general if patients sleep longer than 30 minutes they should use the devices however, was dependent upon on respiratory condition. Review of R1's vital signs included: -On 5/20/21, R1's record lacked respiratory monitoring between 9:08 p.m. and 6:22 a.m. when at 6:22 a.m. R1's oxygen saturations were 96% on 3.0 L of oxygen. -On 5/21/21, respiratory status/vital signs were not recorded after 5:50 p.m. -On 5/22/21, respiratory status/vital signs were not recorded after 5:06 p.m. -On 5/23/21, at 9:10 a.m. R1's oxygen saturations were 86% on room air, pulse was 108/per minute, blood pressure was 89/65. Respirations were not recorded. Review of R1's Point of Care History (record of encounters that identified when assistance/cares were provided to a resident) identified and indicated staff had not assisted R1 with any activities of daily living after 5/22/21, at 11:36 a.m. During a follow up interview on 5/27/21, at 4:45 p.m. FM-B stated R1 remained in the intensive care unit (ICU), prognosis was unchanged. FM-B stated the facility had not notified him of the missing part of [CONDITION(S)] mask, and indicated that could have been avoided, he could have obtained a part from their supplier or told them where to go to get one, this is very unfortunate. R2 During the following observation times on 5/26/21, at 9:07 p.m., 9:20 p.m., 9:35 p.m., 9:45 p.m. R2 laid in bed with his eyes closed, mouth open, shallow respirations with short periods of apnea. R2's had a [CONDITION(S)] mask on the bedside table next to him and was not in use. During an observation on 5/26/21, at 9:56 p.m. R2's contined to be laying in bed and [CONDITION(S)] mask remained on the bedside table and not in use. Nursing assistant (NA)-C was asked why R2 did not have his [CONDITION(S)] on, NA-C stated because he refused. NA-C was then asked where the documentation could be located and if the nurse had been made aware. NA-C then walked into R2's room, asked R2 if he wanted the [CONDITION(S)] on, R2 stated no. NA-C was observed reporting to RN-C, R2 had refused his [CONDITION(S)], RN-C asked NA-C, why, did he refuse? NA-C stated he's refusing just like always. RN-C was observed to walk to R2's room and asked R2 why he didn't want to use his [CONDITION(S)]. R2 told RN-C he wasn't going to wear it. RN-C then told R2 he had been refusing his [CONDITION(S)]. R2 raised his voice and yelled he hasn't been refusing it, R2 indicated there was something wrong with it, he had told somebody, and nothing has been done about it. R2's Face Sheet, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had severe cognitive impairment and required extensive assistance from one staff for dressing and personal hygiene. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's care plan did not identify a plan of care for R2's obstructive sleep apnea and/or respiratory management. R2's progress note dated 4/22/21, included Resident experiencing an episode of shortness of breath at the time of during night shift. Oxygen saturations at 88% on room air at the time. The note indicated a narcotic pain medication and oxygen were administered per standing orders; R2's oxygen saturations then increased to 94% on 2 L. R2's progress note dated 4/23/21, indicted follow up was done regarding shortness of breath and low oxygen saturations. R2's lung sounds were diminished at both lung bases and had wheezing, nurse practitioner was notified. R2's progress note dated 4/26/21, included, New orders received: OK for [CONDITION(S)] use. During an interview on 5/26/21, at 10:00 p.m. RN-C stated he had remembered hearing there was something wrong with R2's [CONDITION(S)] but could not recall what it was. RN-C reviewed R2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/26/21, at 10:09 p.m. licensed practical nurse (LPN)-A indicated she was contracted to work at the facility through a staffing agency. LPN-A stated she had been assigned to work on the unit R2 resided on. When asked if she was aware of any concerns and/or rejections pertaining to R2's [CONDITION(S)] machine, LPN-A stated she didn't work here and didn't know anything about it. LPN-A stated she did not go around and check if residents had their [CONDITION(S)]/[CONDITION(S)] machines on, and stated an unawareness of who was monitoring the application/usage. LPN-A was asked what she was going do with the knowledge R2 had refused his [CONDITION(S)], LPN-A stated she was going to notify the physician. During an interview on 5/26/21, at 10:20 p.m. RN-D stated he was being trained as the new director of nursing (DON). RN-D stated if R2 refused to wear his [CONDITION(S)] it should be reported to the nurse and documented. RN-D stated if residents did not wear their [CONDITION(S)]/[CONDITION(S)] as prescribed the physician should be notified and respiratory status should be monitored during the night. During an interview on 5/27/21, at 10:56 a.m. family member (FM)-A stated R2's [CONDITION(S)] was purchased within the last 2 years and he used it at bedtime. FM-A stated shortly after R2 was admitted to the facility in December 2020, the facility called and told her they did not think he needed it, however they called within the last few months and told her to bring it up to the facility. FM-A stated she was not aware if the physician had discontinued the [CONDITION(S)] or how it was determined R2 did not need it. FM-A stated she had not been notified that there had been anything wrong with the [CONDITION(S)] or that R2 had not been wearing it. FM-A stated she was aware R2 did not like wearing it, but he would wear it anyway. During an interview on 5/27/21, at 9:47 a.m. director of nursing (DON) was not aware that something was wrong with R2's [CONDITION(S)]. DON stated if there was something wrong, the supplier should have been notified and necessary part obtained. An undated facility policy Oxygen Therapy did not address procedures for malfunctioning or broken respiratory devices/equipment. The policy included: Oxygen therapy is provided to residents in a safe manner as identified by prescribed provider. Residents are assessed to ensure their respiratory needs are being met. Residents identified in need of oxygen therapy have interventions/equipment implemented in accordance with the resident-centered care plan. 6) document assessment of resident oxygen status, tolerance, vital signs, and respiratory status in medical record as necessary. 7) Follow manufacturer recommendations for safe handling, cleaning, humidification, storage, and dispensing, maintenance of equipment in accordance with manufacturer specifications and consistent with federal, state, and local laws and regulations. The immediate jeopardy that began on 5/20/21 was removed on 5/28/21, when the facility completed the following: A) Licensed nursing staff were reeducated on facility's oxygen therapy policy with emphasis on provider and responsible party notification of abnormal findings following respiratory assessments. B) Licensed nursing staff were educated on sign/symptoms of abnormal respiratory assessment findings. C) All nursing staff were educated on checking functionality of [CONDITION(S)]/[CONDITION(S)] equipment and notification procedures of malfunctioning or broken equipment. D) An auditing system was developed and implemented for identifying signs/symptoms of respiratory distress and [CONDITION(S)]/[CONDITION(S)] functionality.

Based on observation, interview and document review, the facility failed to ensure 2 of 2 residents (R1 and R4) reviewed for diabetic management were provided adequate diabetic care in accordance with current standards of practice. This practice, including inaccurate insulin administration, inadequate monitoring and notification of the physician, resulted in an immediate jeopardy situation for R1. The immediate jeopardy began on 8/5/20, when R1 required emergent care due to [DIAGNOSES REDACTED] (low blood glucose level) due to a failure of the staff to monitor and assess the resident's diabetic status and was identified on 10/21/20. The administrator, director of nursing, interim infection preventionist, and culinary director were notified of the IJ on 10/21/20, at 12:45 p.m. The IJ was removed on 10/22/20, at 5:45 p.m., but non-compliance remained at a lower scope and severity level of G, a pattern with actual harm but is not immediate jeopardy. In addition, the facility failed to ensure appropriate indication for [MEDICATION NAME] and failed to administer per physician orders [REDACTED]. Findings include: R1's Face Sheet, included [DIAGNOSES REDACTED]. R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had severe cognitive impairment, was independent with eating, and required insulin. MDS dated [DATE], indicated, R1 required one person physical assist and supervision for eating. R1's diabetic care plan revised on 8/27/20, indicated R1 had type 1 diabetes that required insulin. R1 goals included, Will have no complications r/t (related to) diabetes and blood glucose will remain within prescribed parameters. Corresponding interventions included, administered diabetes medications as ordered, monitor blood glucose as ordered, and observe for any signs/symptoms of hypo/[MEDICAL CONDITION] (low/high blood sugar reading). R1's nutrition care plan revised on 10/19/20, directed to document meal intake %, and indicated R1's intake was 0-50% of meals and required cuing and encouragement (10/19/20). During observation on 10/19/20 at 4:30 p.m., R1 was observed to sit alone in his room in his wheelchair with tray table in front of him, with Oreo cookies taken apart. R1 stated he was a diabetic and often times his blood sugar was low, and he did not think he could tell when he was low. R1 was not able to articulate if he had already received his insulin before the evening meal, and could not articulate if he usually received insulin before or after meals. R1's current physician orders [REDACTED].>-Fragile diabetic. Monitor blood glucose at 2:00 a.m. Provide snack as needed (start date 9/14/20) -Blood sugar checks four times a day at 6:00 a.m., 11:00 a.m. 4:00 p.m. and 8:00 p.m. (start date 8/4/20, stop date 8/5/20)- then 8/19/20 to current. -Offer assistance with meals (start date 8/23/20, to current) [MEDICATION NAME] u-100; administer 12, 6, and 7, hold insulin [MEDICATION NAME] if not eating (start date 9/2/20) -[MEDICATION NAME] sliding correction scale for blood sugars above 200 mg/dl, three times a day at 8:00, 12:00 p.m. and 5:00 p.m. (start date 8/19/20) -[MEDICATION NAME] U-100 pen; administer 24 units in the morning and 12 units at bed time (start date 8/19) Facility Standing House Orders for Symptom Management dated 3/20, included orders for diabetic management. -administer short-acting insulin < 15 minutes before a meal due to rapid onset of action. [DIAGNOSES REDACTED]: -If patient is symptomatic, conscious and able to swallow: administer 6 oz. (ounces) of fruit juice, regular pop or other high carbohydrate beverage. Repeat BG (blood glucose) after 10 minutes (min); if < 70, repeat intervention, if after 2 attempts to treat and BG is still <70, notify provider. If patient is unresponsive or unable to swallow: administer [MEDICATION NAME] 1 mg (milligram) IM (intramuscularly). Repeat BG after 10 minutes; if <70 and patient still unresponsive, unless contrary to advance care plan-call 911 and notify provider immediately. If BG remains <70 but patient is conscious, initiate interventions for the conscious patient. Once patient is stable, recheck BG after 60 minutes. Communicate occurrence of any hypoglycemic event to provider the next business day. R1's hospital After Visit Summary dated 8/4/20, included Monitor blood glucose 5 times daily, bed time and 0200 (2:00 a.m.) (To monitor for [DIAGNOSES REDACTED].) Blood glucose goal is 120-180 mg/dl (milligrams per deciliter) higher glucose goal due to advanced age. A review of R1's blood sugar record in conjunction with R1's Medication Administration Record [REDACTED]. R1's record identified blood sugars below 80 mg/dl. R1's record did not always include a reassessment of interventions when readings were low. In addition, R1's record lacked monitoring for signs/symptoms of [DIAGNOSES REDACTED]. Further, R1's record included documentation of late administration of insulin and blood sugar checks, and failed to demonstrate R1's physician was not notified per physician orders [REDACTED]. Progress notes on 8/5/20, at 5:09 p.m. BS was 76 mg/dl, the MAR (medication administration record) indicated late administration: low prior, gave OJ (orange juice). Progress note dated 8/5/20, at 5:57 p.m. indicated R1 was asymptomatic, offered snacks and supper, physician was notified which resulted in an order to give half of the scheduled dose insulin and continue to monitor. No record of re-evaluation/monitoring per physician orders. On 8/7/20, at 12:29 BG was 112 mg/dl, and [MEDICATION NAME]20 units was administered. At 5:35 p.m. BS was 33, gave [MEDICATION NAME] (injection to quickly increase blood sugars) per order and supper. R1's corresponding progress note at 9:04 p.m., included Resident BS checked at 4:30 p .m. and was 33. The note indicated PRN [MEDICATION NAME] was administered, R1 was lethargic, staff assisted him with dinner, and checked BS went up to 62, after the meal it went up to 72, and before bed BS was 291. The record indicated the provider was notified. R1's telehealth physician visit dated 8/7/20, indicated physician reviewed blood sugars and gave new orders for insulin. The note also referenced blood sugar goal range of 120-180 mg/dl. On 8/8/20, at 4:00 p.m. BG was 68 mg/dl. offered orange juice. The progress note identified the BS was checked 30 minutes later however the BG record, was not consistent with the progress note. The BG record read 452 mg/dl at 8:16 p.m. and at 9:45 p.m. was 430 mg/dl. Furthermore, the progress note indicated the recheck was completed 30 minutes later rather than 15 minutes per order, and did not include signs and symptoms of [DIAGNOSES REDACTED]. On 8/9/20, R1's BG record indicated, BG was taken late at 10:12 a.m. and was 289, at 12:28 p.m. BS was 470 mg/dl. On 8/11/20, BG at 10:53 a.m. was 193, meal intake was not recorded, MAR indicated [REDACTED]. Corresponding progress note at 8:29 p.m. included Resident blood glucose at 1600 (4:00 p.m.- inconsistent with recorded time on BG log) was 27 mg/dl other vitals were stable. Resident was symptomatic, positive shakiness, sweating, confused, and drowsy. Standing order [MEDICATION NAME] 1 mg IM given. After 15 minutes rechecked, 140 mg/dl. Resident was closely monitored, after 30 minutes checked again and it was 70 mg/dl resident was conscious. On call doctor updated and order to give additional [MEDICATION NAME] if resident is unable to swallow. The note indicated R1 was offered orange juice with supper, and consumed 75% of meal. After 30 minutes rechecked and BS was 116 mg/dl. At 8:00 p.m. BS was 251 mg/dl. On 8/12/20, BS at 10:53 a.m. was 118 mg/dl, meal intake was recorded at 50%, MAR indicated [REDACTED]. At 4:42 p.m. BS was 61 mg/dl. Corresponding progress note at 8:06 p.m. included BG check at 3:30 (inconsistent with recorded time on BS record). Resident semi alert and was able to swallow fluid. 2 ensure supplements given. BS recheck @ 125. Resident regained his consciousness. The note indicated R1 was responsive the rest of the shift. The note did not identify when BS was rechecked. On 8/13/20, at 3:10 p.m. BS was 69 mg/dl., meal intake was not recorded. R1's record lacked evidence of intervention and monitoring for signs and symptoms of [DIAGNOSES REDACTED]. R1's telehealth physician visit note dated 8/13/20, indicated physician reviewed blood sugars and made adjustments to insulin based on high blood sugars in the morning and bedtime reading of 200-300. R1's MAR indicated [REDACTED]. On 8/15/20, R1's meal intake for lunch and dinner intake was not recorded however, progress note at 1:57 p.m. indicated R1 required encouragement and only ate about 50%. BS was checked at 12:02 p.m. and was 269 mg/dl, MAR indicated [REDACTED]. At 4:54 p.m. BS was 20 mg/dl, at 4:55 p.m. BS was 37 mg/dl, at 4:57 p.m. BS was 41 mg/dl, and at 5:15 p.m. BS was 20 mg/dl. Corresponding progress note at 6:53 p.m. included around 4:15 p.m. (time is inconsistent with recorded time on BS record) to check scheduled blood glucose, resident was unconscious and sweating Check right away and blood sugar and it was 20 mg/dl and other vitals were stable. Administered STAT [MEDICATION NAME] IM as standing order. After 10 minutes still unconscious and blood glucose was 37 mg/dl. Administered another dose of [MEDICATION NAME] 1 mg IM as standing order. After 5 minutes blood glucose was 41 mg/dl. Called 911 around 4:35 p.m. and paramedics arrived approximately 4:40 p.m. Prior to arrival of paramedics resident was starting to make movements opened his eyes but still weak. Resident transferred to the ER around 1650 (4:50 p.m.). R1's MAR indicated [REDACTED]. R1's hospital After Visit Summary (AVS) dated 8/15/20, presented to the emergency room unconscious due to severe [DIAGNOSES REDACTED] in the setting of medication misadministration. He was found on 8/15 with a blood glucose of 20. He received 2 doses of [MEDICATION NAME] prior to EMS arrival with minimal improvement (up to 40 then 50). EMS administered ½ amp of D50 (an [MEDICATION NAME] of 50% glucose) with improvement of blood glucose to 120. BG on arrival to ED was 116. Per EMS report, patient has had repeated episodes of [DIAGNOSES REDACTED] lately. He was hemodynamically stable and shivering on arrival to the ED .In regards to the patient's episode of [DIAGNOSES REDACTED], the collateral history collected by (name of doctor) in Endocrinology reveals that the patient did not eat lunch but he was still given insulin. Additionally, he had skipped his morning [MEDICATION NAME]. Both of these incidents could have precipitated his hypoglycemic episode. The summary indicated R1's [DIAGNOSES REDACTED] resolved and his insulin regimen was adjusted to help with better control of [DIAGNOSES REDACTED]. R1's telehealth physician visit note dated 8/20/20, referenced R1's causal factors of hypoglycemic event on 8/15/20. The note indicated R1 was sleepy in the morning, difficult to administer [MEDICATION NAME], and while inpatient, there was also a strong pattern of him completing 100% of meal when his wife was present and only 25% of his meals when his wife was not there. No adjustments were made to insulin. R1's telehealth visit dated 8/24/20, indicated physician reviewed blood sugars and did not make any adjustments related to significant hypoglycemic event. Indicated plan was follow up next week when we have reliable oral intake. Orders to hold insulin if not eating. On 8/26/20, at 7:15 p.m. BS was 195 mg/dl, meal intake record had 2 different intake amounts for dinner; 51-75% and 76%-100 and did not identify R1 was administered a bedtime snack. MAR indicated [REDACTED]. On 8/27/20, at 1:16 a.m. BS was 54 mg/dl. MAR indicated [REDACTED]. Corresponding progress note included Resident's blood sugar at 12:50 a.m. (inconsistent with recorded BS record) was 54 mg/dl. He was alert and talking. HS (bedtime) snack provided. The note indicated R1's blood sugar was not checked until one hour later at 1:50 a.m. when blood sugar was 159 mg/dl. On 8/31/20, at 10:50 a.m. BS was 70 mg/dl, MAR indicated [REDACTED]. Record lacked evidence of recheck of BS after OJ and monitoring for signs/symptoms of [DIAGNOSES REDACTED]. On 9/3/20, at 11:39 a.m. BS was 65 mg/dl, MAR indicated [REDACTED]. On 9/7/20, at 12:04 a.m. BS was 58 mg/dl; next recorded BS was 4:06 a.m. was 295 mg/dl. Meal intake record did not identify R1 had a snack before bed. According to the MAR [MEDICATION NAME] was administered at 12:14 a.m. Progress note at 5:05 a.m. included, resident BS 58 at midnight check, gave PRN [MEDICATION NAME] per order and BS went up to 83. Gave milk and chocolate pudding and recheck BS after. Went up to 183. No visible signs of [DIAGNOSES REDACTED]. R1's physician telehealth visit note dated 9/8/20, referenced low BS readings, 64 on 9/3 and 58 on 9/6. Note further indicated no adjustments would be made to insulin because of highs and lows. The note directed for nursing to continue administering insulin per orders and, Nursing to continue to monitor patient closely, notifying NP/PA/MD if BS <80. Review blood sugars weekly. On 9/15/20, at 7:02 a.m. BS was 60 mg/dl. MAR indicated [REDACTED]. Progress note at 12:14 p.m. included, BG at 0600 was 60. He was given OJ with 3 sugar packets and ate a good breakfast. The note also indicated R1's blood sugar prior to lunch was 436 mg/dl. The note did not identify that R1's blood sugar was retaken and that R1 was monitored following the interventions. R1's record lacked evidence the physician was notified of blood sugar below 80. R1's progress note on 9/18/20, at 12:49 a.m. indicated R1 was found sitting on the floor; the record did not identify R1's blood sugar was taken. At 3:06 a.m. BS was 74 mg, meal intake record did not identify R1 had a bed time snack. Progress note at 3:00 a.m. included, BS at 0300 (3:00) was 74. Orange juice with some sugar added was given. Recheck at 0400 (4:00) and was 131. The MAR indicated [REDACTED]. BS at 12:07 p.m. was 52 mg/dl, at 1:55 p.m. 144 mg/dl, and at 1:55 p.m. was 66 mg/dl. Progress note at 1:56 p.m. indicated at 11:00 a.m. (time is inconsistent with blood sugar record) was 52, resident was semi alert with stimuli. OJ and ensure given prior to lunch. BG recheck at 66. Staff was assisting with lunch with >50% intake. Recheck BG 144 post lunch. Resident is alert. On 10/5/20, [DATE]:00 p.m. was 273, meal intake record did not identify R1's intake for dinner, R1 was administered [MEDICATION NAME] 11 units and was documented late at 8:07 p.m., it's not evident what time the insulin was administered. At 7:36 p.m. BS was 64 mg/dl and [MEDICATION NAME] was held. Corresponding progress note at 8:06 p.m. Included Resident's BG at evening was 64 mg/dl. Asymptomatic. Offered snacks and will check BG after 15 minutes. The record lacked evidence of snack intake, or R1's BS was rechecked. R1's record lacked evidence the physician was notified of blood sugar below 80. On 10/12/20, at 7:23 p.m. BS was 175 mg/dl, meal intake record did not identify R1 had a bed time snack. On 10/13/20, at 2:20 a.m. R1's BS was 68 mg/dl. R1's record lacked evidence of interventions, and monitoring for signs and symptoms of [DIAGNOSES REDACTED]. R1's record lacked evidence the physician was notified of blood sugar below 80. On 10/14/20, at 4:15 p.m. BS was 78 mg/dl, the MAR indicated [REDACTED]. Corresponding progress notes indicated R1 ate <50% of dinner, did not eat well, insulin was held. The record lacked evidence of rechecks of BS and monitoring for sings/symptoms of [DIAGNOSES REDACTED]. R1's record lacked evidence the physician was notified of blood sugar below 80. On 10/16/20, at 10:30 a.m. BS was 183, meal intake record did not identify R1's intake for