Every finding on record at Majestic Care of Southport

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a sanitary manner for 3 of 3 kitchen observations. Hair was not covered. (Dietary Aide 2) Finding includes: During an observation on 9/22/25 from 8:40 a.m. to 9:00 a.m., Dietary Aide 2 was observed in the kitchen's dishwashing area and food preparation area. Dietary Aide 2 was observed scooping dessert into small bowls for noon meal. Dietary Aide 2 was observed to be lacking hair coverage to the hair on her forehead measuring two inches in length. During an observation on 9/22/25 at 12:37 p.m., Dietary Aide 2 was observed placing food on plates to be served to the residents for the noon meal. Dietary Aide 2 was observed to be lacking hair coverage to the hair on her forehead measuring two inches in length. During an interview on 9/23/25 at 9:25 a.m., the Executive Director indicated that all staff in the kitchen should have all of their hair covered. During an interview on 9/24/25 at 2:58 p.m., the Executive Director indicated 79 of 83 residents received meals from the kitchen. On 9/23/25 at 9:25 a.m., the Executive Director provided a copy of Staff Attire from the Dining Services Policy and Procedure Manual, revised on 1/2025, and indicated it was the current policy in use by the facility. A review of the policy indicated, 1.All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained . On 9/26/24 at 2:00 p.m., a review of the Indiana Food Establishment Sanitation Requirements, Title 410 IAC 7-24, effective November 13, 2004, indicated, (b)food employees shall wear hair restraints, such as hats, hair coverings or nets .that are designed and worn to effectively keep their hair from contacting .exposed food . 3.1-21(i)(2)3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure physician prescribed daily weights were taken and recorded by qualified personnel for 1 of 1 resident reviewed for daily weights. (Resident 74)Finding includes: On 9/24/25 at 2:33 p.m., Resident 74's clinical record was reviewed. The diagnoses included, but were not limited to, end stage renal disease (ESRD), dependence on renal dialysis, and heart failure. The admission Minimum Data Set (MDS) assessment, dated 9/1/25, indicated Resident 74 was cognitively intact.Physician orders included, but were not limited to, obtain daily weights, notify MD [medical doctor] if weight gain greater than 3 pounds in a day or 5 pounds in a week. The start date was 8/27/25 and no end date was indicated.On 9/25/25 at 10:50 a.m., the Director of Nursing Services (DNS) provided a copy of Resident 74's September 2025 Medication Administration Record (MAR). A review of the document indicated that nursing personnel had initialed the document which signified Resident 74's daily weights had been obtained from September 1st through the 24th. The document lacked a recorded numerical number of pounds for each date. During an interview at that time, the DNS indicated the MAR record lacked documentation that identified what the daily weights were. Staff had not recorded the weights on the MAR document.On 9/25/25 at 11:45 a.m., the DNS provided a copy of Resident 74's recorded weights for September of 2025. The record lacked recorded weights for the following dates: 9/4/25; 9/6/25; 9/11/25; 9/13/25; 9/14/25; 9/16/25; 9/18/25; 9/20/25; and 9/21/25. During an interview at that time, the DNS indicated there were nine days where no weights had been obtained or recorded for Resident 74. Resident 74's clinical record lacked documentation for daily weights as prescribed by the physician.During an interview on 9/25/25 at 2:30 p.m., Resident 74 indicated she had dialysis three times per week and was only weighed on her dialysis days.On 9/25/25 at 11:51 a.m., the DNS provided a copy of the Physician Orders policy, dated 1/2/24, and indicated it was the current policy in use by the facility. A review of the document indicated, .qualified nursing personnel will receive and review.communicate results to the ordering physician.documentation.will be maintained in the resident's clinical record.On 9/25/25 at 11:51 a.m., the DNS provided a copy of the Weight Monitoring policy, dated 6/15/25, and indicated it was the current policy in use by the facility. A review of the document indicated, .to regularly measure and record a resident's body weight to assess changes in nutritional status, fluid balance, and overall health status.Daily Weights: orders for daily weights should include physician call parameters indicating amount and timeframe of weight change.should be recorded on MAR or TAR [treatment administration record] should indicate if physician was notified or parameter change.3.1-35(g)(2)