noon meal. MAR indicated [REDACTED]. At 4:15 p.m. BS was 67, and at 4:44 p.m. BS as 88 mg/dl, insulin was held. Corresponding progress note at 10:03 p.m. included Res BS at 4:00 p.m. was 67. Gave snacks and resident ate 25% of his meal. BS went up to 88. BS 180 at HS (bed time), resident did receive snack. Record lacked evidence of rechecks according to order and monitoring of signs/symptoms of [MEDICAL CONDITION]. R1's record lacked evidence the physician was notified of blood sugar below 80. During an interview on 10/20/20, at 11:16 a.m. the director of nursing (DON) stated the facility did not have individual glucometers, but rather a house glucometer was used. The DON stated an unawareness of R1's hypoglycemic events, and stated an analysis or investigation was not completed to ascertain possible causal factors of the hypoglycemic events. The DON indicated having discussion with nurse practitioner about the R1's [DIAGNOSES REDACTED] thought to be a meal intake concern. The DON stated not all staff were educated, only staff involved were provided education. The DON stated she had reviewed R1's record and verified there was a time gap between the administration of insulin and time 911 was called. The DON stated blood sugars are supposed to be checked half hour before meals, and up to 30 minutes prior to [MEDICATION NAME]administration. She stated blood sugars and insulin administration needed to be entered at the time of administration, and if blood sugar is low there should be rechecks completed every 15 minutes until safe range, monitoring for [DIAGNOSES REDACTED]/[MEDICAL CONDITION], with physician notification per orders. The DON stated all information was supposed to be documented in a progress note During an interview on 10/20/20, at 11:39 a.m. registered nurse (RN)-A, stated she took R1's blood sugar at 10:40 a.m., blood sugar was 197 mg/dl, she did not administer insulin, and would when he got his lunch tray. RN-A stated his lunch tray would be delivered around 11:45 a.m. RN-A indicated R1's blood sugar would not be retaken even though it was obtained over an hour before insulin would be administered. During an interview on 10/20/20, at 4:00 p.m. licensed practical nurse (LPN)-B indicated blood sugars are taken when they are scheduled, [MEDICATION NAME] was supposed to be administered with the meal, and if BS low supposed to use interventions and recheck every 15 minutes. During an observation and interview on 10/20/20 at 4:05 p.m. RN-E stated blood sugars had already been obtained. RN-E stated R15's blood sugar was taken at 3:23 p.m. and was 189, RN-E administered short acting insulin to R15 at 4:30 p.m., R15's meal tray arrived at 4:58 p.m. RN-E stated R16's blood sugar was at around 3:30 p.m. was 199, RN-E administered R16's [MEDICATION NAME] 6 units was administered at 4:50 p.m. with meal tray delivery. During an interview on 10/22/20, at 9:23 a.m. NA-C stated meal intakes didn't always get recorded because different staff are assisting with meals and collecting trays. NA-C stated staff would put the tray in front of R1 to see if he would eat by himself but otherwise required assistance with eating, R1 would take a bite then stop. NA-C stated R1 had low and high blood sugars, when he was low he acts different, he would fall asleep. NA-C stated R1's blood sugar would be taken before meals however, unaware of how long before meals. During an interview on 10/22/20, at 9:56 a.m. NA-F stated meal intake was supposed to be documented but didn't always do it. NA-F stated NA's were aware of who were diabetics because they had to wait to give residents trays until after they had their blood sugar checked and the residents got their insulin. If the blood sugar is low the nurse would tell us what to give the resident to eat. During an interview on 10/22/20, at 9:34 a.m. licensed practical nurse (LPN)-A stated rapid acting insulin should be administered 15-30 minutes before the meal. LPN-A indicated if blood sugar was on the lower side before the meal, then the insulin dose and blood sugar should be evaluated, and held if resident not eating. During an interview on 10/29/20, the nurse practitioner (NP)-B verified familiarity with R1 and hypoglycemic events. NP-B indicated R1's blood sugars obtained by the facility are not reflective in his A1C. NP-B indicated she had difficulty getting information from the facility, such as meal intakes. NP-B stated thought that R1's [DIAGNOSES REDACTED] was a result of not finishing his meal and that he required assistance, however that information had not been reported by facility nursing staff. NP-B indicated if the blood sugar was not checked close to meal times and insulin was administered based off the blood sugar and dependent on how much time had elapsed and when the resident ate, could cause [DIAGNOSES REDACTED]. NP-B stated [MEDICATION NAME]should not be administered before 15 minutes prior to a meal- if not with the meal. NP-B indicated documentation should be done immediately after the medication was administered. If the timing of blood sugar checks, insulin administration, and meal intake are not completed accurately, it makes it difficult to make adjustments to insulin doses. NP-B stated parameters for notifications are written for each resident, staff should be notifying the physician per order or per the standing orders. NP-B stated physician's orders [REDACTED]. NP-B stated an expectation that documentation be completed of the interventions and response to the interventions. The IJ which began on 8/5/20, was removed on 10/22/20 at 5:45 p.m., when implementation of an acceptable plan of correction could be verified which included: The facility identified other residents at risk with potential to be affected, re-evalutaion of R1's blood sugars was conducted by the provider again on 10/22/20, with updates to R1's plan of care made. In addition all licensed nursing staff were re-educated on the facility's insulin administration protocol with an emphasis on blood sugar monitoring, and meal intake as well as education on signs and symptoms of hypo/[MEDICAL CONDITION]. Finally, the facility developed and implemented an auditing system to ensure ongoing compliance. R4 INSULIN R4's annual Minimum Data Set ((MDS) dated [DATE], indicated R4 did not have cognitive impairment and was independent with eating. The MDS also indicated R4 required insulin. R4's care plan dated 8/6/20, identified R4's [DIAGNOSES REDACTED]. The interventions included; monitor blood glucose as ordered, instruct resident on importance of not skipping meals and snacks, monitor/document/record any signs/symptoms of hyper/[DIAGNOSES REDACTED]. R4 submitted a grievance on 9/9/20 at 9:00 a.m. The grievance included, Resident was in the coffee area when (name of staff) walked by. She said I still haven't gotten my breakfast and my insulin was given to me over an hour ago. She states staff told her breakfast would be right in. (Staff name) didn't know the details but went to get resident breakfast immediately. Findings and following up included, The culinary staff had not received her menu yet and Nurse administered breakfast and lunch insulin late and without food. Actions: re-educated nurse and completed med error report. During an interview, on 10/20/20, at 12:17 a.m. R4 sat in her room in her wheel chair. R4 stated nurses don't administer her insulin the right way; with meals. R4 stated she had filed a grievance in early September but couldn't remember the date. R4 stated she waited over an hour for her breakfast tray after she was administered insulin, and had to tell staff she didn't get her breakfast. R4 then stated her noon insulin was also a couple of hours late, and in the middle of the night her blood sugar was in the 50's. R4 stated she was tired of telling staff how to administer insulin. Medication and Treatment Incident Report dated 9/9/20, did not identify the administration of insulin prior to breakfast as a medication error. The report identified 5 units of [MEDICATION NAME]was given at the wrong time on 9/9/20 at 3:30 p.m. The report indicated the medication was not administered until 3:53 p.m. The report also included, Insulin to be administered with or just prior to food. Nurse re-educated. R4's physician orders [REDACTED].>-[MEDICATION NAME] Flex Pen U-100 [MEDICATION NAME] insulin; Administer 3 units with morning meal, 5 units noon, and 7 units at evening meal. HOLD IF NOT EATING, or BG <100. Give mealtime [MEDICATION NAME] at the end of each meal so the dose can be reduced if she can not eat as much. Allow patient to ask staff to reduce dose of her mealtime [MEDICATION NAME] based on activity or Oral intake. Patient should not be allowed to increase the dose of mealtime [MEDICATION NAME]. (Start date 8/27/20, stop date 9/28/20. -Tresiba FlexTouch Pen U-100 (insulin degludec) administer 21 units every morning (start date 8/5/20, stop date 10/16/20) -Insulin [MEDICATION NAME]; amount to administer; per sliding scale; if blood sugar is 200 to 250- give 1 unit, if 251 to 350- give 2 units, If 351 to 400-give 3 units, if greater than 400- give 4 units, and if over 500, call the physician. Provide correct post meals correction as follows three times a day: Below 80: subtract 2 units from meal dose. 80-100 subtract 1 unit from meal dose. 101-200 give only meal dose (start date 3/4/20). R4's blood sugar record was reviewed; the record identified on 9/9/20, at 7:32 a.m. and at 7:35 a.m. R4's recorded blood sugar was 193. -On 9/9/20, at 12:16 p.m. recorded BS was 113 mg/dl. -At 4:41 and at 5:23 p.m. recorded BS was 270 mg/dl -At 6:19 p.m. recorded BS was 113 mg/dl -At 7:00 p.m. recorded BS was 227 mg/dl R4's Medication Administration Record [REDACTED]. R4's MAR indicated [REDACTED]. A [DIAGNOSES REDACTED] Event Report dated 9/10/20, at 3:37 a.m. indicated R4's blood sugar at 2:05 a.m. was 50, insulin [MEDICATION NAME] 5 units given late at 3:35 p.m. and 8 units given at 6:20 p.m. Tresiba 21 units given at 7:35 a.m. with symptoms of confusion/mental lapse, weakness/fatigue, impaired speech, cold and clammy. Interventions included; [MEDICATION NAME] injection, glucose tab, fruit juice; the interventions were effective. R4's record lacked identification of the insulin medication errors and/or evidence monitoring for [DIAGNOSES REDACTED] as a result of late administrations. R4's progress note dated 9/10/20, at 3:33 a.m., included, Resident's blood sugar was 50 mg/dL at approx. 0205. She was lethargic with eyes closed and wasn't responding when spoke to or touched. Skin was clammy to touch. [MEDICATION NAME] 1 mg IM injection retrieved from e-kit and was given in left deltoid. at 0220. At 0225 her blood sugar was 69 mg/dL and was still difficult to arouse. At 0233 she started to wake up and was able to chew a glucose tablet and drink some OJ with 2 added sugar packets. At 0240 her blood sugar was 113 mg/dL. At 0300 blood sugar was 197 mg/dL. I was able to have a conversation with her and she stated she felt better During an interview on 10/20/20, at 11:00 a.m. licensed social worker (LSW)-A stated she took R4's grievance on 9/9/20, stated R4 had been yelling out and staff member asked what was wrong. LSW-A stated the staff member identified that R4 had not gotten her food prior to insulin administration, the meal order had been misplaced. LSW stated she brought the concern to the DON. During an interview on 10/20/20, at 11:16 a.m. director of nursing (DON) confirmed R4 had been given insulin after her meals. DON indicated a medication error report was filled out, and the nurse was provided education. DON stated the nurse who made the medication error, resigned her position after she was provided with education on proper insulin administration. R1 [MEDICATION NAME] R1's Face Sheet included [DIAGNOSES REDACTED]. R1's After Visit Summary (AVS) dated 8/4/20, indicated while R1 was hospitalized blood Ammonia levels were 89, [MEDICATION NAME] was started for concern of hepatic [MEDICAL CONDITION]. Cognition improved during the hospital course, so we will continue [MEDICATION NAME] at discharge. The discharge summary indicated R1 was not a transplant candidate at this time. The AVS included the order [MEDICATION NAME] 10 gram/15 milliliters (ml) solution, take 30 ml by mouth three times a day. Goal is for 2-3 BM (bowel movements) per day. R1's elimination care plan dated 8/4/20, included is taking [MEDICATION NAME]; goal of 2-3 bowel movements per day due to [MEDICAL CONDITION]. R1's physician orders [REDACTED]. R1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. 8/4/20, MAR- one dose was not administered; drug/item unavailable. 8/5/20, MAR - 3 of 3 doses were not administered: drug/item unavailable. BMR: none (no bowel movements) 8/6/20, MAR - 2 of 3 doses were not administered: drug/item unavailable. BMR: one large bm. On 8/7/20, BMR one large bm. On 8/8/20, BMR; none 8/9/20, BMR; had two large bm's 8/10/20, MAR - 3 of 3 doses were not administered related to one loose bm yesterday and XL (extra large) bm yesterday, and on hold. BMR: none 8/11/20, MAR - 1 of 3 doses was not administered: Held due to condition. BMR; none 8/12/20, BMR; none 8/13/20, MAR - 1 of 3 doses was not administered: on hold medium loose bm. BMR; 2 medium and large bm R1's physician visit note dated 8/13/20, included Patient also has history of hepatic [MEDICAL CONDITION]. He has orders for [MEDICATION NAME] to be given 3 times daily with goal of having 2-3 bowel movements daily. Patient is not having daily bowel movements. The [MEDICATION NAME] is not being administered on a regular basis and is sometimes held when the patient has a loose stool. 8/14/20, BMR; one large loose bm. From 8/15/20 to 8/18/20, BMR did not identify any documentation 8/21/20, MAR - 1 of 3 doses was not administered: due to condition. BMR; one large bm. 8/22/20, BMR- one large bm 8/23/20, MAR -1 of 3 doses was not administered: On hold loose bm. BMR; none 8/24/20, MAR- one large loose bm. R1's physician visit note dated 8/24/20, included the recapitulation from the hospital visit that d

Based on interview and document review, the facility failed to monitor and assess for change of condition, and failed to follow physician orders, for 1 of 1 resident (R2) who had a history of [REDACTED]. As a result of the facility's failures, an immediate jeopardy (IJ) situation was identified for R2 who had displayed respiratory distress with significantly low oxygen (O2) saturations, requiring an increase in oxygen and emergent transfer to the hospital emergency room (ER). The immediate jeopardy began on 9/25/20, when the facility did not send R2 to the ER per orders and was identified on 10/21/20. The administrator, director of nursing (DON), licensed social worker (LSW), culinary director, and infection preventionist were notified of the immediate jeopardy at 12:45 p.m. on 10/21/20. The immediate jeopardy was removed on 10/22/20 at 5:45 p.m., but noncompliance remained at the lower scope and severity level of G - isolated, scope and severity level, which indicated actual harm that is not immediate jeopardy. In addition, the facility failed to manage, monitor, assess for the use of bowel medications to prevent constipation for 1 of 1 residents (R8), who had a [DIAGNOSES REDACTED]. Findings include: R2's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had moderate cognitive impairment and required extensive assistance from two or more staff for bed mobility and transfers and required extensive assistance from one staff for toileting, hygiene, and dressing. The MDS indicated R2 had not required oxygen, was administered anticoagulant medications, and had a surgical wound. R2's Face Sheet, included [DIAGNOSES REDACTED]. R2's Physician standing orders included the following: Initiate and titrate supplemental 02 at 1-4 l/min (liters per minute) via nasal cannula PRN (as needed) for dyspnea (shortness of breath), [MEDICAL CONDITION] (02 saturation <90%); and to update provider with nursing assessment. R2's care plan dated 9/11/2020, indicated [REDACTED]. The care plan did not address the instructions as outlined in Required Follow Up section of the hospital Discharge Summary to monitor for [MEDICAL CONDITION] (A condition in which the blood clots form in veins located deep inside the body) and PE (pulmonary embolism-A condition in which a blood vessel in the lung(s) gets blocked by a blood clot). R2's hospital Discharge Summary Brief Overview dated 9/14/2020, had a section called, Active Issues Requiring Follow-up. This section included, Continue close monitoring of the right lower extremity for propagation/worsening of swelling, evidence of neurovascular compromise (diminished pulse, numbness/tingling, new/worsening pain in the distal extremity, weakness) and any evidence of shortness of breath, chest pain, and/or hypoxemia that may suggest evidence of possibility of [MEDICAL CONDITION] embolism. Please wrap lower extremity with low stretch wraps daily for swelling control symptoms as tolerated by patient. R2's progress note dated 9/14/2020, at 10:36 p.m. included, 02 84 when lying. O2 started at 1 lit (liter) per minute. Call light within reach. Will continue to monitor. The note also indicated a skin assessment was completed; purple blueish coloration of right lower leg, [MEDICAL CONDITION] +1. Scar from surgery 5 centimeters long. R2's physician visit dated 9/15/2020, included recapitulation of hospital admission and discharge orders for active surveillance of the right lower extremity, monitoring for signs/symptoms of [MEDICAL CONDITION] embolism, worsening [MEDICAL CONDITION], and oxygen requirements. The note indicated nursing reported increased oxygen need when working with physical therapy, and physical therapy requested order to increase oxygen for therapy sessions. Resident denied shortness of breath, chest pain, numbness and tingling in the extremity. The note indicate the physician would consult with vascular clinic for increasing oxygen. Physical exam, skin: Purple bluish coloration of right lower leg. [MEDICAL CONDITION] +1 right leg. The note included orders for ultra sounds and 3. Nursing will continue close monitoring of right lower extremity for swelling, diminished/loss of pulse, numbness/tingling, new/worsening pain in the distal extremity, weakness, shortness of breath, chest pain, and/or hypoxemia that may suggest possibility of [MEDICAL CONDITION] embolism. R2's progress note dated 9/15/2020, at 4:21 p.m. indicated a telephone order was obtained from the NP (nurse practitioner); oxygen needs to be increased to 3 lpm to keep Sp02 above 90%. Resident noted to de-sat with exertion. A subsequent note at 9:49 p.m. included the ultra sound results; No [MEDICAL CONDITION] is seen in bilateral lower extremities. R2's progress note dated 9/16/2020, at 2:01 p.m. PT (physical therapist) found pt (patient) sleeping in w/c (wheelchair) and didn't touch her lunch, refusing it. Pt on room air and O2 SATS 95%. sit to stand CGA (contact guard assist) Pt stood for 1 min (minute) w/ PT limiting time to assess O2 and initially 92% upon sitting and then decreased to 73% and took about 1 min to rebound. PT donned O2 at 1 lpm and O2 93%. Stood 2nd time and able to place oximeter on finger and decreased to 66% after about 45 sec (seconds) of standing and had pt immediately sit down. Vital machine then had dead battery and cord retrieved to plug in and by the time this took place O2 at 78% and then quickly returned to >90%. O2 increased to 3 lpm and pt stood 3rd time and watched O2 and decreased to 78% at 20 sec and had pt stop. Pt took 1 min 20 sec to recover. Reassessed O2 SATS to do quick wean back to room air and at (sic) was in 80's and quickly above >90. Monitored to 2 lpm, 1 lpm and to room air w/ pt at 100% by end. Notified nurse of pt desaturation w/ activity as nurse arrived to give meds. R2's progress note dated 9/17/2020, at 11:39 a.m.stood with PT for 1 minute, and PT would not let patient stand longer to ass O2 sats/tolerance. Donned oximeter after standing and O2>90% entire stand. After sitting, O2 eventually dropped to 81% after sitting for awhile and with therapeutic rest at 100%. Pt stood 2nd time and 15 seconds only as O2 dripped to 85% quickly and made pt sit down with O2 dropping to 74% with about 1 mine to recover. Discontinued standing attempts at this time. R2's progress note dated 9/18/2020, at 11:13 a.m. indicated R2 denied feeling any shortness of breath and did not display symptoms when laying down. A subsequent note at 1:13 p.m. included, PT just completed the following concerning tx (treatment): Pt found asleep in w/c w/ lunch tray, on room air. O2 SATS 84% on R (right) hand and compared to L (left) hand at 80%. PT donned O2 on 3 lpm to increase O2 SATSs for mobility and increased to 95%. Pt stood CGA w/ FWW (front wheeled walker) and decreased to 69% after just 25 sec of standing and had pt sit back down. Pt took 2 1/2 min to recover >90%. PT was not going to stand pt again, however, pt requesting to use toilet urgently and instructed pt on need to transfer quickly to keep O2 SATS up. PT had pt rest prior to toilet transfer CGA and O2 decreased to 49% on 3 lpm. PT immediately notified nsg (nursing). Nurse arrived while pt on toilet and updated and nurse stayed present for toilet>w/c transfer w/ CGA and dependent upon changing and cleaning. O2 SATS then decreased to 39% with O2 on 3 lpm and took 5 1/2 min to recover >90%. Nurse to update NP and rest of tx withheld. At rest in w/c observed O2 SATS in mid 60's to 100% while PT documenting R2's clinic registered nurse telephone encounter note dated 9/18/2020, at 1:23 p.m. included, Call received from nurse (name of nurse) at Madonna Towers, Resident was in PT (physical therapy) when resident's 02 saturation was checked. Room air sats were 95%. Nurse states that resident's 02 sats were going as low as 50% with oxygen 3L on, even at rest. Resident appears in no apparent distress. No shortness of breath or cyanosis (bluish discoloration) noted. Writer asked for accuracy of unit used to test. She states they compared with another machine and were getting the same kind of readings. She states readings were all over the place at standing and sitting positions. Writer requested an S-bar be sent with updated vitals. Resident remains on 3L of 02. R2's follow-up physician's note dated 9/18/2020, at 1:43 p.m. included Called facility and talked to (name of nurse). 02 sat reading was all over the place, at 3L was as low as 50% and they're certain of the accuracy of the equipment. Resident was just admitted to (name of hospital) and treated for [REDACTED]. R2's physician note dated 9/18/2020, at 2:25 p.m. included NP called (nurse name), who reported that the ambulance came, EMT assessed her and found her 02 sat was normal. They stated that she's stable and did not take her to the ED. Nursing was instructed to keep a close eye on her over the weekend. 1. Take VS (vital signs 3 times daily for 3 days. Notify (provider) on call if 02 drops <90% on 1 LNC (baseline since hospitalization ) or if RR (respiratory rate) >24. 2. Assess for SOB (shortness of breath), chest pain, cough, dizziness/lightheadedness, increased leg pain or swelling when taking vital signs. R2's progress note dated 9/18/2020, at 3:00 p.m. indicated the physician was notified, physician recommended sending R1 to the emergency room for further evaluation. Emergency medical services was called and upon arrival; EMS evaluated her and decided she did not require hospitalization at this time. Physician called back and agreed to have nursing staff monitor her closely over the weekend. If any changes occur, we are to send her in. R2's progress note dated 9/22/2020, indicated R2 was seen by the doctor, had an ultra sound that resulted in Bilateral non-occlusive [MEDICAL CONDITION] is seen. R2's record lacked documentation of further monitoring of the right lower extremity. R2's physician visit note dated 9/22/2020, indicated R2 was seen for initial physician visit. The note included a section Physical Exam; the section only included Constitutional: She appears well-developed. Psychiatric: She has normal mood and affect. The physician ordered labs on next lab day and for nursing to continue close monitoring of the right lower extremity. R2's progress note dated 9/25/2020, at 9:22 a.m. included Res (resident) was not responding to command. This AM. oxygen was 67 at 4 L. Her body was very cold to touch. She was covered with extra blanket and was monitored for an hour, oxygen was 56 even with nasal cannula. Ambulance was called and she was transferred to the hospital. The note lacked documentation the physician had been notified of R2's oxygen saturation less than 90% and acute change in condition. R2's progress note dated 9/28/2020, indicated family contacted the facility and reported R2 was close to death. During an interview on 10/20/2020, at 6:22 p.m. family member (FM)-A stated on 9/23/2020, she had been at work and received a call from a nurse at the facility before 4:00 p.m.; the nurse indicated R2 may be going into the emergency room for non-emergent cares. FM-A stated she arrived at the facility around 5:20 p.m. and around 6:00 p.m. the nurse told her that instead of sending R2 to the ER, R2's vascular doctor had ordered an increase in [MEDICATION NAME]. FM-A stated that on 9/25/2020, once at the hospital a tube was put up R2's nose to pump her stomach that resulted in not a huge amount of fluid but a good amount, R2 also had blood in her stools. FM-A stated R2's death certificate included, Complications of right [MEDICAL CONDITION]-fall, hypertension, and [MEDICAL CONDITION]. On 10/21/2020, at 8:00 a.m. director of nursing (DON) reviewed R2's oxygen saturation records and stated the monitoring and assessing of respiratory status was lacking, there was inconsistent documentation of how much oxygen she was being used therefore would not be able to ascertain worsening respiratory condition. DON stated on 9/25/2020, upon discovery of R2's 02 saturations, 911 should have been called as well as the physician instead of monitoring R2 for an hour. The DON also stated staff should have notified the family member on 9/18/2020, when they were going to send her in to allow participation in the care plan. DON then stated progress notes and record are not complete and leave a lot of unanswered questions. There was a lack of monitoring of the lower extremity for changes in color/warmth/sensation or color. During an interview on 10/21/2020, at 3:03 p.m. registered nurse (RN)-C indicated if resident had low oxygen saturations, would check standing orders, place on oxygen and call 911 and/or physician dependent upon situation. During an interview on 10/23/2020, at 5:03 p.m. RN-B stated he was the nurse that found R2 with low oxygen saturations. RN-B stated it was an error in judgement at the time and should have called the physician and ambulance immediately. The Immediate Jeopardy was removed on 10/22/2020, at 5:45 p.m. when it was determined the facility provided re-education and competency testing to licensed nursing staff on the facility's change of condition policy with emphasis on abnormal respiratory status and signs/symptoms of [MEDICAL CONDITION] embolism. In addition, the facility developed and implemented an auditing system for respiratory monitoring. R8 CONSTIPATION: R8's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R8 had been admitted to hospice, did not have cognitive impairment, and did not have rejection of care behaviors. According to the MDS, R8 required extensive assistance from two or more staff members for bed mobility, dressing, and toilet use. The MDS indicated R8 was always incontinent of bowel. R8's Face Sheet, included [DIAGNOSES REDACTED]. R8's care plan dated 7/17/2020, included Resident has a terminal [DIAGNOSES REDACTED]. Interventions included, Administer medications as ordered, monitor and document effectiveness of medication. Follow-up with hospice/provider as needed. The elimination care plan edited on 7/28/2020, indicated R8 had alteration in elimination related to decreased mobility and opioid medication with the goal of will have no s/sx (signs/symptoms) of constipation through the review date (goal dated 6/29/2020). The interventions included, administer medications as ordered and observe for effectiveness, see comfort/pain opioid care plan (7/28/2020), If no bowel movement in three days follow bowel protocol per standing orders (6/29/2020), Observe for s/sx of constipation: passing hard/no stools, abdominal bloating/swelling, cramping, nausea and/or vomiting, mental status changes (6/29/2020) assist of one stand pivot wheelchair to/from toilet. R8's physician orders [REDACTED]. -[MEDICATION NAME] concentrate solution 5 milligrams (mg) as needed (PRN) by mouth every hour as needed for shortness of breath or pain (start date 7/18/2020, end date 8/9/2020) -[MEDICATION NAME] (laxative) 15 milliliters (ml) once a day PRN for constipation (start date 7/15/2020, end date 8/5/2020) -[MEDICATION NAME] 15 ml by mouth daily and may also take 15 ml daily as needed for constipation (Start date 7/15/2020, end date 8/5/2020) -[MEDICATION NAME] 30 ml twice daily (start date 8/5/2020, end date 8/11/2020) -Senna with [MEDICATION NAME] Sodium 8.6/50 mg, take two tablets in the morning and 3 tablets at bedtime (start date 7/15/2020, end date 7/28/2020), order was changed on 7/28/2020 - take 3 tabs twice a day with a stop date 8/11/2020. -[MEDICATION NAME] 10 mg suppository once a day PRN (start date 7/19/2020, end date 8/10/2020. -[MEDICATION NAME] tablet 5-10 mg once daily PRN (start date 7/15/2020, end date 8/5/2020) -[MEDICATION NAME] tablet 5 mg by mouth once day (start date 8/5/2020, stop date 8/11/2020) -Fleet enema 19-7 gram/118 ml; 1 tube, one time dose per standing order (7/26/2020) -Fleet enema one tube, every three days PRN for constipation if no results from suppository (start date 8/2/2020, end date 8/11/2020) [MEDICATION NAME] 17 grams once a day (start date 8/5/2020, end date 8/11/2020. Facility standing orders signed by medical director on 3/1/2019, for Bowel and Bladder Management included the following for constipation; (Perform step sequentially) Perform rectal check to determine if impaction is present, [MEDICATION NAME] suppository 10 mg per rectum twice a day for constipation. Reattempt Senna or [MEDICATION NAME] if no results after 24 hours. Fleets enema per rectum every 3 days PRN for constipation if no results from suppository. R8's Medication Administration Records (MAR), in combination with Bowel Movement Record (BMR), and progress notes were reviewed. The record consistently lacked a comprehensive bowel assessments; the record did not identify physical examination such as abdominal distention, presence of bowel sounds, or firm/soft abdomen. The record identified bowel medications were not given per physician order [REDACTED]. R8's progress note dated 7/22/2020, indicated R8 reported constipation relieved with suppository and laxatives had large bowel movement. R8's BMR identified R8 did not have bowel movements on 7/23, 7/24, and 7/25/2020. One PRN dose of [MEDICATION NAME] was administered on 7/25/2020; dose was documented as not effective, no further interventions documented. MAR indicated [REDACTED] R8's MAR indicated [REDACTED]. The BMR at 1:22 p.m. indicated R8 had a large bowel movement and at 7:22 p.m. had a medium bowel movement; consistency of BM was not identified on the BMR. R8's BMR included the following recordings: - 7/27/2020, medium bowel movement (no consistency identified). -7/28/2020, no bowel movement -7/29/2020, no bowel movement -7/30/2020, no bowel movement, MAR indicated [REDACTED]. -7/31/2020, no bowel movement, MAR indicated [REDACTED]. -8/1/2020, no bowel movement - 8/2/2020, R8 had medium bowel movement that was dry and hard. MAR indicated [REDACTED]. -8/3/2020, no bowel movement. PRN [MEDICATION NAME] suppository and [MEDICATION NAME] administered and was not effective. -8/4/2020, medium bowel movement that was soft/formed. MAR indicated [REDACTED]. - 8/6/2020, no bowel movement; MAR indicated [REDACTED]. -8/7/2020, no bowel movement; MAR indicated [REDACTED]. R8 was administered [MEDICATION NAME] 5 mg at 4:52 p.m. for bottom pain 5/10; record lacked evaluation of effectiveness. -8/8/2020, small bowel movement that was dry and hard; MAR indicated [REDACTED]. R8 refused Senna S, record lacked evidence after refusal R8 was re-approached. R8 was administered [MEDICATION NAME] 5 mg at 2:58 p.m. for discomfort when trying to have bowel movement and shortness of breath, and at 4:58 p.m. for bottom pain. - 8/9/2020, 2 small bowel movements (consistency was not identified); MAR indicated [REDACTED]. - 8/10/2020, indicated R10 had small soft/formed stool, large loose stool, and another large bowel movement. R8's progress note dated 8/2/2020, included Resident complaining of discomfort in abdomen. Has no bowel movement for 6 days. On scheduled and as needed [MEDICATION NAME] sulfate. Oral laxatives and [MEDICATION NAME] suppository ineffective. Fleets enema given as per standing order. Effective with medium hard stool. Resident verbalized relief with abdominal discomfort. The note also indicated oral laxative encouraged. R8's progress note dated 8/3/2020, hospice called to update on not eating and need for bowel medication due to constipation. R8's hospice visit note dated 8/3/2020, included patient received suppository and nurse assist to digitally remove hard stool. Patient reports she is no longer constipated and staff confirm she had a small BM today. Bowel sounds active in to all four quadrants, abdomen soft and not tender. Writer discussed bowel regimen with facility nurse, who reports they will continue to monitor and utilize PRNs as the pt refuses to schedule more laxatives at this time despite writer's education and recommendations. The note also indicated the nurse reported the facility had been giving PRN [MEDICATION NAME] suppositories. R8's hospice note dated 8/4/2020, at 9:45 a.m. indicated family member called hospice, stating that pt is in significant pain due to constipation, and pt is requesting to go to the hospital. The note indicated hospice called the facility and instructed the nurse to give prn dose of [MEDICATION NAME]. Nurse reported that [MEDICATION NAME] and suppository would be administered later that afternoon. At 12:15 p.m. the family had communicated back to hospice that a suppository and enema were used with no results, the hospice nurse called hospice physician and obtained new orders. The note indicated the facility would call hospice when R8 had results after medications were given as directed by hospice nurse. R8's progress note dated 8/4/2020, at 1:09 p.m. indicated R8 reported constipation, scheduled bowel medication suppository and enema given per hospice order with small smeared results. PRN [MEDICATION NAME] given for comfort during care, transferring, and discomfort due to constipation. The note indicated hospice was updated during visit and via phone related to bowel management. A subsequent note at 1:46 p.m. included, STAT verbal order for another [MEDICATION NAME] PRN per hospice for constipation placed. Note at 9:54 p.m. included, Resident had a medium bowel movement this evening. Results were communicated to hospice nurse. R8's progress note dated 8/5/2020, indicated hospice at the facility and gave new orders; [MEDICATION NAME] 10 mg daily and increase [MEDICATION NAME] to 30 ml twice a day. A subsequent note at 7:50 p.m. indicated staff had reported R8 had large bowel movement during evening cares. According to R8's MAR indicated [REDACTED]. R8's progress note dated 8/8/2020, indicated took her bowel and pain medications. A subsequent note at 8:47 p.m. indicated cream was applied to residents bottom due to discomfort after bowel movement. R8's progress notes dated 8/9/2020, at 8:25 a.m. indicated hospice was updated related to pain management due to discomfort with direction from hospice to stay on PRN medications as ordered. The note indicated R8 was administered the pain medications and had good results. A subsequent note at 4:04 pm. indicated R8 had refused her morning medications. Family member was present, asked medications be administered including [MEDICATION NAME] and senna. Resident started to have peristalsis (the involuntary [MEDICATION NAME] and relaxation of the muscles of the intestine or another canal, creating wavelike movements that push the contents of the canal forward) which caused abdominal discomfort and pain. PRN [MEDICATION NAME] given hourly per order with less effect on pain management. The note then indicated hospice was contacted and increased [MEDICATION NAME]. R8's record lacked staffs re-attempt of administration of bowel medications after it was initially refused. R8's progress note dated 8/10/2020, at 5:51 a.m. indicated R8 had a soft small bowel movement when she was repositioned. R8's progress note dated 8/10/2020, at 1:28 p.m. (late entry documented on 8/11/2020 at 1:40 p.m.) included, Resident restless and c/o (complained of) pain. Note indicated R8 was administered pain medication and [MEDICATION NAME] for anxiety. This writer brought [MEDICATION NAME] suppository to her room to administer d/t resident refusing oral bowel medications and only having small bm's. Resident refusing stating NO, NO, NO suppository. Residents daughter was in the room at the time and agreed with residents request. Hospice here around lunch time and resident still having increased anxiety and restlessness the note indicated the nurse tried to offer the suppository again and the resident refused. R8's hospice visit note dated 8/11/2020, included RN did rectal check due to complaints of having rectal pain. (Name of nurse) LPN (licensed practical nurse) did not give suppository as requested by this RN on 8/11/2020 due to pt refusal. RN noted pt to have hard stool in rectum and disimpacted XL (extra large) hard stool. RN was unable to complete disimpactaction due to pt have bleeding from rectum in moderate amounts (possible hemorrhoid). RN applied pressure to rectal area to slow down the bleeding. RN gave pt [MEDICATION NAME] suppository to promote further BM. Bowel sounds hypoactive x 4. After pt was disimpacted, she was able to relax with no facial grimacing or restlessness noted in bed. The note also indicated the resident was transferred to hospice house. During an interview on 10/21/2020, at 8:51 a.m. nursing assistant (NA)-D stated NA's were supposed to record bowel movements, sometimes things didn't get charted, and didn't think there was a way to look back at the history. NA-D stated the nurses were supposed to make sure residents had bowel movements and administer suppositories if they didn't have one every three days. During an interview on 10/21/2020, at 9:23 a.m. NA-C stated NA's were supposed to document bowel movements however, needed work. NA-C indicated agency staff were not documenting. NA-C indicated a suppository was supposed to be given if a resident did not have a bowel movement every three days; that it was up to the nurse to administer the suppository. During an interview on 10/21/2020, at 9:34 a.m. licensed practical nurse (LPN)-A stated NA's were supposed to document bowel movements and report to the nurse if haven't had a bowel movement in 3 days or if resident complained of constipation. LPN-A stated TMA's have to check with nurses prior to holding any medications for an assessment to be completed. LPN-A stated physician's orders [REDACTED]. If a bowel medication was not effective, then more follow-up was required. During an interview on 10/21/2020, at 12:16 p.m. registered nurse (RN)-A stated there was a bowel movement report sheet. RN indicated the report was supposed to be pulled up during the shift; if no bowel movements in 3 days then a suppository was supposed to be given. RN indicated if it was not effective then more follow-up was supposed to be completed. RN stated a complete bowel assessment should be completed prior to the administration of bowel medications and/or when a resident would complain of constipation. During an interview on 10/21/2020, at 3:03 p.m. registered nurse (RN)-C stated a complete bowel assessment should be completed and documented prior to the administration of laxatives. RN-C indicated if no bowel movement in three days supposed to get a suppository, and if there was not results then more intervention needed to be completed. RN-C stated documentation is not always accurate, and does not always identify consistency; stated there isn't a standard for size documentation and indicated it was left up to the person recording to determine difference between small/medium/large. During an interview on 10/23/2020, at 7:42 a.m. director of nursing (DON) reviewed R8's record; and confirmed physician orders [REDACTED]. DON stated nursing should have followed the bowel regimen per physician orders. DON stated they should be documenting refusals and need to re-attempt to administer, if a TMA documented refusals they should have reported to a nurse and document what happened. DON stated bowel assessments should be completed when complaints of constipation and/or before administering a PRN medication. During a return phone interview on 10/29/2020, at 3:30 p.m. with nurse practitioner (NP)-B, NP-B stated staff should be administering bowel medications per orders. NP-B indicated fleets enema should not be given before using the prescribed medications. NP-B stated an expectation that nurses complete full bowel assessments daily if there was constipation concerns and before administration of as needed medications. R9 FLUID OVERLOAD R9's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R9 did not have cognitive impairment and required extensive assistant of two or more staff for bed mobility, dressing and personal hygiene. The MDS also indicated R9 received one administration of a diuretic during the assessment period. R9's Face Sheet, included [DIAGNOSES REDACTED]. R9's nutrition care plan dated 9/23/2020, identified R9 was on a fluid restriction; interventions included document meal intake %, fluids, bowel movements, and urinary output as applicable each shift. Notify licensed nurse for low intake and refused meals. R9's Hospital Discharge Summary Brief Overview dated 9/21/2020, indicated R9 was hospitalized related to [MEDICAL CONDITIONS] blood loss. The section Active Issues Requiring Follow-Up included primary care provider to consider starting [MEDICATION NAME] (diuretic) at dose of 10 milligrams (mg) based on creatinine (lab) levels. R9's physician orders [REDACTED].>-Check heart rate, blood pressure, and Sp02 (oxygen saturations) daily (include oxygen requirement) Special instructions: Notify (name of clinic staff) if SBP (systolic blood pressure) >160 or SBP <90, HR (heart rate) >100 or <60, Sp02 <90% or increased oxygen needs, or with any other concerns (start date 9/24/2020, stop date 10/2/2020) - Check heart rate, blood pressure, and Sp02 daily (include oxygen requirement) Special instructions: Notify (name of hospital staff) if SBP (systolic blood pressure) >160 or SBP <90, HR (heart rate) >100 or <60, Sp02 <90% or increased oxygen needs, or with any other concerns. For heart rate <60 only notify provider if symptomatic (dizziness/lightheadedness or [MEDICAL CONDITION] (start date 10/2/2020, stop date 10/5/2020) -No added salt diet. Special instructions <1.5 fluid restriction (start date 9/21/2020) -Weight daily before breakfast. Use the same scale. Notify provider if weight gain >267 lbs. (pounds) or <261 lbs. (start date 9/28/2020. -[MEDICATION NAME] 10 milligrams (mg) now and then daily in the morning (start date 9/28/2020) -Apply low stretch wraps to bilateral lower extremities, on in the a.m. and off in the p.m. (start date 9/28/2020) R9's vital sign record was reviewed; the record identified heart rates under 60 without evidence the physician had been notified. 9/21/2020, 11:49 a.m. HR 56 9/22/2020, 2:59 p.m. HR 55 9/22/2020, 9:32 a.m. HR 58 9/22/2020, 6:51 p.m. HR 55 9/23/2020, 7:28 p.m. HR 57 9/