Based on record review and interview the facility failed to document treatments that were completed in the residents clinical record for 1 of 3 residents reviewed for skin issues. (Resident B) Finding includes: On 9/26/25 10:37 a.m., the clinical record for Resident B was reviewed. The diagnoses included, but were not limited to, diabetes mellitus and neuropathy. Physician orders, dated August 2025, indicated wound Care-left heel: Apply skin prep every morning and at bedtime. The Medication Administration Record lacked signatures that the treatment was completed on the following dates and times: - August 8, 2025, at bedtime. - August 9, 2025, in the morning. - August 10, 2025, at bedtime. - August 13, 2025, in the morning. - August 15, 2025, in the morning. - August 16, 2025, in the morning and at bedtime. - August 19, 2025, in the morning. During an interview on 9/26/25 at 10:00 a.m., the Director of Nursing Services indicated the treatments were completed. The treatments should have been documented in the resident's clinical record once the treatment was completed. On 9/26/25 at 11:21 a.m., the Executive Director provided a policy titled Documentation In The Medical Record, dated 12/12/23, and indicated it was the current policy being used by the facility. A review of the policy indicated Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include information to provide a picture of the resident's progress through complete, accurate, and timely documentation. This citation relates to Intake 2613003. 3.1-50(a)(1)

Based on interview and record review, the facility failed to ensure a resident's transfer to the emergency department was documented in the medical record for 1 of 3 residents reviewed for documentation. (Resident B) Findings include: During an interview on 2/26/25 at 8:10 a.m., Resident B's daughter indicated, on 2/21/25 at approximately 3:00 p.m., she noticed Resident B was lethargic, so she called 911 to have Resident B sent to the emergency department. The clinical record for Resident B was reviewed on 2/26/25 at 8:20 a.m. The diagnoses included, but were not limited to, bladder cancer, asthma, and chronic atrial fibrillation. A hospital palliative care note, dated 2/23/25 at 2:19 p.m., indicated, on 2/21/25, Resident B presented to the emergency department with altered mental status and was admitted to hospital. During an interview on 2/26/25 at 9:10 a.m., the Director of Nursing indicated the nurse that was caring for Resident B, when she was transferred to the emergency department, should have documented a note in Resident B's record regarding the transfer. On 2/26/25 at 11:57 a.m., the Administrator provided a copy of facility policy, titled Transfer Discharge, dated 1/2/24, and indicated this was the current policy used by the facility. A review of the policy indicated document relevant information regarding the transfer in the medical record. This citation relates to Complaint IN00454230. 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review, the facility failed to protect a resident's right to be free from verbal and physical abuse when a resident cursed at and spit at another resident for 1 of 3 residents reviewed for abuse. (Resident B, Resident C) Findings include: During an interview on 2/17/25 at 9:20 a.m., Resident B indicated, on 1/22/25 or 1/23/25 at approximately 6:30 p.m., Resident B was with other residents waiting to go outside to smoke. Resident C wheeled up to Resident B and called her a b**** and then said Resident B knew what the f*** Resident C was talking about. Resident B got scared and started wheeling back to her room. Resident C wheeled after her. Resident B was afraid Resident C was going to hit her. Resident B got to her room and Resident C continued to yell and curse at her. LPN 2 came and told Resident C to go to the nursing station. Resident D and Resident E wheeled up to Resident B's room to talk to her. A little while after that, Resident B was sitting near her door talking with Resident D and Resident E when Resident C wheeled up again and called Resident B a b**** and told Resident B she was going to break her neck. Then Resident C spit on Resident B. Resident B had been scared since then. At that time, Resident B became tearful and indicated she didn't feel safe, she was afraid of Resident C, and there was nothing preventing Resident C from coming back to her room if Resident C wanted to. During an interview on 2/17/25 at 9:48 a.m., Resident D indicated he saw Resident C in her wheelchair chase after Resident B. Then Resident B was sitting in her wheelchair at her door when Resident C wheeled up and was yelling and cursing. Resident C spit on Resident B's leg. During an interview on 2/17/25 at 9:55 a.m., Resident E indicated he watched Resident C chase Resident B about a month ago. It started in the hallway so Resident B went to