Based on observation, interview and document review, the facility failed to ensure food items were served in a manner to accommodate known allergen for 1 of 1 residents (R5) who had a known allergy to peanuts, and history of anaphylactic reaction (a severe, potentially life threatening allergic reaction) to peanuts. This resulted in an immediate jeopardy (IJ) situation for R5 when he was served food items which contained peanuts. The IJ began on [DATE], when R5, with a known allergy to nuts was served a dessert containing peanut butter. Dietary staff served a different dessert than what R5 ordered from the dietary card which listed an allergy to nuts. The administrator and director of nursing (DON) were informed of the IJ on [DATE] at 6:45 p.m. The facility implemented corrective action and the IJ was removed on [DATE] at 6:00 p.m. However, non-compliance remained at the lower scope and severity of D, isolated, no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Findings include: R5's Face Sheet included [DIAGNOSES REDACTED]. R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R5 had adequate hearing and speech, understood and was able to comprehend. R5 refused to answer questions for the brief interview for mental status (BIMS) and had no signs and symptoms of [MEDICAL CONDITION]. R5 was independent with bed mobility, walking, dressing and toileting. R5's care plan for nutritional status dated [DATE], identified an allergy to nuts, specifically peanuts and cashews. During an interview on [DATE], at 9:06 a.m. R5 stated he recently received a dessert containing peanut butter and stated he was allergic to peanuts. R5 stated after taking a small bite, he'd recognized the peanut taste and spit it out. R5 stated he had a light asthma attack, adding two hours went by and I was bent out of shape. I could have died and damn right I was scared. R5 stated he didn't go to the hospital this time but added, it took a good two days to get it out of my system. Review of R5's progress note dated [DATE], at 6:07 p.m. registered nurse (RN)-B documented R5 was anxious and agitated because he had a bite of a peanut which he was allergic to. R5 reported to RN-B he swallowed a small amount and when he tasted the peanut, he spit most of it out. At 7:04 p.m. RN-B contacted a provider and received an order for [REDACTED]. R5 was monitored closely and did not develop signs or symptoms of an allergic reaction and did not require [MEDICATION NAME]. A prior incident from [DATE] at 6:40 p.m., was documented in the record indicating the severity of R5's reaction to nuts. The documentation included: Rt (resident) reported that he had ingested the dessert that had peanut butter in it. Rt. has a documented allergy to nuts. Rt. stated he had a small bite. Rt reported an upset stomach. Rt. unable to state symptoms of last allergic reaction but when asked if his mouth or tongue swelled up he responded, 'yes'. Rt. remained A x O x 4 (alert and oriented times 4) and was able to answer all questions clearly. No rash, difficulty breathing, itching or mouth swelling noted. VS WNL (vital signs within normal limit) see chart. On call for (doctor name), (doctor name) notified and gave orders to send pt. to ER via (ambulance name) emergently. Pt's contact (name), notified. Report called to (name of hospital) ER. During an interview on [DATE], at 9:48 a.m. cook (C)-C stated all food is made in the main kitchen and then delivered to the kitchen at the nursing home, referred to it as nursing care kitchen. C-C stated some foods came from the main kitchen with nuts in them and it was up to the server to make sure R5 did not receive them. C-C stated R5 had requested a butterscotch bar for dinner on [DATE], but received a scotch-a-roo bar which contained peanut butter. C-C did not know how this occurred. During an interview on [DATE], at 9:53 a.m. culinary services director (CSD)-A stated residents were given a paper menu at breakfast to fill out for the next day. For residents with food allergies, their menus were customized to include their allergies; CSD-A verified R5's menu listed his allergy to peanuts. CSD-A was aware of the incident on [DATE], when R5 received a dessert containing peanuts (a scotch-a-roo bar). CSD-A verified R5 ordered the proper product, but we sent the wrong one. In addition, CSD-A stated on [DATE], R5 requested an oatmeal cookie on his menu, but a Monster cookie containing peanuts was placed on his tray. The error was discovered in the nursing care kitchen and R5 did not receive the cookie containing peanuts. CSD-A verified there was nothing in place for culinary staff to know specific ingredients in food items to ensure a resident does not receive food for which they were allergic. When asked if an incident report had been completed when R5 received food for which he was allergic, CSD-A stated it would be a grievance filed by the social worker (SW). When asked how the SW would learn about this incident, CSD-A stated he didn't know. During an interview on [DATE], at 11:03 a.m. SW-A stated she heard about R5 receiving the scotch-a-roo bar made with peanut butter at a leader meeting. SW-A stated it was up to the person who discovered the event to fill out an incident report, adding in this case, it was nursing. During an interview on [DATE], at 11:09 a.m. the director of nursing (DON) stated she was not aware R5 received a dessert which contained peanuts on [DATE]. The DON stated the nurse on duty that evening RN-B, was an agency nurse and added, I'm surprised I wasn't notified. The DON stated she would follow up with RN-B. During an interview on [DATE], at 6:35 p.m. lead cook (LC)-B stated all food was made in the main kitchen of the facility and delivered in metal containers to nursing care for distribution. LC-B provided a document displaying the menu for fall week 1, Thursday which indicated the quantities of food items to send to nursing care. While the document did not indicate ingredients for any food items, LC-B stated nursing care was responsible for determining resident allergies. On [DATE], at 6:45 p.m. dietary aide (DA)-A stood in the kitchen at the steam table, as he placed the entrees onto individual plates and handed the plate to an aide who set the plate on a tray and added cold food, beverages and dessert items to each tray. DA-A stated pans of food were delivered to the nursing care kitchen from the main kitchen in steel containers and put in steam wells. DA-A stated desserts arrived plated with plastic over the top, in a tall enclosed cart on wheels. DA-A stated staff looked at the individual resident's paper menu and diet card in order to plate the food accurately. Resident diet cards included name, room number, allergies, likes, dislikes and food preferences. DA-A verified R5's diet card indicated an allergy to nuts: cashews and peanuts. DA-A stated he was working the evening of [DATE], when R5 received the scotch-a-roo bar. DA-A was unaware the kitchen brought over scotch-a-roo bars and stated he thought the bars looked like butterscotch bars. DA-A stated staff went by the menu to determine the food being served and on [DATE], there was no indication they were serving scotch-a-roo bars. During an interview with dietary staff on [DATE], at approximately 6:55 p.m., dietary aides (DA)-B, (DA)-C and (DA)-D, indicated they did not know there were nuts or peanut butter in scotch-a-roo bars. In addition, they were not able to articulate the difference in appearance between butterscotch bars and scotch-a-roo bars. The dietary aides verified no one had talked with them following the incident on [DATE]. They further stated there were no changes made to prevent it from occurring again, nor did they receive new training. DA-B stated they talked among themselves that night and just decided they needed to be more careful. During an interview on [DATE], at 12:51 p.m. CSD-A stated after the first incident with R5 she told staff not to change the menu on their own. CSD-A went on to say there was only one dessert that day and it was supposed to be butterscotch bars, but it was changed to scotch-a-roo bars. CSD-A verified scotch-a-roo bars were periodically served to residents in nursing care and when asked how staff would know they contained peanut butter, he verified they wouldn't. The facility policy titled Meal Tray Identification, dated 2012 indicated: A tray card (or approved alternative) is provided for each resident receiving meals from the culinary services department, to ensure that meal conforms to physician diet order and that likes, dislikes and individual special needs of the resident are being met. The culinary services director is responsible for providing an accurate tray card for each resident, with diet conforming to physician order, and which contains the following minimum information, updated as needed: --Name (first and last) --Room number --Diet exactly as physician ordered --Beverage preference --Food preferences --Known food allergies --Special needs (e.g., adaptive devices, salt substitute) The tray card will remain with the corresponding tray throughout the meal service. The immediate jeopardy that began on [DATE], was removed on [DATE], at 6:00 p.m. when it could be verified through observation the facility had implemented a new process to ensure residents were not served food for which they were allergic. Staff were observed to conduct a pre-meal service huddle to review resident diet changes, a red dot was added to diet cards to bring attention to food allergies. Review of diet cards and food menus were followed by staff to ensure adherence to resident food allergies and preferences. During meal service, food items which contained known resident allergens were labeled in order for staff to avoid serving them. In addition, the facility conducted a verification of food allergies on diet cards against food allergies identified in the resident's electronic medical record. Staff education on the meal tray identification policy, including utilization of diet cards, began on [DATE], continuing for staff to be conducted prior to the next scheduled shift staff worked. A communication book for staff had been established to identify resident diet changes. Lastly, an audit was conducted by the culinary manager or designee, of diet cards to verify they were accurately labeled for diet accuracy and food allergens. Audit results were reported to the quality council.

Based on observation, interview and document review, the facility failed to ensure prompt staff implementation of appropriate transmission based precautions including use of personal protective equipment (PPE), when an outbreak of gastrointestinal (GI) infection was identified affecting 4 of 57 residents (R11, R5, R6, R40). The facility failed to operationalize their Infection Prevention Program in order to prevent the spread of Norovirus which had the potential to cause serious illness, hospitalization and even death for residents, visitors and staff. The facility's failures resulted in an immediate jeopardy (IJ) situation. In addition to the IJ, the facility failed to ensure staff utilized proper hand hygiene and glove use during wound care for 1 of 4 residents (R31) observed for pressure ulcer care, and failed to ensure clean laundry was covered while being transported from in hallways from the laundry room to resident bedrooms with the potential to affect all resident who utilized the facility's laundry services. The IJ began on 2/11/20, when R11, R5, R6, R40 were observed to have symptoms of GI infection and the facility failed to implement appropriate transmission based precautions to prevent the spread. The IJ was identified on 2/12/20, and the Interim Executive Administrator, Director of Nursing (DON), Operations Vice President and Registered Nurse (RN)-D were notified of the IJ at 2:50 p.m. on 2/12/20. The IJ was removed on [DATE] at 4:57 p.m. however, noncompliance remained at the level of F (widespread scope and severity level, with a potential for more than minimal harm). The findings include: According to the Centers for Disease Control (CDC): Norovirus is the leading cause of vomiting and diarrhea from acute gastroenteritis (inflammation of the stomach and intestines) among people of all ages in the United States. The elderly, and people with other medical illnesses are most at risk for more severe or prolonged infection. Like all [MEDICAL CONDITION] infections, norovirus are not affected by treatment with antibiotics. Norovirus infections spread very rapidly. Healthcare facilities are particularly at-risk for outbreaks because of increased person-to-person contact. The illness can contribute to hospitalization and even death primarily in children and the elderly. During observation at approximately 7:30 a.m. on 2/12/20, the facility's infection preventionist (IP), RN-F was observed moving carts containing PPE around in the hallways. During observation at 8:15 a.m. on 2/12/20, an unidentified nursing assistant (NA) was seen wearing a surgical mask, no gown or gloves, while walking in the hall near the C unit. The NA stated, You might want a mask. We have diarrhea, lots of it. During interview on 2/12/20 at 12:33 p.m., licensed practical nurse (LPN)-E stated she had learned there was a GI illness outbreak during morning report around 6:00 a.m. that day. LPN-E stated staff should use appropriate PPE when providing cares including gowns and gloves. Furthermore, LPN-E stated she had not put PPE out for staff, but the IP had put out supplies for staff to use after arriving at the facility that morning. During interview on 2/12/20 at 12:23 p.m., NA-I said she had arrived to work and received report shortly before 6:00 a.m. and had been provided a list of people who were suffering loose stools, vomiting or both. NA-I stated she and NA-J had assisted R16 to the toilet early that morning and R16 had had multiple loose stools. NA-I said she had not been informed of what PPE to use, and only had gloves available when assisting R16, who had been on the list of persons ill with GI symptoms. During interview with RN-F (the facility's IP) and the DON on 2/12/20 at 10:18 a.m., RN-F stated the facility had, A possible norovirus outbreak. RN-F stated he was in the process of putting PPE carts out by the rooms of residents affected with symptoms of the illness and stated, It would be fair to say I started that process at about 7:30 a.m. RN-F stated he had also gone to the affected residents' rooms to gather additional information about the onset of symptoms and to let them know they needed to remain in their rooms for at least three days to prevent the spread of infection. RN-F stated he had learned about the outbreak symptoms on 2/11/20 at about 9:00 p.m. The DON then stated she had been notified by the night nurse RN-G, by text at 5:55 a.m. on 2/12/20, that four residents, R11, R5, R6, R40 were sick with GI symptoms. The DON stated she'd told RN-G to keep those residents in their rooms and to be sure to use precautions. The DON said she had then called RN-F to go to the facility. RN-F stated he thought he had arrived at the facility around 6:30 a.m., and said the DON arrived at about 7:45 a.m. RN-F and the DON confirmed the carts with the PPE were not put in place before their arrival to the facility, but stated any staff person could have retrieved the PPE and put it out for staff use. The DON also stated they had posted signs on the doors of the facility to alert visitors that they had an illness outbreak. The DON stated the signs were posted between 8 and 8:45 a.m. When asked, RN-F and the DON stated there were four employees who had called in sick that morning, and several had symptoms of GI illness. One employee worked in the dietary department, but the reason for her absence was unknown at the time of the interview. The DON stated the facility's policy related to employee absences for illness was for the staff person to call in, and for the person taking the call to document the employee's symptoms and notify the RN-F as the IP. RN-F said staff needed to be absent for at least 24 hours after symptom abatement and longer if it was a GI illness. The DON said she had contacted the dietary employee's supervisor for information about symptoms, but had not received any information as to whether or not the employee was ill with GI symptoms. The DON also stated they had notified their medical director but had not received any specific directions for testing any residents. RN-F said he had been reminding staff to use hand-washing instead of alcohol based hand sanitizer as that product was not effective against norovirus. RN-F also stated he was reminding nursing staff and housekeeping to use the appropriate cleaning products with the shortest kill time when cleaning and disinfecting. On 2/12/20 at 11:00 a.m., RN-F provided a document titled LTC (long term care) Acute Gastroenteritis Surveillance Line List. The document R11 was the first resident with symptoms, had become ill on 2/10/20 and lived on unit C, and the symptom identified was vomiting. The document indicated on 2/11/20, three more residents were identified to exhibit illness: R5 who resided on unit A had symptoms including fever and vomiting; R6 who resided on unit C had symptoms including diarrhea and vomiting; R40 who also resided on unit C had symptoms including fever and vomiting. On 2/12/20, an additional three residents had fallen ill with GI symptoms: R48 who resided on unit B had symptoms of fever and vomiting; R16 who resided on unit C had vomiting; and R39 who also resided on unit C had symptoms of vomiting and diarrhea. On 2/12/20 at 11:50 a.m., the DON stated she had notified the facility's medical director of the outbreak at 11:00 a.m. The DON stated the medical director had not provided any other recommendations but to continue what they were doing. During observation and interview on 2/12/20 at 12:25 p.m., dietary aide (DA)-C stated they were using their standard cleanser, Multiquat, to clean the dining room tables and equipment. DA-C stated they cleaned after every meal using the product. The product information did not indicate it was effective against norovirus. DA-C verified residents were still being served meals in the dining room. According to a document titled [STATE] Department of Health Resident GI Illness Log dated 2/18/19, indicated along with the initial four residents with GI symptoms, the following residents had also developed GI illness symptoms for a total of 35 out of 62 residents (56%): 2/12/20- R7, R34, R31 [DATE]- R18, R42, R8, R19, R28, R22, R29, R33 2/14/20- R36, R20, R41, R52, R13, R49 2/15/20- R4, R44, R43, R15, R9, R10, R207 2/16/20- R27, R37 2/18/20- R24, R30 In addition, three stool specimens had been sent for laboratory testing and on 2/18/20, two of the three results had been received by RN-F. Samples for R7 who lived on the C unit and R36 who lived on the B unit were both definitively positive for the norovirus. The third sample had not been returned by 2/18/20. The facility's [ENTITY] Management of Norovirus policy dated June 2017, included: It is the goal of BHS to recognize any potential foodborne outbreaks and to limit the exposure of residents and associates if it is noted. Further, the procedure indicated contact precautions should have been implemented immediately to prevent cross-transmission when a resident presented with signs and symptoms of gastroenteritis. In addition, the policy indicated any resident with acute symptoms should be restricted to their rooms, and staff providing care for the acutely ill were not to share their time with non-infected residents. The policy did not include instructions as to the proper solutions for cleaning equipment or the environment during an outbreak. The immediate jeopardy that began on 2/11/20, was removed on 2/12/20, when it could be verified the facility had implemented a system to identify residents at risk, those with active symptoms, identified and implemented appropriate PPE and cleaning supplies, and conducted comprehensive staff education. LAUNDRY: According to an observation and interview 2/14/20, 1:25 p.m. laundry specialist (LS)-A kept resident clothing that had been laundered in baskets or hung on racks on the clean side of the laundry room. The racks/baskets were observed to be open to the air with no covers. LS-A confirmed there were no covers for the racks. LS-A stated the industrial laundry that was returned to the facility from the commercial laundry came in covered containers, but the resident clothing washed on site was delivered to rooms using the racks/baskets without covers. According to an interview [DATE] at 12:32 p.m. RN-F stated laundry carts with clean clothing should be covered according to facility policy. The facility's Benedictine Health System Linen and Laundry policy dated July 2017 included: It is the policy of BHS communities to handle clean linen in a manner that reduces the chance of infection transmission. Additionally, the procedure included, Clean linens must be transported by methods that ensure cleanliness and protect from dust and soil during intra or inter-facility loading, transport and unloading. PRESSURE ULCER CARE: According to a History and Physical dated 1/8/20, R31 had [DIAGNOSES REDACTED]. During an observation on 2/18/20 at 10:36 a.m., RN-E prepared to provide wound care to R31's deep pressure injuries (DPI) on her heels. RN-E brought supplies to R31's room in a container and set them on a chair next to R31. RN-E then went into the bathroom and washed her hands, placing exam gloves in her pocket. RN-E returned to R31 and removed a compression sleeve from each of R31's legs. RN-E then elevated the resident's legs in a recliner and then without washing hands again applied a pair of gloves she removed from her uniform pocket. RN-E then looked around the room, went into the bathroom and returned to the room with a dry washrag that she placed between R31's feet and the recliner footrest. RN-E then removed the soiled dressing from R31's left heel and a foul odor was noted. The dressing was soiled with blood tinged drainage. The left heel had a moist appearing patch of necrotic tissue. RN-E disposed of the soiled dressing, and without removing the soiled gloves or performing hand hygiene, RN-E took a clean gauze pad from the box of supplies and after wetting it, cleansed the wound on the left heel. RN-E then removed the soiled gloves. Without [MEDICATION NAME] hand hygiene or washing her hands, RN-E removed another pair of gloves from her pocket and put them on. RN-E then took a sterile cotton tip applicator from the box of supplies and applied a layer of Iodosorb (a product that helps debride, maintain moisture and fight infection in wounds) to the necrotic tissue. Following this, RN-E applied an occlusive, adhesive dressing to the left heel. RN-E then removed her gloves. Following this, RN-E went into the bathroom where she placed more clean gloves in her pocket before she retrieved hand sanitizer from a dispenser in the bathroom to sanitize her hands. RN-E then returned to R31, again removing the soiled dressing, this time from the right heel, cleaned the wound without changing her gloves or [MEDICATION NAME] any hand hygiene, disposed of the gloves and reapplied clean gloves without washing or using hand sanitizer. RN-E applied Iodosorb to right heel wound and applied a clean dressing as she had on the left heel. RN-E then removed her gloves and disposed of them. Without performing hand hygiene or washing, RN-E re-applied the compression sleeves to R31's legs and then applied a pair of pressure reducing boots. She gathered up the supplies and then went to wash her hands. During interview with RN-E on 2/18/20, immediately following the observed wound care, RN-E stated she had received training in hand hygiene, stating they emphasized the importance of using alcohol based hand sanitizer in most cases. RN-E stated she had washed her hands prior to performing wound care and after, but confirmed she had not performed hand hygiene after removing her gloves. RN-E stated it was expected to perform hand hygiene after glove removal. During interview with RN-F on 2/18/20 at 12:06 p.m., RN-F stated the expectation for hand hygiene during wound care was to wash hands prior to performing cares and glove application; following removal of soiled dressings, gloves should be removed and hand hygiene practiced. Each time gloves were removed during wound care, or at any time, hand hygiene should be done. RN-F stated hand-washing should be performed when all cares were completed and before leaving the resident room. The facility's undated Non-sterile Dressing Change Competency policy, indicated during wound care a nurse should wash hands and apply gloves prior to removing the soiled dressing. After removal of the dressing, the competency policy indicated the gloves should be removed and disposed of, and wash hands again before continuing with clean supplies.

Based on interview and record review, the facility failed to ensure adequate assessment and root cause analysis were conducted to develop appropriate patient-centered interventions to minimize/prevent falls for 2 of 4 residents (R157, R61) reviewed for accidents. This resulted in an immediate jeopardy (IJ) for R157 who was admitted with a high risk for falls, continued to experience falls during her stay, and after five prior falls, fell on [DATE], sustaining a head injury. R157 later died . In addition, R61 sustained actual harm related to a fall which resulted in a right [MEDICAL CONDITION] requiring hospitalization and surgery. The immediate jeopardy began on [DATE] when R157 had an unwitnessed fall in the common area where she bumped her head on the corner of a brick wall, sustained injury to the right side of her forehead, and bruise to the left hand. The IJ was identified on [DATE], and the Operations Vice president, regional registered nurses RRN-A and RRN-B, Interim Executive Administrator and director of nursing (DON) were notified of the immediate jeopardy at 2:56 p.m. on [DATE]. The IJ was removed on [DATE], but noncompliance remained at the lower scope and severity level of G - isolated scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings included: During an interview on [DATE] at 3:29 p.m., family member (FM)-A stated she had inform facility staff about R157's normal routines from prior to her admission to the nursing home including: wake and sleep times, eating habits, and her routine trips to the bathroom. FM-A stated R157 would wake in the middle of the night for hot chocolate. FM-A said she had requested a walker to be placed nearby the resident's bed because R157 had to hang on to something to walk due to an unsteady gait. FM-A said the facility refused to implement the use of the walker. According to FM-A, the facility told FM-A having the walker near the bed, would encourage R157 to walk. FM-A said she'd asked the facility why they did not want R157 to walk and was told it may cause falls. FM-A said without the walker available nearby, it still caused R157 to fall, so she wondered what the harm would have been to allow R157 to have the walker? FM-A said after each fall, she'd asked facility staff whether the walker was nearby for her to use, and was always told it was not. FM-A said when staff finally implemented the walker, it was after the [DATE] fall. FM-A stated by that time R157 was unable to get up on her own, and R157 died [DATE]. FM-A said after the 6th fall, she'd asked the nurse to get the administrator and had asked the administrator if she'd seen her mother. FM-A said she'd told the administrator to look at her mother and never forget what she looked like. Pictures of R157 showed the resident with a bandage to her forehead, a large swollen nose and what looked bags of blood under her eyes. FM-A said the administrator had told her staff were nervous and afraid of FM-A. FM-A said to writer, all because I asked questions? R157's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R157 was cognitively impaired requiring extensive assistance of 2 persons for bed mobility and transfers. R157's MDS further indicated R157 was incontinent of bowel and bladder with no toileting program. R157's [DIAGNOSES REDACTED]. The MDS indicated she required the use of a walker and wheelchair for mobility devices. Furthermore, the MDS indicated R157 did not have a condition or disease with a life expectancy of less than six months. According to the electronic health record, R157 was admitted [DATE] from the hospital. The record indicated R157 had a 6-night stay in the hospital due to an unwitnessed fall with facial trauma and presumed urinary tract infection. R157's clinical progress note (PN) documentation dated [DATE], indicated the resident had clear speech, was usually able to express ideas and wants, could sometimes understand verbal content, had impaired vision, no behaviors and was occasionally incontinent of bowel and bladder. A PN indicated, R157 would be receiving therapy for transfer status. A Fall assessment dated [DATE], indicated R157 had experienced 3 or more falls in the past three months, had no limitation in range of motion and normally used a walker and or wheelchair. The PN indicated R157 fall score was a 22, (the assessment indicated anything over 10 reflected a high risk). The PN also indicated R157 would most likely not use the call light appropriately due to dementia so staff would anticipate her needs, and would check on her frequently and offer toileting routinely. R157's record lacked how often R157 was to be checked on, or routine toileting schedule according to fall assessment, and a schedule was not care planned. R157's care plan summary of goals dated [DATE] sent to family member included, will be safe and secure with assistance of staff and avoid significant injury; R157 will have needs met by staff and family to maintain quality of life. R157's care plan indicated R157 was a vulnerable adult and would be kept free from harm, neglect and maltreatment, and all incidents would be investigated by the administrator. The care plan included: If alert, may ambulate with Ax2 (assist of 2) using FWW (front wheeled walker), and w/c (wheelchair) to follow. Staff must have constant contract (sic) during all transfers & ambulation. May ambulate up to 100 feet or as tolerated. Regarding behaviors, R157's care plan included: Continue to keep awake and engage during the day, and in a settled and quiet atmosphere without interruption at night. Attempt to follow same daily routine as well as consistency of staff as able. R157 care plan for pain included to monitor for non-verbal s/sx (signs and symptoms): furrowed brow, agitation, resistance to cares, moaning, grimacing, [MEDICAL CONDITION], restlessness, decreased oral intake, and combativeness. R157's physician visit PN for admission to the nursing home dated [DATE] included: If patient is able to get back to assist of one and able to feed self, will be able to return to her previous living environment. Daughter feels that this would bring her improved quality of life. The physician's PN further indicated that was an appropriate goal to shoot for, and included Will be working with therapies and remains a high fall risk. Medications are minimized with the exception of [MEDICATION NAME] (antipsychotic) and [MEDICATION NAME] (antidepressant), which is noted to be appropriate goals of care and desire to avoid discomfort/distressing experiences. R157 PN were reviewed from ,[DATE] to [DATE]. The notes revealed R157 had 20 documented attempts to self-transfer, and 6 unwitnessed falls, the last three of which R157 sustained head injuries. In addition, according to the PN hospice services had been initiated [DATE] with changes in medications. Although the record identified fall interventions to be tried, they were not care planned, nor evaluated, to determine whether they were appropriate or effective. Review of R157's incidents/fall records included: -[DATE] at 6:45 a.m., was found sitting on the floor next to her bed, no injuries. Documentation indicated the resident's incontinent pad was soiled with a large amount of urine and feces. R157's blood pressure was recorded as ,[DATE]. Interventions were identified as: Introduce a bladder program-difficult d/t (due to) combativeness and refusal of cares. On [DATE], use of [MEDICATION NAME] (an antipsychotic medication) was added, 0.5 mg (milligrams) every 2 hours as needed for agitation, and staff to offer sensory stimulating materials. R157's care plan was not updated with interventions. -[DATE] at 11:15 a.m., found on the floor in her room, no injuries. Vitals taken included respirations recorded as 18, no others vitals obtained. Interventions identified included: [MEDICATION NAME] changed to liquid vs tablet and to give specialty blanket for comfort. R157's care plan was not updated with interventions. -[DATE] at 9:20 p.m., found on the floor in her room, no injuries. Vitals- blood pressure ,[DATE]. Interventions identified included: Medication refused often due to sleeping or combative. New orders for [MEDICATION NAME] and [MEDICATION NAME] to be given under the tongue. Offering toileting frequently at least upon rising and in the AM, before meals, and after meals, at HS (bedtime) and with nightly rounds. Documentation also indicated R157's daughter had requested she have walker in front of her at all times, and for staff to walk R157 when she is restless. -[DATE] at 4:50 a.m., found in common area hit head on corner of wall, injuries were a bump to the right side of the forehead with skin tear and bruise on left hand. Vitals-blood pressure ,[DATE], ~15 minutes later ,[DATE]. No other vitals. Interventions identified included: Hospice to review medications as daughter feels that her mother is sleeping too much. [MEDICATION NAME] ordered scheduled at 8:00 a.m. for agitation. [DATE] at 7:00 p.m., found in common area on the floor. Injuries were a bump on the left forehead. Vitals-blood pressure ,[DATE]. Interventions identified included: If sleeping comfortable in bed, do not try to wake her. Pharmacist completed a drug review. No recommendations made. [DATE] at 4:50 a.m., found in common hallway, injuries: bleeding and swelling from forehead, bridge of nose and nostrils. Vitals-none. Interventions identified included: walker within reach at all times, therapy performing fall screen ,[DATE], move to room on the LTC (long term care) unit. Review of R157's therapy notes did not include an evaluation/assessment of R157 after the [DATE] fall. R157's follow-up vital signs and neuro checks forms were reviewed for the falls ,[DATE], ,[DATE] and ,[DATE]. None of the checks had been completed in their entirety. The forms indicated R157's blood pressure readings were elevated at ,[DATE], ,[DATE] and ,[DATE]. Although a PN entry indicated Hospice would review medications as a follow up to the [DATE] fall, no other documentation was found regarding follow up, or increased blood pressures. During an interview on [DATE], at 3:14 p.m. Hospice registered nurse (RN)-D said R157 was admitted to Hospice due to dementia. RN-D also said although FM-A's requests may have come off as intimidating to staff, her expectations were not out of line. RN-D said the cares being requested were normal cares staff should have been able to do. When asked why R157 was not sent to the ER after the [DATE] fall, RN-D stated hospice avoids a transfer to the ER when they can keep the resident comfortable. When asked about comfort care, RN-D said comfort care allows for a natural death. When asked whether a fall with a sustained head injury would be considered a form of natural death, RN-D did not respond. During an interview on [DATE], at 5:45 p.m. the director of nursing and RRN-A verified the interventions documented from incidents reports or IDT (interdisciplinary team) recommendations were not implemented nor care planned. The DON verified the facility was aware of the family's request to have the walker nearby R157, and stated it was an unrealistic expectation for R157 to use her walker, and they were afraid R157 would self-transfer and fall. When asked why the walker had been implemented after the [DATE] fall then, the DON said, (R157) was no longer able to transfer herself after the last fall. During interview on [DATE], at 1:07 p.m. certified nurse practitioner (CNP) and social services said, Expectations for cares after a significant fall would be to follow policy, but of course they should put interventions in place. CNP was asked if she had spoken to FM-A regarding any treatments or plan of care for R157 after the [DATE] fall. The CNP denied having ever spoken to FM-A by phone or in person. The CNP said she was in contact with the hospice staff regarding R157 cares, but never with the family. R61's admission MDS dated [DATE], indicated R61 required physical assist of one person for transfers, walking in room, and toileting. In addition, the MDS indicated R61 was cognitively intact, had no prior falls, and [DIAGNOSES REDACTED]. A facility reported incident dated [DATE], indicated R61 had an unwitnessed fall at 5:00 a.m. The nurse was called to the resident's room and the resident was found on the floor. R61's head was against his bed, and his legs facing his recliner towards the door. The report indicated the resident had stated, I was transferring from chair to bed and did not recall how he'd gotten on the floor. The report also indicated the resident had his call light within reach, but did not use it for help, had non-grip socks on, but was not wearing shoes. When assessed, R61's VS and neurological checks had been recorded as WNL (within normal limits). Upper extremities ROM (range of motion) was identified as 'ok', but R61 had C/O (complained of) pain in right hip when the nurse attempted to do ROM on lower extremities. Pain on right hip rated ,[DATE] (10 being the worst on a scale of ,[DATE]) at the time of fall. (Physician) authorized resident to be sent to ER (emergency room ) for evaluation. R61's fall risk assessment dated [DATE], indicated the resident was at risk for falls as evidenced by a score of 14 (score of 10 or higher represents a high risk for falls). The fall risk assessment also indicated R61 had [MEDICAL CONDITION]/orthostasis, with recent [MEDICAL CONDITION] episodes. A facility fall event documentation dated [DATE], indicated the same information as the facility reported incident documenation. In addition, the fall event documentation indicated R61 had experienced a prior fall on [DATE]. Facility fall event documentation dated [DATE], indicated around 4 p.m., staff were informed by R61's family member that R61 had fallen in the bathroom. The family member stated, My father wanted to use the bathroom and I told him to wait. After a few minutes I heard something and when I went into the bathroom, I saw him on the floor. The event indicated on [DATE] fall champions had reviewed the fall from [DATE] and the new intervention in place was to have staff respond to call lights with as quick a response as able. R61's care plan, edited [DATE], included R61 was at risk for falls related to alteration in mobility with potential for injury. Approaches included respond to call lights with quick response and transfer assist of one to stand pivot. Urinary incontinence with actual/potential for alteration in elimination related to decreased mobility. Approaches included toileting assist of one to stand pivot for transfers. The care plan did not indicate how often staff should assist R61 with toileting. R61's physician progress notes [REDACTED]. The note indicated R61 had a history of [REDACTED]. R61's physician progress notes [REDACTED]. R61's progress notes indicated the following: [DATE] risk for falls as evidenced by score of score 14. [DATE] has an indwelling Foley catheter, placed [DATE]. [DATE] has had a few [MEDICAL CONDITION] episodes recently related to [MEDICAL CONDITION]/orthostasis. It is imperative to be careful and move slowly with all ambulation and transfers. He requires one assist, gait belt and walker for transfers and mobility. He is requiring one one liter oxygen with activity. [DATE] new orders remove catheter at 6 a.m. on [DATE]. [DATE] at around 1[AGE]0 (4 p.m.) this staff was informed by resident (family member) that the resident fell down in the bathroom. [DATE] Fall champions reviewed fall from [DATE]. New intervention in place to have staff respond to call lights with quick response as able. [DATE] alert with baseline confusion. Assist of one transfers, ambulation and cares. He continues to self transfer at times related to forgetfulness. [DATE] called to room [ROOM NUMBER]:00 a.m., resident on the floor. Per resident was transferring from chair to bed and did not recall how he got on the floor. Resident had call light in reach, but did not use for help. Sent to emergency room for complaints of pain right hip. [DATE] resident being admitted to hospital for right femoral neck fracture. [DATE] resident is having surgery for [REDACTED]. [DATE] update from family member, will no longer be holding bed. Resident will likely be passing in the next few days. R61's record lacked direction for how frequently staff should assist R61 with toileting after removal of the Foley catheter on [DATE]. During interview on [DATE], at 10:50 a.m., LPN-A stated R61 would self transfer and his oxygen saturation (a measurement of your blood oxygen) would drop at times. During interview on [DATE], at 12:53 p.m., RN-A stated R61 was pleasantly confused and did not have safety awareness. RN-A stated R61 self transferred on multiple occasions and had two falls in the facility. One fall was while transferring in the bathroom and one while transferring from his bed to chair, which resulted in a [MEDICAL CONDITION]. RN-A said R61 did not use his call light all the time, and verified R61 had his indwelling catheter removed on [DATE] at 6 a.m. R61 was always assist of one for transfers, ADL's (activities of daily living) and mobility. RN-A confirmed R61's record lacked direction for how often staff should assist with toileting after removal of the catheter. RN-A stated in regards to the new intervention implemented after the fall on [DATE], for staff respond to call lights with as quick a response as able, R61 did not always use his call light, so it woudl be difficult to respond to it any quicker. RN-A also confirmed R61 was not on a toileting program after removal of the catheter. Facility policy titled Integrated Fall Management dated [DATE], purpose is Fall risk assessment, identification and implemntation of approperiate inteventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls. The envoirnment of the fall is evlauated for possible contributing factors and addressed, the IDT reviews the fall and care plan changes and may if needed, implement additional interventions. The facility updated theie policy and proticol and included education and training of the changes on [DATE] and [DATE] which included doucuments titled belief and perception of nurses:Falls, Fall definitions, fall event checklist, post fall huddle, guidelines for immediate post fall medical record documentation, post management flow chart, fall interventions and a power point titled fall management and prevention program. Policy titled Safety and Supervison of Residents dated ,[DATE], prupose is to provide a safe enviroment ofr residents byt identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce harzards and risks and monitoring for the effectiveness and modifying intervention when necessary. The immediate jeopardy that began on [DATE], was removed on [DATE], when it could be verified the facility had implemented a system to identify residents' fall risks prior to admission, and with change in condition, initiated fall huddles to help identify root cause, identification of non-pharmacological interventions, and conducted comprehensive staff education.

Based on interview and document review, the facility failed to notify the provider and appropriate resident representative of a significant change in condition for 1 of 3 residents (R62), when R62 developed mental status changes and symptoms of hypothermia. R62 was sent to the emergency department (ED and was diagnosed with [REDACTED]. The facility's failures resulted in an immediate jeopardy (IJ) situation for R62. Although the immediate jeopardy began on 2/9/19, when R62 exhibited clinical change in condition symptoms and the facility failed to notify the physician and resident representative, the facility had implemented corrective action by 2/21/19 so the IJ is being cited as past non compliance. The operations vice president (OVP)-H, regional nurse specialist (RNS)-C, regional nurse (RN)-D, interim executive director (IED)-I and director of nursing (DON) were notified of the immediate jeopardy finding at 2:56 p.m. on 2/14/20. Findings include: R62's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R62 required one to two assist with activities of daily living (ADLs), was cognitively intact and had [DIAGNOSES REDACTED]. R62's resident progress notes included the following: On 2/9/19 at 1:27 a.m., staff reported the resident was having increased confusion at night, especially upon waking. The last 3 nights disoriented, episode of hallucination, seeing animals on the ceiling. Staff states that he has been easily reoriented with the exception of the hallucination episode in which it took several minutes for him to come out of it. Will continue to monitor. On 2/9/19 at 6:48 a.m., R62 had an episode of confusion with hallucination upon waking, low urine of output of 100 ml (milliliters), urine was dark and sludgy. BP (blood pressure): right arm [AGE]/42, left arm 101/70. Temperature was not reading above 92.0 (Fahrenheit) in either ear. Resident is noted to have cool skin. Purple mottling is noted at the finger pads and foot pads. HR (heart rate) 62 presence of pacemaker noted. LS (lung sounds) diminished with wheeze heard in the right upper field. Heart sounds are difficult to auscultate. Upon completion of assessment the resident's mentation had returned to baseline. Staff was alerted to practice safety and report any status changes to the LN (licensed nurse) immediately. Resident's condition was reported to oncoming LN who will repeat assessment and continue to observe for changes. Will continue to monitor. -2/9/19 at 2:06 p.m., resident continues to be lethargic today, very sleepy. He ate breakfast and lunch in the dining room as usual. VS (vital signs): (BP)117/76, pulse [AGE], SpO2 (oxygen saturation) 96%. His family member (FM-O) visited today and was updated about his condition, and he does not want him to be sent to the hospital at this time, but instead to keep monitoring him. (Late Entry recorded 2/10/19) for 2/9/19 at 9:37 p.m., resident continues to be lethargic and not at baseline, mentally. He responds to his name and to discomfort. He is able to answer questions but is slow with his responses. When asked how he is feeling states OK. He wheeled down to supper in his motorized wheelchair slowly and cautiously. No complaints of feeling cold. Coloring is at baseline. -2/9/19 at 9:57 p.m., resident continues to be sleeping and not as alert. When asked how he is doing/feeling, he states good. Denies having pain. -2/10/19 at 1:31 a.m., resident continues with periods of confusion especially upon waking, easily redirected. He has had no urine output this night as of 1:30 a.m. [MEDICAL CONDITION]: +3 bilateral LE (lower extremity). LS diminished with crackles all fields. VS: BP 96/[AGE], HR [AGE], RR (respiratory rate) 18 , SPO2 94%, T 91.4 (Fahrenheit) left ear, 90.8 right ear. Skin is cool to touch, denies being cold. Mottling to foot pads more pronounced this night since this morning. Petechiae type rash noted to the palms of hands bilaterally, and trunk. Resident denies pain, SOB (shortness of breath). Resident is urged to notify staff of any changes. Will continue to monitor. -2/10/19 at 3:23 a.m., resident called this writer to the room complaints of SOB. RR 16, SPO2 [AGE]% with [MEDICAL CONDITION] (continuous positive airway pressure). He stated he needed to take deeper breaths to feel ok. It was noted that the [MEDICAL CONDITION] was not functioning properly. [MEDICAL CONDITION] was removed and O2 (oxygen) applied PSO (per standing orders) at 2L (liters) NC (nasal cannula). SPO2 increased to [AGE]% but RR dropped to 12 bpm (beats per minute) with 5-10 second apnea during sleep. Resident was pleased with this course of action and agreed to call back if SOB progressed. Will continue to monitor. -2/10/19 at 10:32 a.m., resident was still lethargic and seemed confused this morning, unable to answer simple questions. Pupils round and reactive. He did get up and his mentation improved greatly, and he went out to breakfast in his electric wheelchair and filled out his menus, etc. His temperature reading was between 91-92 degrees, taken multiple times in both ears and also axillary, with different machines. Other VSS (vital signs stable): BP 102/57, P [AGE], SpO2 94% on RA (room air), RR 18. He stated that he felt fine. Petechiae noted to trunk and extremities. (Physician) on-call for (primary provider), was notified of his condition and she recommended to send him in to the ED for evaluation. (FM-G), POA (power of attorney), was also notified and she was in agreement. The resident also agreed to go in. Ambulance took resident to ED at 1030. -R62's summary of care document, dated 2/25/19, identified brief hospital course; admitted on [DATE] in profound hypothermic state of 32.8 centigrade (91.22 F). After being brought to the ED, he was diagnosed with [REDACTED]. Definitive treatment was initiated before transfer to the ICU. He received intravenous (IV) [MEDICATION NAME]/T3 and fluids. He was in encephalopathic state with inattention, thought disorganization and intermittent agitation requiring low dose [MEDICATION NAME] (antipsychotic). A critical care medicine document dated 2/10/19 at 6:14 p.m., included: this morning (R62) was found altered and noted to be hypothermic with temperature of 91.04 F and was referred to the ED. In the ED, his initial blood pressure was [AGE]/51, heart rate was [AGE] (paced). He was confused but answering questions appropriately. Labs were notable for TSH 61.8 (normal range for TSH 0.4 to 4.0 milli-international units per liter) and T4 less than 0.3 (T4 test in adults generally range from 5.0 to 12.0 micrograms per deciliter). He received warmed IV fluids and a Bair Hugger (warming blanket system ) and had improvement temperature to [AGE].2 F. During interview on 2/14/20 at 10:49 a.m., family member (FM)-G stated all of a sudden (R62) was not really there, mumbled seemed really out and was very weak. FM-G stated R62 did not know people, which came on suddenly. The hospital found his [MEDICAL CONDITION] was not functioning properly. (R62) received [MEDICAL CONDITION] medication and he became better. FM-G said she first became aware of (R62) change in condition was the day the facility had called her to have him sent into the hospital. FM-G stated she was the primary person to be contacted with a changes for (R62). FM-G stated she was not aware (R62) had a change in condition on 2/9/19 and the facility had asked FM-O if R62 should be sent to the hospital and FM-L had declined to have R62 sent to the hospital. During interview with R62's primary physician on 2/14/20, at 11:06 a.m., physician (P)-J stated staff were expected to notify the physician with this type of significant low temp, confusion and mottling. The doctor said no changes of condition had been communicated to him until 2/10/19. The physician said the resident's condition change was significant which would merit notification of the provider, to ensure increased evaluation was initiated. P-J stated, This was significant [MEDICAL CONDITION], rarely seen, being notified earlier might have helped, I am sure it would have. During interview on 2/14/20 at 11:19 a.m., registered nurse (RN)-C stated R62 was lethargic, but he was still going about his day. RN-C verified she had asked FM-O on 2/9/19, if R62 should be sent to the hospital and he had declined to have R62 sent. However, RN-C further verified FM-O was not R62's primary person to be notified for a change of condition and said she'd been unaware FM-G should have been contacted regarding R62's change in condition. RN-C verified she had not documented a temperature for R62 and stated if she had checked R62 temperature, she would have documented the result. RN-C verified she had not documented an assessment of R62 skin condition. During interview on [DATE], at 11:34 a.m., the director of nursing (DON) verified the provider had not been called regarding R62's significant changes. The DON said the expectation was for staff to contact the provider when staff notice abnormal vitals or change in baseline. Further, the DON said staff could utilize an on call nurse for a second opinion if unsure when to call the provider. The DON also stated she would have expected FM-G to be contacted right away with R62's change in condition on 2/9/20. The facility had implemented interventions in response to the situation by 2/21/19. Therefore this is an issue of past non-compliance. Interventions verified as having been implemented by the provider included investigation of the situation, education of all nursing staff, review of facility policies and implementation of audits. The facility's policy re., Change In Condition was reviewed. The policy included: When a change in condition is identified, the nurse will do the following: Assess significant change in the resident's condition noted through direct observation, interview or report from other staff. Obtain a set of vital signs and repeat as needed or as ordered. Conduct a symptom review and assessment, as condition warrants. Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitoring as directed. Document symptom(s) assessment, observations, resident/resident representative, and medical provider notification. Monitor and provide treatment as ordered by the attending provider.