her room. A few minutes later, Resident E was in the hallway next to Resident B's room when he watched Resident C spit on Resident B. Resident D was with Resident E when it happened. The clinical record for Resident B was reviewed on 2/17/25 at 10:15 a.m. The diagnoses included, but were not limited to, anxiety, depression, and psychotic disorder. An annual Minimum Data Set (MDS) assessment, dated 12/15/24, indicated Resident B was cognitively intact. A Progress Note, dated 1/22/25 at 11:05 p.m., indicated Resident B was argumentative with Resident C. Resident B was yelling at Resident C to get away from her. Resident C wheeled past Resident B's room and started yelling at her. Then both residents began yelling at each other. LPN 1 encouraged Resident B to fill out a report. A Progress Note, dated 1/28/25 at 2:57 a.m., Resident B requested the nurse call the Nurse Practitioner to get her medication for nervousness. Resident B was nervous because of the altercation with Resident C last Thursday (1/23/25). The clinical record for Resident C was reviewed on 2/17/25 at 10:55 a.m. The diagnoses included, but were not limited to, schizophrenia, alcohol abuse, psychoactive substance abuse, and dementia. A quarterly MDS assessment, dated 10/30/24, indicated Resident C was moderately cognitively impaired. A Progress Note, dated 1/22/25 at 11:00 p.m., indicated Resident C had become agitated with Resident B. Resident C was very argumentative with Resident B. Resident C was redirected to her room then Resident C came back out into the hallway and started yelling at Resident B and attempted to spit on Resident B. Resident C was redirected to her room. A psychiatric progress note, dated 1/23/25 at 12:00 a.m., indicated staff report Resident C threatened to spit on Resident B with no known provocation. The clinical record for Resident D was reviewed on 2/17/25 at 11:04 a.m. A quarterly MDS assessment, dated 12/24/24, indicated Resident D was cognitively intact. The clinical record for Resident E was reviewed on 2/17/25 at 11:05 a.m. A quarterly MDS assessment, dated 12/16/24, indicated Resident E was cognitively intact. During an interview on 2/17/25 at 11:32 a.m., LPN 1 indicated she heard Resident C call Resident B a b**** and then told Resident B she was going to spit on her. Then Resident C spit at Resident B, but the spit didn't touch Resident B. On 2/17/25 at 8:50 a.m., the Director of Nursing provided a copy of a facility policy, titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation, dated 9/6/24, indicated this was the current policy used by the facility. A review of the policy indicated residents have the right to be free from abuse. This citation relates to Complaint IN00452293. 3.1-27(a)(1) 3.1-27(b)

Based on interview and record review, the facility failed to report an allegation of abuse to the state health department when a resident cursed at and spit at another resident for 1 of 3 residents reviewed for abuse. (Resident B, Resident C) Findings include: During an interview on 2/17/25 at 9:20 a.m., Resident B indicated, on 1/22/25 or 1/23/25 at approximately 6:30 p.m., Resident C called Resident B a b****. Then Resident C spit on Resident B. The clinical record for Resident C was reviewed on 2/17/25 at 10:55 a.m. The diagnoses included, but were not limited to, schizophrenia, alcohol abuse, psychoactive substance abuse A Progress Note, dated 1/22/25 at 11:00 p.m., indicated Resident C had become agitated with Resident B. Resident C was argumentative with Resident B. Resident C was redirected to her room then Resident C came back into the hallway and started yelling at Resident B and attempted to spit on Resident B. Resident C was again redirected to her room. Director of Nursing notified. During an interview on 2/17/25 at 11:06 a.m., the Administrator indicated he received a phone call from LPN 1 that there had been a verbal altercation between two residents. It should have been reported. During an interview on 2/17/25 at 11:32 a.m., LPN 1 indicated she heard Resident C call Resident B a b****. Then LPN 1 watched Resident C spit at Resident B. If LPN 1 would not have been right there, Resident C would have been able to get to Resident B to spit on her. LPN 1 did not report this until the next day when the Administrator called her. LPN 1 was not sure if anyone else reported this when it happened. During an interview on 2/17/25 at 1:37 p.m., LPN 2 indicated she did not see Resident C spit at Resident B. LPN 2 couldn't remember if LPN 1 told her about Resident C spitting at Resident B. LPN 2 thought she might have reported this to the Administrator and Director of Nursing but wasn't sure. On 2/17/25 at 8:50 a.m., the Director of Nursing provided a copy of a facility policy, titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation, dated 9/6/24, and indicated this was the current policy used by the facility. A review of the policy indicated all allegations of abuse must be reported immediately to the Administrator or designee. This Federal tag relates to Complaint IN00452293. 3.1-28(c)