Based on interview and record review, the facility failed to provide personal hygiene, medications, food and water for 1 of 1 resident (R157) reviewed for an allegation of neglect. The facility's failure resulted in an immediate jeopardy (IJ) for R157 who did not receive care and services to meet basic needs including, toileting assistance, food, water and medication administration in a timely manner. The immediate jeopardy began on 8/13/19 when R157 was intentionally left in her room for approximately 13 hours without provision of care. The IJ was identified on 2/14/20, and the operations vice president, regional registered nurse (RRN)-A and RRN-B, interim executive administrator and director of nursing (DON), were notified of the immediate jeopardy at 2:56 p.m. on 2/14/20. The IJ was removed on 2/18/20, but noncompliance remained at the lower scope and severity level of D - isolated scope and severity level, with the potential to cause more than minimal harm. Finding included: R157's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R157 was cognitively impaired requiring extensive assistance of 2 persons for bed mobility, transfers, dressing, toileting and one person assist for eating. R157's MDS included R157 was incontinent of bowel and bladder with no toileting program. R157 [DIAGNOSES REDACTED]. The MDS also indicated she did not have a condition or disease with a life expectancy of less than six months. During an interview on 2/12/20 at, 3:29 p.m. family member (FM)-A said she told the facility about R157 normal routine she had prior to being admitted to the nursing home which included wake and sleep times, eating habits, even her normal bathroom trips even what to offer R157 if she wakes in the middle of the night. FM-A said she felt she had to complete the cares for her mom because the staff were not doing it. FM-A said the administrator had told the FM the staff were nervous and afraid of FM-A. FM-A said to writer, all because I asked question's? FM-A described a time line for R157: -8/9/19 FM-A received a call from the director of nurses and the quality manager (who also holds their administration license) asking for someone to come sit with her mom because they did not have the staff to handle her. -8/12/19 during a care conference FM-A was informed staff did not feel the resident would be able to return to her previous living arrangements (assisted living), and FM-A was asked again about enrolling R157 in hospice services. FM-A said hospice was described as a service to enhance R157's life, not just for a person who was near death. -8/13/19, at around 10:30 a.m. R157 was in her bed. FM-A said she had verified with RN-C, R157 had been there since 9:00 p.m. the night before. FM-A said she got R157 up, gave her some water, assisted with her lunch and had to ask for her medications to be given. FM-A said she had reported the incident to the nurse manager. -[DATE] FM-A noticed there was a jug of water in R157's room with a straw that had not been opened. FM-A asked R157 if she was thirty, and R157 replied yes, very. R157 drank 425ml (milliliters) at one time. FM-A added she had added to the white board in R157's room, to offer water because the jug the facility supplied was too heavy for R157 to lift. -[DATE] at 12:30 p.m. FM-A visited R157 finding her sitting in the TV room in a recliner, still in her pajamas. FM-A asked licensed pratical nurse (LPN)-A how long she R157 had been sitting in the chair. LPN-A told her since about 9:00 p.m. the night before, verifying R157 had been provided no food, no water, no medications and could not get out of the chair due to the chair being in a full reclined position. FM-A was offered assistance with R157 but FM-A declined. FM-A said she was upset no one had attended to R157 for over 15 hours. There was a care conference that day where FM-A expressed the concern for lack of care being provided to R157. -[DATE], at 10:45 a.m. FM-A arrived to find R157 asleep in her room. FM-A asked staff how long she had been asleep and staff said all night. Nurse manager (NM)-A assisted FM-A with changing R157. FM-A said R157 had not had anything to drink and her brief was soaking wet. NM-A returned later to update FM-A, a vulnerable report was filed on the facility due to the lack of care being unacceptable. R157's progress notes (PN) included an entry on 8/12/19 at 9:20 p.m., and not another until 8/13/19 at 1:31 p.m. R157's PN dated 9/15/19 at 8:49 p.m., indicated R157 went to bed after supper and at 10:15 p.m. was brought out to the common room, given yogurt and juice, back to bed at 11:30 p.m. on [DATE] at 1:30 a.m. R157 was brought back out to the common room where she remained the rest of the night and most of the day shift according to PN written at 1:12 p.m. on [DATE]. R157's delineation of services between the facility and hospice company indicated the facility was to provide safe enviornment of care, staff responsibilities to meet the care needs, assist with activities of daily living and administer medications. R157's care conference note indicated FM-A provides personal care for R157, and indicated FM-A had mulitiple questions answered during the care conference, however did not indicate what the questions were, or how they were answered. R157's clinical admission assessment dated [DATE], indicated the resident had clear speech, was usually able to express ideas and wants, sometimes understood verbal content, had impaired vision, no behaviors and was occasionally incontinent of bowel and bladder. R157's care plan dated 7/31/19, indicated R157 was a vulnerable adult and would be kept free from harm, neglect and maltreatment, and all incidents would be investigated by the administrator. Revision to the care plan 10/3/19, included for R157 to be encouraged to attend out of room activities, to decrease risk of isolation and increase mental and social stimulation. R157's care plan also identified a problem with behaviors dated 8/14/19: Continue to keep awake and engage during the day, and in a settled and quiet atmosphere without interruption at night, and attempt to follow same daily routine as well as consistency in staff as able. R157's Care Plan Summary of Goals dated 7/31/19, included: will be clean, dry and odor free daily, will be safe and secure with assistance of staff and be dressed and groomed appropriately daily, will be kept free from harm, neglect and maltreatment, will be kept comfortable as able with collaboration with Hospice, resident will have needs met by staff and family to maintain quality of life. During an interview on 2/13/19, at 3:14 p.m. Hospice regiserted nurse (RN)-D said R157 was admitted to Hospice due to dementia. RN-D also said although FM-A's requests may have come off as intimidating to staff, her expectations were not out of line. RN-D said the cares being requested were normal cares staff should have been able to do. RN-D was asked about R157 having been left unattended in wet clothes, and not changed. RN-D verified that would not reflect staff providing the care needed for the resident. RN-D further stated FM-A was R157's best advocate, and the staff were not [MEDICATION NAME] good standards because they weren't listening to FM-A. RN-D said she had spoken to the administrator previouly, and the administrator had told her staff were told to leave the room by FM-A. During an interview on [DATE] at 5:45 p.m., with the DON with RRN-A, the DON verified they may have anywhere from 10-14 nursing staff on the floor at any time, in addition to the DON and other office staff, to meet the needs of their residents up to a census of 62. The DON stated R157 received hospice services and that added additional staff. When asked about FM-A's concerns about R157 being left to sit in urine and feces, the DON said the daughter had asked staff to leave R157 alone and not wake her. The DON verified R157 had not been provided care because staff did not want to go against the daughter's wishes. When asked if R157 was neglected as a result of staff not providing care, the DON acknowledged this was neglect. During an interview on 2/18/20 at 2:12 p.m., with the administrator, operations vice president and interim Executive administrator present, the administrator said the situation with R157 occurred because there was communication from the daughter to leave R157 alone. The immediate jeopardy that began on 8/13/19 was removed on 2/18/20, when the facility had developed an implemented an appropriate removal plan including comprehensive education for staff related to care for residents to meet their hygiene, medication administration and resident supervision needs while maintaining resident rights. In addition, the facility implemented systems to improve on complaint and grievance communication from families and/residents.

Based on observation, interview and document review, the facility failed to assess, develop and implement interventions to reduce the risk of pressure ulcer development or decline, for 2 of 4 residents (R31 and R39). R31 experienced harm, deterioration or persistence of pressure ulcers related to the facility's failures. Findings include: According to the National Pressure Ulcer Advisory Panel (NPUAP): Stage II (2) Pressure Injury includes: Partial thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage III (3) Pressure Injury includes: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage IV (4) Pressure Injury includes: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable Pressure Ulcer includes: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. According to the electronic health record (EHR) face sheet R31 suffered from age-related debility, delusional disorder, [MEDICAL CONDITION] and among other things, pressure-induced deep tissue damage of right and left heels. R31 was also listed as being a hospice patient. R31's care plan identified a problem area, category: pressure ulcer initially dated 7/23/14 and edited 1/3/20. The interventions included, vascular boots when in bed as resident will allow (1/3/20), bed mobility: assist of one as needed ([DATE]), keep skin as clean and dry as able ([DATE]), lamb's wool between toes ([DATE]), pressure reduction mattress to the bed and pressure reduction cushion to the chair ([DATE]), bed cradle to end of bed to reduce pressure on toes (3/6/17), inspect skin with cares. Report reddened areas, rashes, bruising or open areas to charge nurse ([DATE]). Interventions failed to include any standard nursing actions such as repositioning, off-loading, nutritional interventions or specific skin cares. The care plan did not indicate a problem related to a refusal of pressure reducing interventions. A progress note in the EHR dated 11/19/19 at 1:40 p.m. included: During bath today it was found that resident had purple areas on bilateral heels. Left heel measures approximately 2.5 cm (centimeters) by 2.8 cm and right heel measures approximately 2.5 cm by 2.2 cm. Resident denied pain. SBAR (Situation, Background, Assessment, Recommendation) submitted to NP and [ENTITY] was called and notified. A progress note dated 11/21/19, indicated the nurse practitioner had seen R31 for deep pressure injury of both heels and gave an order to assure heels were offloaded off the surface of the bed at all times. A progress note from 11/26/19, resident had behaviors and refused her elevation and boots. A progress note from 12/9/19, indicated refusal of care. No further wound assessment was documented in the progress notes until 1/13/20 when the left heel measurements were identified as 4 cm by 3.3 cm; and the right was 4 cm by 3 cm with 1 cm of redness surrounding the wound. During observation 2/11/20 at 3:55 p.m., a hospice registered nurse (RN)-D and a hospice nurse practitioner NP-F were providing wound care and assessing the wound. The resident's heels had wounds about the size of a silver dollar covered with a thick, but moist brownish eschar (necrotic tissue) with a thick, white drainage coming from around the edges of the wound. The skin surrounding the wound was red in color. RN-D stated the week prior, the wounds had smelled so bad it was noticeable even upon entering the room and without uncovering the wounds themselves. NP-F stated she was primarily visiting R31 to review her medications on that date, but did review the wounds and stated they were not improved. When interviewed on 2/10/20 at 3:08 p.m., family member (FM)-P stated R31 had pressure ulcers on both of her heels. FM-P stated she also thought perhaps R31 had a sore on her bottom. FM-P said the facility had tried to put pressure reducing boots on R31 but she had refused so she didn't think they were using them anymore. In addition, FM-P was unsure of what was being done to reduce pressure to the heels, but stated she and her brother were often at the facility to oversee R31's care to make sure she got the assistance she needed. FM-P stated she felt more at ease having hospice involved as that provided more help. (A progress note dated [DATE], indicated the family requested a referral to hospice care.) During the conversation with FM-P, R31 was observed to be sitting in her wheelchair wearing slippers with her feet resting on the floor. During observation at 8:00 a.m. on 2/12/20, R31 was sitting in her wheel chair. Large pressure reducing boots were observed laying in a chair in her room. R31 was wearing slippers and her feet/heels were resting on the foot pedals of the wheelchair. According to a nursing assistant plan of care dated 2/14/20, R31 required assist of two persons to transfer with a Hoyer lift, assist of one person with bed mobility and personal cares. Skin marked as being at risk. A note section indicated a nurse was to apply Rooke Boots at bedtime, off load feet from bed with pillow. The nursing assistant plan of care failed to indicated off-loading or repositioning should be done at any time or frequency through the day or night. No directions were given to document or report any refusal of cares. A request was made for nursing assistant documentation of cares from August of 2019 through February 2010. The documentation did not include any indications of a turning or repositioning program or off-loading. The documentation did not include any refusal of such cares. During interview 2/14/19, 9:27 a.m. a licensed practical nurse (LPN-E) stated there was not one person responsible for monitoring wound in the facility, but if a wound needed to be monitored there would be an order in the chart to monitor it once a week. LPN-E said documentation should be done in the progress note and should include the size of the wound, the condition of the wound bed and the condition of the skin around the wound. LPN-E stated she would notify a doctor if the wound was getting worse or not getting better. LPN-E was unaware that the EHR contained a section titled Wound Management specific to wound assessments. According to an interview 2/18/19 at 11:57 a.m., RN-A a clinical manager, stated hospice was responsible to monitor wounds for R31. RN-A stated documentation on wounds assessed by facility staff should be included in the Wound management portion of the EHR. RN-A stated R31 should have off-loading performed frequently throughout the day and night. RN-A defined frequently as meaning at least every two hours and stated that should be listed in the resident care plan. Hospice care plan problem area integumentary (skin) dated as starting 12/3/19 with a goal for patient/caregiver will understand and demonstrate how to care for patient's skin/wound and indications for when to contact Hospice through 3/9/20. A listed intervention was to educate on measures to reduce the risk of skin breakdown and infection with the following description: SN (skilled nurse) to educate on how to perform a visual skin inspection to look for signs and indications skin breakdown, SN to educate on positioning for pressure relief measures offloading techniques signs and symptoms to monitor, and measure to help keep the skin clean and dry. Wound care intervention included wound care/dressing change performed by hospice nurse and facility nurse. Hospice care plan did not indicate they were solely responsible to assess and document on the wounds. During an interview 2/18/19 at 12:28 p.m., certified nurse practitioner (NP)-E stated she had spoken with R31 multiple times about recommendations for her pressure injuries but that given R31's age, refusal of recommendations and overall condition, it was likely unavoidable that she end up with pressure areas. A request was made to the facility to provide all medical provider notes from September 2019 through February 2019 including providers contracted by the facility or through hospice: The facility provided no notes from NP-E indicating any interactions, assessments or orders. A physician recertification note from an on-site visit [DATE], also made no mention of skin breakdown on heels or coccyx. A Physician order [REDACTED]. An order from NP-E dated 11/19/19, indicated staff were to assure while resident was in bed, to keep heels elevated off the surface of the bed at all times. Offloading heel boots were also recommended for bilateral use. In addition, NE-E recommended assisting R31 with mobility to assure she did not have to self-propel utilizing her heels. According to a History and Physical by a physician dated 1/8/20, R31 had a [DIAGNOSES REDACTED]. The physician documented that R31 was uncomfortable with removal of socks for examination of feet, but she had an order for [REDACTED]. Hospice RN visit note dated [DATE] (faxed to facility on 1/26/20), indicated R31 had pain in her heels from deep tissue injures and pain when sitting in one spot too long. The note further indicated R31 had very fragile skin on lower extremities and an excoriated area on buttocks likely caused by friction. The following assessment of the right heel indicated it was non-healing, 3.5 cm by 4 cm in size with small amount of brown, foul drainage. The Left heel was assessed as non-healing 4 cm by 3.8 cm with small amount of brown, foul drainage. Notation regarding any refusal of care, or refusal of repositioning, offloading or other standard skin protective interventions was not included in the note. Hospice RN visit note dated 2/6/20 (faxed to facility 2/10/20), indicated assessment of the right heel's deep tissue injury (DTI) as non-healing, size 4 cm by 3 cm with black, necrotic slough tissue with a small amount of foul, brown drainage. Left heel DTI, non-healing, 4 cm by 3 cm with black, necrotic slough tissue with a scant amount of foul brown drainage. The note also indicated R31 had a pressure injury (PI) on her bottom that was not visualized during the visit. Notation regarding any refusal of care, or refusal of repositioning, offloading or other standard skin protective interventions was not included in the note. A facility Skin Integrity Event: pressure sore/status dated 1/28/20 at 4:10 p.m., indicated R31 had a stage II pressure area (stage two involves the upper layers of the skin effecting the superficial, upper layers of the skin) 1 cm by 1cm and 0.2 cm in depth on the right buttocks and 2 cm by 1.5 cm by 0.2 cm of depth on the left buttock. All additional areas of assessment with the character of the wound bed, any drainage or odor etc. were not completed. No contributing factors were documented, no notifications to medical provider were documented and no immediate measures or interventions were documented. One follow up progress note associated with the event was documented on 2/9/20 at 4:57 p.m., indicating the left buttock wound was 2 cm by 1.5 cm in area with a pink wound bed and no drainage or odor, and the right buttocks wound was 1 cm by 1 cm with a pick wound bed, no drainage or odor. A facility Skin Integrity Event dated 11/21/19 at 2:14 p.m., indicated R31 had pressure induced deep tissue damage to both heels. Right heel wound measured 2.5 cm by 2.2 cm and left 2.5 cm by 2.8 cm. The additional details and assessment were again left incomplete as were contributing factors or immediate interventions; however it did indicate the physician and family had been notified two days earlier on 11/19/19. The Wound Management Detail Report from the EHR for R31 indicated an initial identification date of 11/21/19, with assessment charted 1/28/20, for the right heel wound including measurements of 3.5 cm by 4 cm in size with purulent, foul drainage. Documentation on 2/9/20 indicated the wound measured 3.5 cm by 4 cm with purulent, foul drainage. For the left heel, documentation on 1/28/20 included measurements of 4 by 3.8 cm, with purulent, foul drainage. No Wound Management Detail Reports with documentation between 11/21/19 and 1/28/20 were provided by the facility, or observed in the EHR. According to interview with the director of nursing (DON) on 2/14/20 at 9:45 a.m., any new skin injury or redness should be immediately entered into the EHR as an event. The DON said if the first person to note the wound is a nursing assistant, they are to report so a nurse can create the event. The nurse should document measurements and a detailed description, write an SBAR and communicate with the physician and family. The communication should be documented. DON stated for pressure wounds, the expectation was for dressing changes as ordered; for an assessment to be completed every week and documented under the event or in their wound management system or in the progress notes. DON stated they did not currently have a dedicated wound nurse so it was up to the unit clinical manager to collaborate with the floor nurses to make sure assessments were completed. DON stated they had meetings every morning where the clinical manager met with the DON, the MDS nurse, therapy, the Administrator and social services, and wound progress was discussed. The DON stated she was unfamiliar with the specific details of R31's heel ulcers and said she had not personally seen them. The DON stated she knew R31 had been provided pressure reducing boots to wear but had been refusing them. The DON also stated a progress note should be entered in the EHR when residents refuse their care and a medical provider should be notified of the refusal as necessary. The facility's Benedictine Health System Prevention and treatment of [REDACTED]. The policy indicated skin integrity would be monitored and abnormal findings documented: skin observed daily with cares. If any concerns are noted they are to be reported to the nurse. Skin audits are to be performed weekly by a licensed nurse. The policy indicated an evaluation should be done for pressure reduction interventions and nutritional interventions. The nurse is to stage, measure and examine the wound bed and surrounding skin weekly. If there is deterioration the provider is to be notified. If no progress in two weeks to notify the provider and re-evaluate the plan of care. R39's quarterly Minimum Data Set (MDS) assessment, dated 1/7/20, indicated R39 required one physical assist with activities of daily living (ADL's), had severe cognitive impairment, two stage three pressure ulcers upon admission and [DIAGNOSES REDACTED]. R39's care plan, dated revised 1/13/20, indicated R39 had potential for alteration in skin integrity related to: impaired mobility, admitted with pressure ulcers and interventions included keep vascular boots on at all times (even when in bed), keep skin as clean and dry as able. Monitor skin with cares; red areas, rash, irritation, skin tears, bruises. Notify nurse. Nursing to follow up with physician as needed Monitor wounds for s/sx of infection; excessive redness, increased swelling, fever, pus, or foul odor.etc. Follow up with physician for concerns. Pressure reduction mattress to the bed and reduction cushion in chair, or wheelchair and R39 required assist with mobility. R39's care plan lacked to indicate how often R39 should be repositioned. R39's physician progress notes [REDACTED]. It is noted to be pink at this time with no drainage noted. Cream applied at this time we will continue to monitor. New orders included OT (occupational therapy) to evaluate for appropriate cushion due to report of developing pressure ulcerations buttocks, recommend low air loss bed or alternating air mattress and resident to rest am and pm out of wheelchair. R39's current physician orders [REDACTED]. Monitor daily and report worsening condition of infection. Avoid shoes, utilize Rooke boots for protection except for outings. [DATE] cleanse bilat lower extremity wound with facility wound cleanser and gauze. Apply Honey alginate, moistened or [MEDICATION NAME] to wound base. Apply skin barrier film around perimeter of wound to reduce maceration. Cover with secondary dressing, island gauze or foam. Rooke Boots at all times. Avoid sleeping on right side. Keep extremities elevated. Two layers [MEDICATION NAME] bilateral or low stretch wraps to be applied for [MEDICAL CONDITION] management. Notify provider for worsening, signs or symptoms of infection. Use Rooke Boots only. Avoid sleeping on right side. Pressure ulcer of left heel, stage 3. Keep vascular boots on at all times (even when in bed), remove to transfer or walk ONLY. OT to eval and treat for appropriate cushion due to report of developing pressure ulcerations buttocks. Nurse to inspect, measure, and document (R) and (L) foot ulcer condition noted on admission in MATRIX Wound Management weekly. Recommend laying down with feet at or above heart level for at least 1-2 hours AM and PM. Review of R39's resident progress notes, dated since admission on 9/17/19, lacked consistent documentation of weekly would assessments for R39's pressure ulcers located on his feet which were present on admission. In addition, the progress notes identified on 1/28/20 at 5:47 a.m., has small stage two pressure ulcer on left buttock upper thigh. There was no other documentation in R39's record by the facility nursing staff regarding the left buttock pressure ulcer. During observation on 2/10/20, at 1:28 p.m., R39 was seated on a cushion in his wheelchair in his room. During interview on 2/11/20, at 10:33 a.m., family member (FM)-S stated R39 has had wounds on his feet when he was admitted to the facility. FM-S stated the facility had not informed her of the development of the pressure located on R39's left buttock. During continuous observation on 2/12/20, from 7:19 a.m. until 10:03 a.m. (a period of two hours and 44 minutes), R39 remained seated in his wheelchair without being repositioned. During interview on 2/12/20, at 10:03 a.m., licensed practical nurse (LPN)-A stated there were no treatment orders on R39's current physician orders [REDACTED]. LPN-A stated she had completed treatment for [REDACTED]. buttock area. LPN-A stated it was informed about R39's pressure ulcer on his left buttock during report this a.m. LPN-A stated wound assessments with measurements should be documented in the resident progress notes once weekly. LPN-A verified R39's records lacked consistent documentation of weekly wound assessments being completed for R39's pressure wounds. LPN-A confirmed there was no documentation in R39's record of FM-S being informed of the development of the left buttock pressure wound. LPN-A verified R39's record lacked to indicate how often R39 should be repositioned and there was no assessment completed to determine how often he should be repositioned. LPN-A confirmed R39 could not offload totally of of his buttocks independently. During observation on 2/12/20, at 10:44 a.m., with LPN-A, R39 had a [MEDICATION NAME] dressing in place on left buttock. During interview on 2/12/20, at 10:52 a.m., nursing assistant (NA)-A verified R39's care guide did not indicate how often R39 should be repositioned. NA-A stated she was aware R39 had an open area about dime size on his left buttock. NA-A stated R39 should be repositioned at least every two hours. During interview on 2/12/20, at 2:01 p.m., director of nursing (DON) verified weekly assessments of R39's pressure wounds were not being completed. DON stated she would expect a physician order [REDACTED]. During interview on 2/12/20, at 3:16 p.m., the DON stated she expected repositioning needs to be on the care plan for R39. DON verified R39 was unable to reposition himself.