Based on interview and record review, the facility failed to ensure written bed hold notifications were provided to the resident and to the resident's representative for 1 of 6 residents reviewed for transfers. (Resident 10). Finding includes: On 10/10/24 at 1:15 p.m., Resident 10's clinical record was reviewed. The diagnoses included, but were not limited to, COPD (a lung disease that makes it difficult to breathe), heart failure, and type 2 diabetes. The clinical record's census tab indicated Resident 10 had been transferred to the hospital emergency department on 5/23/24. A progress note, dated 5/23/24 at 2:52 p.m., indicated [Resident 10] returned from ED [Emergency Department] . The clinical record lacked documentation that the written bed hold notification was provided to Resident 10 or to the resident's representative for the hospital transfer on 5/23/24. During an interview on 10/10/24 at 1:15 p.m., Unit Manager 2 indicated Resident 10 was transferred to the hospital emergency department on 5/23/24. The facility lacked verification that the written bed hold notification was given to the resident and their representative. On 10/11/24 at 8:10 a.m., the Administrator provided a copy of the [NAME] Care Bed Hold policy, dated 1/2/24, and indicated it was the current policy in use by the facility. A review of the policy indicated that the resident and the resident's representative would be provided the bed hold policy at the time of the hospital transfer or therapeutic leave, or would be provided written notice within 24 hours for an emergency transfer of the resident, and that the facility would keep a signed and dated copy of the bed-hold notice information given to the resident and /or resident representative in the resident's file. 3.1-12(a)(25) 3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 1 of 4 residents reviewed for environment. Call lights were not within reach. (Resident 8) Findings include: During an observation on 10/7/24 from 11:47 a.m. to 11:55 a.m., Resident 8 was observed resting in bed. Resident 8's call light was observed mounted to the wall between Resident 8's bed and the roommate's bed. The call light cord was attached to the wall mount and the other end of the cord was observed lying on the floor behind Resident 8's headboard. The call light was out of reach of Resident 8. During an interview at that time, Resident 8 indicated she was not able to find her call light. During an interview on 10/7/24 at 11:58 a.m., RN 3 indicated all call lights were to be kept within reach of the resident. During an observation on 10/8/24 from 9:13 a.m. to 9:20 a.m., Resident 8 was observed resting in bed. Resident 8's call light was observed mounted to the wall between Resident 8's bed and the roommate's bed. The call light cord was attached to the wall mount and the other end of the cord was observed lying on the floor behind Resident 8's headboard. The call light was out of reach of Resident 8. During an interview on 10/8/24 at 9:22 a.m., Unit Manager 2 indicated Resident 8's call light was supposed to be kept within reach of the resident. On 10/9/24 at 3:00 p.m., Resident 8's clinical record was reviewed. The diagnoses included, but were not limited to, history of falling and anemia. The Annual Minimum Data Set (MDS) assessment, dated 8/22/24, indicated Resident 8 was moderately cognitively intact. Resident 8's care plan, revised on 6/13/24, indicated the resident was at risk for falls. Interventions, dated 10/16/23, included keep call light .within reach. During an interview on 10/10/24 at 3:05 p.m., the Director of Nursing Services indicated call lights were to be kept within reach of the resident. On 10/10/24 at 8:30 a.m., the Director of Nursing Services provided a copy of the Resident Rights policy, dated 12/12/23, and indicated it was the current policy in use by the facility. A review of the policy indicated, .Safe environment: the resident has a right to a safe .environment . On 10/10/24 at 8:30 a.m., the Director of Nursing Services provided a copy of the Call Lights policy, dated 12/12/23, and indicated it was the current policy in use by the facility. A review of the policy indicated, .Staff will ensure the call light is within reach of resident .The call system will be accessible to residents while in their bed . 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to develop a comprehensive person centered care plan for a resident who refused care for 1 of 1 residents reviewed for Activities of Daily Living. (Resident 62) Finding includes: On 10/7/24 at 10:16 a.m., observed Resident 62 in his room. The resident was in bed and awake. A strong foul smell was noted inside the room. On 10/8/24 at 10:22 a.m., observed Resident 62 in his room. A strong foul odor was noted in the residents room. On 10/9/24 at 9:00 a.m., observed Resident 62 in his room. A strong foul odor was noted in the resident's room. On 10/7/24 at 11:00 a.m., the clinical record of Resident 62 was reviewed. The diagnosis included but was not limited to, morbid (severe) obesity. A care plan, dated 7/19/24, indicated Resident 62 required assistance with activities of daily living secondary to diagnosis of acute on chronic respiratory failure, heart failure, morbid obesity, decreased mobility. The interventions included, but was not limited to, requires the assistance of one staff. The clinical record lacked a person centered care plan that included the refusal of showers and refusal of other care. During an interview on 10/9/24 at 9:10 a.m., the Director of Nursing indicated Resident 62 refused care, including showers. On 10/9/24 at 9:30 a.m., the DON indicated a care plan for Resident 62's refusal of care was not available. On 10/10/24 at 9:49 a.m., the DON provided a policy titled Comprehensive Care Plan, dated 1/2/24, and indicated it was the current policy being used by the facility. A review of the policy indicated, .3. The comprehensive care plan will describe, at the minimum, the following: .b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. 3.1-35(a)

Based on interview and record review, the facility failed to ensure that written Notice of Transfer and Discharge was provided to the resident and the resident's representative for 1 of 6 residents reviewed for transfers and discharges. (Resident 10) Finding includes: On 10/10/24 at 9:57 a.m., Resident 10's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes, COPD (Chronic Obstructive Pulmonary Disease, a lung disease that makes it difficult to breathe), heart disease, and risk for falls. Resident 10's face sheet identified a family member as the resident's representative. The clinical record's Census tab indicated Resident 10 had been transferred to the hospital emergency department on 5/23/24. A progress note, dated 5/23/24 at 2:52 p.m., indicated [Resident 10] returned from ED [Emergency Department] . The clinical record lacked documentation that the written Notice of Transfer and Discharge was provided to the resident and the resident's representative for the facility-initiated hospital transfer on 5/23/24. During an interview on 10/10/24 at 1:15 p.m., Unit Manager 2 indicated Resident 10 was transferred to the hospital emergency department on 5/23/24. The facility was unable to provide verification that the written Notice of Transfer and Discharge was provided to the resident and the resident's representative for the facility-initiated hospital transfer on 5/23/24. On 10/11/24 at 8:10 a.m., the Administrator provided a copy of the Transfer & Discharge policy, dated 12/12/23, and indicated it was the current policy in use by the facility. A review of the policy indicated, .Emergency Transfers/Discharges: initiated by the facility for medical reasons to an acute care setting such as a hospital .provide a notice of transfer and the facility's bed hold policy to the resident and representative .ombudsman .The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii)

Based on interview and record review, the facility failed to ensure weekly weights were recorded in the clinical record and failed to monitor a resident's weight for significant weight changes for 1 of 3 residents reviewed for nutrition. (Resident 23) Finding includes: On 10/8/24 at 3:14 p.m., Resident 23's clinical record was reviewed. The diagnoses included, but were not limited to, Huntington's Disease, diabetes, dementia, asthma, and abnormal weight loss. The Registered Dietician assessment, dated 8/29/24, indicated Resident 23 had a history of abnormal weight loss and required assistance with meals. The clinical record lacked additional dietician evaluations or dietary notes. Physician orders, dated 9/13/24 with no end date noted, indicated weekly weights. Resident 23's care plan, revised on 10/7/24, indicated Resident 23 had a potential nutritional risk related to abnormal weight loss and malnutrition. The care plan goal included will not exhibit significant weight loss. Interventions initiated on 9/25/24 included weights as ordered/indicated, notify MD [physician] of significant weight changes .Registered Dietician to evaluate and make diet changes/recommendations as needed. Resident 23's September 2024 Treatment Administration Record (TAR) indicated weekly wt [weight] one time a day every Friday, start