Based on document review and interview, the facility failed to ensure physician orders [REDACTED]. This practice caused harm for R201, R209, R213 when medications were not administered in accordance with physician orders [REDACTED]. Findings include: R201's Face Sheet indicated the resident was admitted to the facility at 11:00 a.m. on 8/25/18. A Progress Note (PN) dated 8/25/18, at 2:01 p.m. indicated R201 had a medial history of hypertension, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. The note indicated R201 had been admitted to the nursing home for physical and occupational therapies (PT/OT) following a right shoulder surgery. The note also indicated R201 was expected to return to the previous level of functioning, and indicated R201 required assist of 1 for activities of daily living (ADLs) and is continent of bowel and bladder. R201's hospital Discharge Summary dated 8/25/18, included an order for [REDACTED].; AM Med Pass 7:00 AM-10:30, PM, Med Pass 2:15 PM-6:30 PM. On the Physician order [REDACTED]. Although the physician had identified the need to correct the order to twice/week on Mon & Fri as of 8/27/18, R201's Medication Administration Record [REDACTED]. According to the MAYO Clinic website article dated 2/7/18: The main consequence of vitamin D toxicity is a buildup of calcium in the blood (hypercalcemia), which can cause nausea and vomiting, weakness, and frequent urination. R201's PNs from 8/31/18, 9/1/18, 9/5/18, 9/7/18 and 9/14/18, indicated R201 had expressed complaints of nausea and vomiting, and had staying in bed entire shifts. The notes indicated R201 had little interest in any activity and had presented as tired on each of those days. R201's PN dated 9/21/18, at 1:06 p.m. included an entry from Social Services indicating R201 had reported she'd felt like she was moving or speaking slowly every day in the past two weeks. A PN dated 9/23/18, at 1:01 p.m. indicated R201 had another emesis. A PN dated 9/26/18, at 2:16 p.m. indicated R201 had refused to get out of bed and that her blood pressure had been elevated before breakfast. The note indicated the nurse practitioner NP had been notified of R201's elevated blood pressure. A PN dated 9/26/18, at 7:11 p.m. indicated the NP had given orders for R201 to be sent to the local emergency department due to receiving too much vitamin D, the potential cause of R201's nausea, vomiting, tiredness and weakness. A facility Medication and Treatment Incident Report with date 9/26/18, with date of incident on 8/27/18, indicated R201 had received vitamin D3 twice a day instead of twice a week. Although R201 had received the extra doses of vitamin D3 8/26 and 8/27/18, 9/6, 9/7, 9/15, 9/16 and 9/17/18, the Medication and Treatment Incident Report only included the extra doses given on 9/16 and 9/17/18. R201's hospital Discharge Summary dated 10/2/18, indicated R201 had been hospitalized from [DATE] to 10/2/18, for moderate hypercalcemia (high calcium level in the blood) secondary to hypervitaminosis D (vitamin D toxicity). The Discharge Summary also also had presented to the hospital with a three day history of confusion, nausea , generalized weakness and constipation. The discharge notes included She was aggressively volume resuscitated and given Zoledronic acid and high doses [MEDICATION NAME] for 2 days . Her mental status improve to baseline with correction of hypercalcemia . During an interview with the facility administrator on 10/25/18 at 12:20 p.m., the administrator stated the facility staff had worked hard to correct the medication error problem. During a follow up interview at 1:26 p.m., the administrator and director of nursing (DON) said their medication system problem had been identified with weekend admissions. They said that on week days a health unit coordinator (HUC) places in orders and is doubled checked by a nurse. On weekends only they had one nurse transcribe orders with no verification system. In addition, they stated R201 was seen by attending physician on 8/27/18, and the provider had noticed the medication error which they stated had occurred due to the second staff check being missed. Upon identification of this error, they had changed their system to have all orders doubled checked. The DON also stated they'd had an in house meeting for staff who transcribe orders however, no education or training had been completed to double check medication labels before administration. During interview on 10/26/18 at 10:01 a.m., nurse practitioner (NP)-A verified R201's physician had identified the transcription error on 8/27/18. However, NP-A stated she had not been notified of the error until 9/26/18. NP-A stated she expected to be updated in a timely manner regarding any medication errors. During interview on 10/26/18 at 3:22 p.m., R201's attending physician, who had originally identified the transcription error on 8/27/18, said she was not aware of the doses given after having identified the transcription error. R201's physician explained that when a resident discharges from the hospital to the facility, the physician tries to see the resident within 24 hours. The physician stated orders are provided to the facility by at least 4:00 p.m. and should be in place no later than the next morning. During interview on 10/26/18, at 3:49 p.m. the administrator, DON and administrator in training, verified all orders are scanned in by the HUC. The DON stated there process includes: the doctor sees the resident within 24 hours, medications are reviewed by the doctor, then documents are uploaded by the HUC. The nurse then signs after checking the orders and then transcribes the orders to the MAR (medication administration record) for accuracy. The DON said the process was missed for R201's Vitamin D. The DON said the attending physician had written on two different forms regarding medication changes. The DON said following the incident with R201's vitamin D, the team had looked at the cause and asked NP-A to be part of the discussion. She said Epic (the facility's electronic medical records system) had started in (MONTH) or (MONTH) (YEAR), and that it had been a mess with orders since. The DON stated education was provided to staff 10/5/18, regarding medication order verification, with an additional email on 10/7/18, sent to staff who input the orders electronically. When asked about the reporting of errors, the DON said she had not seen the other vitamin D3 errors until the surveyor brought it to her attention. R209 was admitted on [DATE], at 8:00 a.m. with a history of [MEDICAL CONDITION] with removal of bilateral implants and pain according to the face sheet. R209's care plan dated from her prior stay in (YEAR), had been added to her chart for use immediately following the current admission. The care plan indicated R209 was at risk for re-hospitalization and included an intervention, medications as per orders as an intervention. The care plan also identified pain as a problem area with interventions including: Medications as ordered. Monitor and document for effectiveness, follow up with MD/NP for concerns. R209's 10/13/13 admitting physician orders [REDACTED].>[MEDICATION NAME] (Tylenol) 500 mg (milligrams) 2 tablets as needed for mild pain. [MEDICATION NAME] 5 mg 1 tablet q4hrs (every 4 hours) as needed for moderate pain. The physician orders [REDACTED]. The plan indicated staff were to report to the provider as indicated. R209's PN dated 10/13/18 at 2:39 p.m., indicated R209 was able to adequately verbalize her needs appropriately and had reported pain as high as 8 in the past week with pain at a 2 at the time of the PN, and that R209 would report pain more than 3 (on the 1 to 10 scale) to staff. R209's medication administration history indicated Tylenol had been given for pain rated as a 6 on 10/13/18, at 11:46 p.m. Documentation indicated the medication was not effective and R209 had continued to rate the pain at a 6. The medication administration history indicated a stronger pain medication ([MEDICATION NAME]) could have been given, but was unavailable. On 10/14/18, the MAR indicated [REDACTED]. R209's PN dated 10/14/18, at 6:30 a.m. included, writer went into resident's room to give her 6 a.m. meds. Resident immediately complained of (c/o) what an awful night she'd had. She was c/o right side and arm pain. She stated that she was up to the bathroom a 'dozen times during the night.' She thought that her arm was hurting because of the way she was leaning on it while sitting on the toilet. Medications were administered. Resident then stated that she needed to used the rest room. This writer assisted her to sit up. Resident attempted to stand and sat back down stating that she felt light headed. Resident attempted again to stand and the same thing, she sat back down. Resident was then going to attempt to use the w/c (wheelchair) to go to the bathroom. She then stated that she felt like she was going to pass out. Resident was then assisted to lie back down and the day shift charge nurse was then notified of resident's condition. R209's PN dated 10/14/18, at 8:18 a.m. included: Resident is alert x 3. Up almost all night c/o pain. Had PRN (as needed) Tylenol and ice packs at 23:42 with no effective results. Pharmacy did not have the script (for the [MEDICATION NAME]) until about 5:00 a.m. Resident had [MEDICATION NAME] and Tylenol at 5:00 a.m. with no effective results. Resident self transferred herself to the bathroom . VS (vital signs) at 2:00 a.m. were within normal limits . R209's PN dated 10/14/18, at 8:29 a.m. included: Resident sent to the hospital at 7:56 a.m. for c/o arm/ shoulder/ wrist pain. Resident kept changing her stories about the location of the pain. Per resident she thinks she has a dislocation on the shoulder joint. The note indicated R209's family member (FM)-A, and the on-call physician (MD-B) were notified of the resident's hospital transfer. During an interview on 10/26/18, at 2:42 p.m. the pharmacist verified they'd received the prescription for [MEDICATION NAME] on 10/14/18, at 4:43 a.m. The pharmacist stated the resident had originally been prescribed the [MEDICATION NAME] on 10/9/18, with the following instructions: 5 mg every 4 hour prn pain, 4-6 out 10, if Tylenol not effective. During interview with licensed practical nurse (LPN)-A on 10/26/18, at 12:30 p.m., licensed practical nurse (LPN)-A stated a couple weeks ago it was very busy and they'd had trouble getting R209's prescription for the [MEDICATION NAME]. LPN-A stated there is not normally an issue with receiving medications unless a new resident comes in or an emergency, otherwise most only have to wait about 4 hours to get their medications. During interview with the DON on 10/26/18, at 3:49 p.m. the DON said R209 had been admitted after surgery. The DON verified the resident had been sent to the emergency department for severe pain on 10/14/18. When asked whether she'd been aware of R209's [MEDICATION NAME] had not been given during due to the prescription not having been called in until the early hours of 10/14/18, the DON said there was [MEDICATION NAME] in the facility's emergency stock the staff could have used. According to the admission sheet, R213 was admitted [DATE] with [DIAGNOSES REDACTED]. A Medication Incident Report dated 9/7/18, indicated R213 was to have received a dose of [MEDICATION NAME] (a diuretic) 40 mg po, and was to have received a dose upon return from a blood transfusion. Incident details indicated R213 was in heart failure, and had returned at 8:00 p.m. but the evening [MEDICATION NAME] had not been administered as ordered. A PN dated 9/8/18 at 11:07 a.m., indicated: Give 20 mg [MEDICATION NAME] PO now. Then increase her dose to 60 mg BID (twice a day). A PN dated 9/9/18 at 9:16 a.m., indicated: legs continue to be [MEDICAL CONDITION] (swollen). Low stretch wraps applied per order. A PN dated 9/10/18 at 12:32 p.m., indicated: new order, [MEDICATION NAME] (used to treat fluid retention ([MEDICAL CONDITION]) in people with [MEDICAL CONDITION].) 2.5 mg tab once PO today 9/10/18. A PN dated 9/11/18, at 1:43 p.m. indicated: transport to ED (emergency department) for evaluation related to [MEDICAL CONDITIONS] exacerbation and SOB (shortness of breath). A physician's progress note dated 9/11/18, included: current weight 201 and being sent to the hospital. R213's hospital discharge notes included: was inpatient in hospital from 9/11/18, requiring aggressive use of diuretic. R213 remained in the hospital until 10/1/18, when she was admitted back to the facility after a 17 pound weight lost. During an interview with the DON and administrator on 10/26/18 at 3:49 p.m., they stated R213 had returned from her blood transfusion late and the nurse passing medications had decided it was too late to give the medication that evening. The administrator added they felt they'd addressed the medication errors and interventions were effective. R205's face sheet indicated an admission date of [DATE], with a [DIAGNOSES REDACTED]. R205's Medication Treatment Incident Report dated 10/11/18, indicated R205 had missed doses of [MEDICATION NAME] (medication injection used for prevention of blood clots) 0.8 ml (milliliters) BID. There was a laboratory order with orders attached to the Incident Report dated 10/5/18, which included to continue [MEDICATION NAME] 120 mg SQ (subcutaneous) BID through 10/8/18. On 10/8/18, the order indicated to continue [MEDICATION NAME]. The Incident Report indicated the order for [MEDICATION NAME] had been discontinued instead of continuing it. Subsequently, R205 missed 3 doses. When the error was identified, the order to continue the [MEDICATION NAME] was re-entered on 10/10/18. A hand written note on the Incident Report included: How could this have been prevented: Nurse stated it was a busy night with a lot of orders. New system implemented to have two nurses check orders. R205's Medication Administration History for the month of 10/2018, indicated on 10/9 and 10/10/18, there was a total of four missed doses of [MEDICATION NAME] (blood thinner), of the physician ordered 0.8 ml BID order. A PN indicated R205 developed a [MEDICAL CONDITION] ([MEDICAL CONDITION] and was admitted to the hospital on [DATE] and was readmitted back to the facility on [DATE], on comfort cares. A physician's PN dated 10/22/18 at 10:18 a.m., indicated R205 had developed left lower extremity swelling, pain and weakness, and had presented to the emergency room with a finding diagnosed as an acute to subacute thrombus. R205 was admitted to the hospital and started on intravenous [MEDICATION NAME] (a blood thinner). The record failed to indicate the physician had been notified of the missing doses of [MEDICATION NAME]. During interview on 10/26/18 at 3:22 p.m., R205's attending physician was asked if she was aware of R205's missed [MEDICATION NAME] doses which occurred after she'd seen him at admission. The doctor said she'd not been aware, and in her opinion, the missed [MEDICATION NAME] doses may have contributed to the resident's [MEDICAL CONDITION]. The facility's policy Administering Medications, included: All medication orders are double checked by 2 nurses before uploading. Administer medications following the 6 rights of medication administration: (1) right resident, (2) right medication, (3) right dose, (4) right time, (5) right route, (6) right documentation. The facility's policy Controlled Substance Prescriptions dated 8/14, included: Before a controlled drug can be dispensed, the pharmacy must be in receipt of a clear, complete, and signed written prescription from a person lawfully authorized to prescribe. Verbal orders for controlled medications are permitted for CII controlled drugs only in emergency situations.

Based on interview and document review, the facility failed to ensure adequate supervision during toileting for 1 of 3 (R1) reviewed for falls. This resulted in actual harm to R1 who fell and sustained a pelvic fracture. Findings include:R1's medical record was reviewed and revealed that R1 was admitted to the facility with [DIAGNOSES REDACTED]. A brief interview for mental status (BIMS) assessment dated [DATE] indicated that R1 had severe cognitive impairment. A fall risk assessment dated [DATE] revealed that R1 was at risk for falls due to a history of falls, dementia and poor safety awareness . R1's careplan dated 3/27/2013 indicated that R1 was at risk for falls and revealed that R1 required the assistance of 2 staff for transfers with a Hoyer lift and a TABS alarm was to be on at all times. A nursing assistant assignment sheet dated 8/9/2013 was reviewed and revealed that staff were directed to toilet R1 every three hours with assistance of two staff and the Hoyer lift and not to leave R1 unattended on the toilet. A fall safety event report dated 8/15/2013 was reviewed and revealed that R1 was found on R1's bathroom floor on 8/15/2013 after an unwitnessed fall. At the time of the fall, R1 complained of left hip pain and Hospice was called. Hospice gave orders to staff to administer as needed (PRN) pain medication.A hospice clincial note dated 8/15/2013 at 4:10 p.m. revealed that hospice was alerted by the facility that R1 was found on the floor and complaining of left hip pain. Hospice advised staff to provide R1 with PRN pain medication. A hospice clincial noted dated 8/15/2013 at 4:56 p.m. revealed that Hospice staff spoke with R1's family who decided to have R1 transferred to the emergency room for x-rays and evaluation due to R1's complaints of left hip pain. Hospital records dated 8/16/2013 indicated that R1 was evaluated on 8/15/2013 and found to have a left pelvic fracture and returned to the facility on [DATE] to continue on hospice services. An internal investigation dated 8/19/2013 was reviewed and revealed that R1 was found on the floor in R1's bathroom on 8/15/2013 and was later diagnosed with [REDACTED]. NA-A told another nursing assistant (NA-B) that s/he was going on break, but did not tell NA-B that R1 was on the toilet; NA-B later found R1 on the floor. An interview with the nurse (RN-C) on 9/4/2013 at 3:00 p.m. revealed that RN-C was working at the time R1 was discovered on the floor. RN-C stated that R1 had a history of [REDACTED]. RN-C stated that staff did not indicate that R1 had been left unattended in the bathroom. An interview with NA-B on 9/23/2013 at 3:55 pm. revealed that NA-B had discovered R1 on the floor on 8/15/2013. NA-B stated that NA-A had stated that NA-A was going on break and shortly after, NA-B found R1 on the floor when NA-B went to answer R1's call light. NA-B stated that when NA-A went on break that NA-B did not know R1 was left on the toilet unattended. NA-B stated that all resident's with TABS alarms are not to be left unattended on the toilet. An interview with an administrative nurse (RN-D) on 9/25/2013 at 10:30 a.m. revealed that RN-D was informed of R1's fall on 8/16/2013. RN-D stated that when RN-D began to investigate the cause of R1's fall, RN-D became aware that R1's care plan was not followed at the time of R1's fall on 8/15/2013. RN-D confirmed that NA-A was interviewed by RN-D and admitted to leaving R1 unattended on the toilet on 8/15/2013. RN-D also confirmed that R1 was diagnosed with [REDACTED]. RN-D also confirmed that resident's with TABS alarms are not to be left unattended on the toilet. NA-A was interviewed on 9/30/2013 at 3:45 p.m. and confirmed that on 8/15/2013 NA-A left R1 on the toilet unattended. NA-A stated that s/he had assisted R1 to the toilet using the Hoyer lift and was assisted by an unknown staff member who was in training. NA-A then stated that s/he told NA-B that NA-A was going on break and NA-B stated that s/he would "be right there" to assist R1. NA-A stated that s/he trusted that NA-B would be there to care for R1, and stated that NA-A had never left R1 unattended on the toilet before this incident and knew that R1 should not be left unattended. NA-A stated that when NA-A returned from break NA-A was informed of R1's fall but did not know how the fall occurred. NA-A stated that staff have access to resident care plans and carry with them the care plans of the residents. NA-A also confirmed that NA-A had received training on following resident's care plans and knew that resident's with TABS alarms should not be left unattended.

Based on interview and record review, the facility failed to provide appropriate services regarding a resident's change in bladder function that included incontinence and symptoms suggestive of a urinary tract infection [MEDICAL CONDITION] for 1 of 1 residents (R1) reviewed for a symptomatic UTI who required an emergency medical evaluation, was diagnosed with [REDACTED]. Findings include: Record review for R1 revealed a hospital Dismissal Summary dated 03/12/2013 that included a [DIAGNOSES REDACTED]. This report also showed a urine culture for R1 grew a bacterial organism known to cause UTI's (particularly in persons who have a urinary catheter); R1 received orders for antibiotic treatment, to continue through 03/14/2013, for a total of seven days (fourteen doses) to treat a possible catheter associated UTI. There was no evidence of any urinary incontinence problems at the time of this hospital discharge summary. This discharge summary included post-op instructions of calling the hospital upon a loss of bladder control (to manage any potential complications related to the spinal fusion surgery). R1 was discharged from the hospital (without a catheter) to the skilled nursing facility on 03/12/2013. A Resident Progress Note for R1 dated 03/12/2013 showed R1 used a urinal at the bedside and was continent of bladder. R1's Observation Report (initiated on 03/12/2013 at 2:42 p.m.) completed by Registered Nurse (RN)-F on 03/14/2013 at 9:45 a.m. showed R1 to be continent of bladder with complete control. R1's Primary Care Internal Med Nursing Home Multi-system Evaluation showed the facility's NP initially evaluated R1 on 03/13/2013 at 9:53 a.m. and contained the following documentation: "Patient is being bladder scanned. Limited residual. Will discontinue [MEDICATION NAME] (the antibiotic medication ordered to treat the bacterial organism/possible catheter associated UTI)). Microbiology did not support treatment." (R1's record did not contain any evidence of any additional lab/microbiology studies done in addition to the hospital urine culture that grew the bacterial organism associated with the cause of R1's UTI). R1's nursing home Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R1's Resident Progress Note entered on 03/13/2013 at 9:40 a.m. showed R1 verbalized the feeling of a full bladder, however, refused the bladder scan due to not being able to lay supine in bed; documentation on R1's Licensed Nurse Flowsheet for bladder scans was consistent with this resident progress note. R1's record showed one attempt at a bladder scan on the day of admission (03/12/2013), did not include any evidence of the results of this bladder scan and no bladder scans were completed the following day (03/13/2013). Additional resident progress notes dated 03/13/2013 showed R1 to be alert with confusion, restless and experiencing episodes of incontinence. R1's Vitals Report showed R1 was admitted on [DATE] with a temperature of 98.3 degrees Fahrenheit (F) via a tympanic thermometer. R1's Vitals Report showed that on 03/13/2013 at 6:51 p.m., R1's temperature via a tympanic thermometer was 99.5 degrees F. R1's Medication Flowsheet for March 2013 showed R1 received 1,000 milligrams (two extra strength tablets, which is the maximum individual dosage (Lippincott Williams & Wilkens Nursing 2012 Drug Handbook page 66) of Tylenol (an [MEDICATION NAME] used to reduce fever and pain) three times daily. A Resident Progress Note dated 03/14/2013 (a Thursday) showed R1 complained of urinary frequency and burning; R1's spouse requested a urinalysis be done and licensed practical nurse (LPN)-C explained protocol to R1 and R1's spouse. R1's record did not contain any evidence that the physician was notified regarding these changes or R1's/R1's spouse's request for a urinalysis. When interviewed on 04/24/2013 at 12:36 p.m., R1's family member (F)-B stated R1 started to show changes a couple of days after admission to the nursing home, which included confusion. F-B stated R1 complained of having to urinate often and having burning when urinating; F-B stated R1 felt something was wrong and F-B reported R1's changes to LPN-C and requested a urinalysis be done. F-B stated LPN-C told F-B there was no need for this as R1 did not have a fever. F-B stated that R1 did not have a fever with past bladder infections and indicated R1 routinely takes Tylenol. F-B again reported these concerns to the nurse on Sunday and received no information from the nurse as to whether or not R1's physician was contacted. R1's record did not contain any evidence of any notification to any NP or physician. When interviewed on 04/25/2013 at 10:42 a.m., LPN-C stated the NP is at the facility 8 a.m. to 5 p.m. every day except Thursdays and on Thursdays, the clinical manager (Registered Nurse (RN)-F) or on call NP would be notified. LPN-C also indicated that the NP emails the physician regarding resident changes. On 04/25/2013 at 2:26 p.m., LPN-C stated she could not recall if she considered the medications R1 received that can suppress a fever when deciding that a urine collection could not be done for R1. LPN-C also indicated she verbally told the NP on the afternoon of 03/14/2013 (a Thursday) and R1's record "just doesn't say that." (LPN-C entered the documentation for R1's urinary changes, urinalysis request and LPN-C's reason for not collecting a urine sample (facility protocol) in R1's record on 03/14/2013 at 7:13 p.m.). When interviewed on 04/25/2013 at 3:00 p.m., RN-F verbalized unawareness of R1's urinary symptoms of 03/14/2013. R1's record did not contain any evidence of physician notification or NP follow-up to LPN-C's verbal notification regarding R1's urinary changes and family request for a urinalysis. When interviewed on 04/25/2013 at 2:26 p.m., LPN-C stated when talking with R1's spouse on 03/14/2013, LPN-C was referring to the facility's protocol for urine collection and a resident needs to have a fever, dysuria (painful urination) and back pain to collect a urine specimen. LPN-C indicated uncertainty as to whether or not this is a written policy and LPN-C further indicated she became aware of this protocol via word of mouth from nurses and the NP. When interviewed on 04/25/2013 at 3:00 p.m., RN-F stated the nurse needs three documented symptoms in order to collect urine for a urinalysis; the investigator inquired if RN-F meant to indicate that these symptoms are needed to treat a UTI (versus obtaining a urine specimen for a urinalysis) and RN-F verified that RN-F meant this is needed to even be able to obtain a urine specimen. The facility's policy titled "Urinary Tract Infection Protocol", last revised 07/2012, contained documentation that the purpose of this policy is to assure residents receive appropriate treatment and services to treat and prevent UTI's and restore as much bladder function as possible. This policy also contained documentation that a resident without a catheter should have at last three of the listed signs and symptoms to treat a UTI (these signs and symptoms, aside from fever, included confusion, decreased appetite, incontinence of recent onset, urinary burning and urinary frequency). This policy showed the indication of three symptoms is used as a basis for the treatment of [REDACTED]. This policy contained a procedure for the nurse to notify the NP/physician if signs and symptoms of a UTI are present. R1's Resident Progress Note entered by LPN-C on 03/15/2013 at 10:42 a.m. showed R1's bladder assessment as completed. An additional entry by LPN-C on 03/15/2013 at 2:02 p.m. showed R1 displayed irritability, requested pain meds on an hourly basis, voided small amounts and had poor oral intake. An entry by RN-F dated 03/15/2013 at 2:23 p.m. showed that RN-F agreed with the findings of R1's bladder assessment. R1's Bladder Assessment, dated as completed by LPN-C on 03/15/2013, did not identify several factors possibly contributing to R1's bladder function changes (including, but not limited to, R1's [DIAGNOSES REDACTED]. R1's record, which included this form, contained no evidence of assessing these risk factors. R1's Bladder Assessment did not show evidence of identifying any reversible causes of these urinary changes and did not identify any additional interventions to benefit R1 (such as increased fluid intake). Additionally, R1's Bladder Assessment (completed 03/15/2013) did not include a summary of the findings of the 3 day bladder diary, did not accurately identify symptoms of mixed incontinence and did not include an analysis to determine the type of incontinence that R1 was most likely experiencing. This bladder assessment included LPN-C's progress note entered on 03/15/2013 that contained documentation that "(R1) has a tendency to not use the urinal at night and just wets the bed and calls for a bed change." When interviewed on 04/25/2013 at 2:26 p.m., LPN-C stated she did not know how to classify the incontinence for R1, usually would inform RN-F regarding situations such as this and did not recall if she spoke to RN-F about this. LPN-C could not provide a reason for the missing information on R1's bladder assessment. When interviewed on 04/25/2013 at 3:00 p.m., RN-F could not provide a reason for R1's record not containing any information pertaining to an analysis of R1's Bladder Assessment information (including a summary of the 3 day voiding diary) and could not determine the frequency of bed wetting when reviewing R1's record with the investigator, nor the frequency/pattern of incontinence. When asked for the reason the type of incontinence was not identified for R1, RN-F stated it must have been missed. When interviewed on 04/24/2013 at 12:36 p.m., R1's family member (F)-B stated she frequently assisted R1 with the use of the urinal while at the nursing home and spent approximately 11 1/2 (eleven and one half) hours daily with R1 while at the facility. F-B stated R1's urinal would spill in the bed and also questioned if the urinal was being emptied during the night, because F-B would have to empty the full urinal upon arrival to the facility in the morning. F-B indicated facility staff assisted R1 to the bathroom for bowel elimination but F-B took care of assisting R1 daily with voiding into the urinal (usually between 8:30 a.m. to around 8:30 p.m.). Review of the facility's policy titled, "Incontinence", last revised 06/2012, indicated the purpose of this policy included the comprehensive assessment of a resident who is incontinent of bladder in order to provide appropriate treatment or services to achieve or maintain as much normal bladder function as possible. This policy contained documentation that a comprehensive assessment consists of a Bladder Assessment Form and referenced the areas of this form that are used for the identification and evaluation of factors relevant to this assessment. Review of an additional facility policy titled, "Bladder & Bowel Policy & Procedure", last revised 09/2012, included several purposes of this policy, such as identifying a history of bladder function, identifying types of incontinence, avoiding the possibility of a urinary tract infection [MEDICAL CONDITION] and restoring optimum level of bladder function. This policy also indicated the resident would be assessed for 72 hours for bladder voiding patterns, the licensed nurse would review and analyze this 72 hour voiding pattern information and the licensed nurse will gather information from the resident's chart, staff members, resident observations and family members to complete the bladder assessment. R1's Resident Progress Notes dated 03/15/2013 through 03/18/2013 showed the following: R1 voided small amounts of urine, displayed poor oral intake, refused meals, continued with pain (location of pain not documented), displayed irritability, refused cares, unable to sleep, restless and was unable to void unless in a side-lying position. These notes also showed R1's son reported R1's behavior was not usual for R1, R1 verbalized "I haven't been myself" and staff responded to R1's frequent call light for pain med, repositioning and a urinal. R1's Vitals Report for 03/15/2013 through 03/18/2013 showed R1's urinary output ranged from small to large and included both continent and incontinent episodes. R1's PRN (as needed) Medication Notes form showed R1 received prn pain medication for back pain and use of this prn pain medication increased to three times daily. R1's Primary Care Internal Med Nursing Home Miscellaneous visit note showed the NP evaluated R1 on 03/18/2013 at 11:06 a.m. for a family concern of R1 appearing depressed, not sleeping, not eating well and not wanting to participate in therapy; R1's spouse was concerned R1 was over-sedated with pain medication. This visit note showed R1 "wants to lay in bed on side and mumbles" and did not participate in a depression screening. The NP gave new orders for an antidepressant medication, reduced the doses of current pain medications and gave new orders for an opioid [MEDICATION NAME] for treatment of [REDACTED]. This visit note contained no evidence that the NP was aware of R1's urinary changes. The NP declined an interview. R1's Resident Progress Notes dated 03/19/2013 referenced R1's behaviors during the night shift (3/18/2013 through the morning of 03/19/2013) and indicated the NP was at the facility on the morning of 03/19/2013 and informed of R1's behaviors. This documentation showed R1's spouse was concerned. The NP called R1's surgeon's office and received orders to send to the hospital emergency room (ER) for an evaluation. A urine specimen for R1 was collected at the skilled nursing facility and sent for a urinalysis. R1 was diagnosed with [REDACTED]. The hospital also informed facility nursing staff that R1's cardiac markers were elevated and being monitored. R1's hospital Emergency Record showed a triage date/time of 03/19/2013 at 10:47 a.m. R1's was evaluated for a chief complaint of mental status change. This report showed R1 expressed dysuria during this ER evaluation. R1 had signs of mild dehydration, [MEDICAL CONDITION] and increased urinary frequency. R1 voided small frequent amounts in the urinal, R1 displayed urinary hesitancy and R1's urine was foul smelling. A [DIAGNOSES REDACTED]. R1's hospital admission note indicated R1's urinalysis contained pyuria (pus), which possibly accounted for some of the mental status changes and R1 also presented with high blood sugars. R1 expressed feeling rotten and was unable to describe this further. R1's hospital Dismissal Summary dated 03/26/2013 showed R1's primary [DIAGNOSES REDACTED]. Following treatment with intravenous (IV) antibiotics, R1's mental status resolved and returned to baseline.

Based on interview and record review, the facility failed to provide the necessary care and services to 1 of 3 residents (Resident #1) as ordered, when staff failed to provide ongoing monitoring of the resident, after she received another resident's medications in error. Findings include: Resident #1's medical record was reviewed and revealed that she has [DIAGNOSES REDACTED]. Her care plan, dated [DATE], documents that she communicates clearly with staff, but has difficulty with "word finding." She requires assistance of staff for her activities of daily living. On [DATE], a CPR-DNR/DNI Informed Consent documents that her code status was changed to: "Do not resuscitate, do not intubate (DNR/DNI), do not hospitalize/comfort cares." The internal investigation (no date noted) documented that on [DATE], at 9:20 a.m., Resident #1 was given her morning medications which included: [MEDICATION NAME] (diuretic), Os-Cal (calcium), Aspirin (blood thinner), Folic Acid (vitamin) and [MEDICATION NAME] (Alzheimer's medication), and then at 9:30 a.m., Resident #1 was administered additional medications intended for another resident. These medications included: [MEDICATION NAME] CD (cardiac medication), [MEDICATION NAME](stool softener), [MEDICATION NAME] XR (anti-depressant), [MEDICATION NAME] (laxative), [MEDICATION NAME] ([MEDICATION NAME] therapy), [MEDICATION NAME] (cholesterol medication), Vitamin D, Vitron C (vitamin), and [MEDICATION NAME] (cardiac medication). Employee (J)/nurse was interviewed on [DATE] at 10:15 a.m. and stated that on [DATE] she was called in to work, and was asked to assist in passing medications. She stated that at approximately 9:,[DATE]:15 a.m., Employee (D)/nurse asked her to give medications to a resident, and she thought Employee (D) said Resident #1's name. She went to administer the medications, and was to give the medication [MEDICATION NAME], so she monitored her apical pulse. Resident #1's pulse was too low to give the [MEDICATION NAME], so she held that medication, and gave Resident #1 the remainder of the medications. She went to document the apical pulse, and found that Resident #1 did not have [MEDICATION NAME] ordered. She notified the Nurse Practitioner/(H) of the error, and received orders to monitor Resident #1's blood pressure every two hours for 12 hours, and then every four hours for 12 hours. She stated that she did take Resident #1's blood pressure at 10:00 a.m. and then between 11:30a.m.-12:00 p.m., and stated that she did take her blood pressure and pulse again, but did not document the readings. Nurse Practitioner (H) was interviewed on [DATE] at 1:43 p.m. and stated that she was notified of the medication error on [DATE] at approximately 9:30 a.m., and gave verbal orders to Employee (J) to monitor Resident #1's vital signs every two hours for 12 hours, and then every four hours for another 12 hours. She also stated to notify her if Resident #1's pulse falls below 50 beats per minute, or her systolic blood pressure falls below 100. At approximately 12:00 p.m., Resident #1 was "not feeling well." Nurse Practitioner (H) examined her and stated that her clinical examination was "normal," and Resident #1 stated she just didn't "feel well." She gave orders to monitor her vital signs (as previously ordered), and to notify her if her physical symptoms do not improve. She stated that she was not contacted following this order. A review of Resident #1's vital signs record indicated that her vital signs were monitored on [DATE] at: -- 12:46 p.m. BP: ,[DATE], pulse: 56, no respirations were documented, and her oxygen saturation was 96%. --No vital signs documented from 12:46 to 5:33 p.m. --5:33 p.m. oxygen saturation was 96%. --6:20 p.m. BP: ,[DATE], pulse: 72, respiration (RR) 20, temperature 95 F. --8:45 p.m. BP: ,[DATE], pulse: 69, RR 21, temperature 93.8F. This is the last documented set of vital signs on [DATE]. The next documentation in Resident #1's medical record was on [DATE] at: --12:30 a.m. temperature 94.9 F --2:01 a.m. BP: ,[DATE], pulse: 38, RR 20, temperature 95.5 F --3:42 a.m. No BP documented, pulse: 31, RR 22, and temperature 95F A review of the nurse's notes dated [DATE]and [DATE] document: -- [DATE] at 6:15 p.m., Employee (F) documented the orders for vital sign monitoring received from the Nurse Practitioner, by Employee (J), at approximately 9:30 a.m. on [DATE]. --[DATE] at 11:56 p.m., Employee (F) documented that Resident #1 was up in wheelchair in dining room "this evening," and stated that she "did not feel good," and she had the "dry heaves." The note documents that Resident #1 refused her evening meal, was given Tylenol for comfort, and her vital signs were stable. --On [DATE] at 2:03 a.m., Employee (G)/ nurse documented that Resident #1's systolic blood pressure was 89, and her diastolic blood pressure was "unattainable." Her apical pulse was 38 and her respiratory rate was 20 and "labored." The physician on call was updated, and ordered warm fluids to increase her volume. --A 3:47 a.m., (late entry note written on [DATE] at 3:16 p.m.) documents that the Director of Nursing was notified of Resident #1's "declining condition," and she instructed Employee (G) to notify the family, and "take guidance" from them, as to whether they want Resident #1 sent to the hospital. Nurse's notes document that the family was notified at 3:15 a.m. Resident #1 expired at the facility at 4:35 a.m. on [DATE]. The family arrived at the facility at 4:45 a.m., after Resident #1 had expired. Employee (F)/nurse was interviewed on [DATE] at 10:33 p.m. and stated that she worked the evening shift on [DATE]. She received report from Employee (K)/nurse, and no concerns were reported regarding Resident #1. At approximately 5:20 p.m., she found a faxed order from the nurse practitioner for vital sign parameters, due to a medication error. She asked other staff at the facility, and no one was aware of a medication error. She called the nurse practitioner, and found that she had left for the day, and called Employee (K)/nurse, who was not aware of a medication error. She called Employee (E)/administrative staff who was also not aware of the error. She stated that she wanted to know what medications Resident #1 was given in error, but was unable to find a person who was aware of a medication error. She did pass on the Nurse Practitioner orders to Employee (G)/nurse in report. Employee (G)/nurse was interviewed on [DATE] at 3:03 p.m. and stated that on [DATE], she did receive report from Employee (F) regarding monitoring of Resident #1's vital signs due to a medication error. She assumed that Employee (F) completed a set of vital signs at 10:00 p.m. She asked a TMA (Trained Medication Aide) to do a set of vital signs for her between 12:,[DATE]:30 a.m. The TMA came back and stated that Resident #1's systolic blood pressure was 80, but she was unable to get a diastolic reading. She stated that she went to Resident #1's room at approximately 12:30 a.m., and her systolic blood pressure was 89, but she was unable to get a diastolic blood pressure. She stated that she did document a set of vital signs at this time (no vital signs, except temperature was documented at 12:30 a.m.). She stated that she had had a couple of narcotics to pass, and then placed a call to the physician on call, who ordered warm fluids to increase her volume. She stated that he was aware of the medication error. She notified Employee (A) who directed her to call the family. The family was notified at 3:15 a.m. regarding Resident #1's condition, but she stated that she did not talk to the family about the medication error, at this time. Resident #1 expired at 4:35 a.m.