date: 9/13/24. A review of the TAR record indicated clinical staff signed the document on 9/13/24, 9/20/24, and 9/27/24, which signified the weekly weights were obtained. The TAR record lacked the actual weekly recorded weight amounts for those specific dates. Resident 23's Vital Record weight report indicated the following: - On 8/26/24 at 1:19 p.m., Resident 23's weight was 141.4 pounds. - On 9/2/24 at 1:07 p.m., Resident 23's weight was 141.0 pounds; a 0.4-pound loss between 8/26/24 and 9/2/24. - On 10/1/24 at 7:55 a.m., Resident 23's weight was 151.8 pounds; a 10.8-pound weight gain between 9/2/24 and 10/1/24. - On 10/2/24 at 12:48 p.m., Resident 23's weight was 127.2 pounds, a 24.6-pound weight loss between 10/1/24 and 10/2/24. The clinical record lacked documentation that weekly weights were recorded as prescribed by the physician. The clinical record lacked documentation that the physician was notified of the significant weight changes. The clinical record lacked documentation that monitoring for the weight fluctuations had been identified and corresponding interventions were implemented. During an interview on 10/9/24 at 8:45 a.m., Qualified Medication Aide (QMA) 4 indicated resident weights were to be recorded in the Vital Record weight report tab in the electronic clinical record. During an interview on 10/9/24 at 10:45 a.m., the Assistant Director of Nursing Services (ADNS) indicated Resident 23's clinical record indicated the staff signatures on the TAR record reflected the weekly weights had been taken. However, the actual weight amounts had not been recorded in the clinical record. The ADNS indicated perhaps there was a problem with the weight scale machine which caused the weight fluctuations for 10/1/24 and 10/2/24 recorded weights. The record lacked evidence of any updated weight monitoring or interventions for Resident 23. During an interview on 10/11/24 at 10:20 a.m., the Director of Nursing Services indicated the weekly weights should have had data entered into the clinical record. All documentation entered into the record was to be accurate. No additional assessments or interventions were implemented as a result of Resident 23's weight changes. On 10/10/24 at 9:55 a.m., the Director of Nursing Services provided a copy of the Nutrition Management policy, dated 12/12/23, and indicated it was the current policy in use by the facility. A review of the policy indicated, .the resident's nutritional care .will be reviewed .as needs/interventions change .at least monthly to provide nutrition assessment/recommendations for those residents determined to be at risk . On 10/11/24 at 10:20 a.m., the Regional Clinical Consultant provided a copy of the Physician Orders policy, dated 12/12/23, and indicated it was the current policy in use by the facility. A review of the policy indicated, .to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality .documentation .will be maintained in the resident's clinical record . 3.1-46(a)(1)

Based on interview and record review, the facility failed to document the drug disposition records for 2 of 2 records reviewed for discharged residents. (Resident 77, Resident 78) Findings include: 1. On 10/10/24 at 9:45 a.m., the clinical record of Resident 77 was reviewed. The diagnoses included, but were not limited to, COPD (a lung disease that makes it difficult to breathe) and type 2 diabetes. A physician's order summary report of medications, dated for active orders as of 9/1/24, included but were not limited to: - acetaminophen 500 mg (milligrams) for pain, fever, or headache - cholecalciferol (vitamin D3) 1,000 units for vitamin deficiency - insulin glargine subcutaneous solution 20 units injection for diabetes - insulin lispro subcutaneous solution with a sliding scale (dosage varied based on blood sugar at time of administration) for diabetes - metformin hydrochloride 500 mg for diabetes - sertraline hydrochloride 50 mg for depression - sodium chloride 1,000 mg for hyponatremia (low sodium levels) - solifenacin succinate 5 mg for bladder spasm A progress note, dated 9/1/24 at 5:20 a.m., indicated that resident had passed away at facility. Resident 77's clinical record lacked documentation of medications being sent back to the pharmacy or destroyed. 2. On 10/10/24 at 10:00 a.m., the clinical record of Resident 78 was reviewed. The diagnoses included, but were not limited to, COPD (a lung disease that makes it difficult to breathe) and unspecified heart failure. A physician's order summary report of medications, dated for active orders as of 6/1/24, included but were not limited to: - acetaminophen 650 mg for general discomfort - atorvastatin calcium 40 mg for high cholesterol - benztropine mesylate 1 mg for neurologic/mood - Combivent Respimat inhalation 20-100 mcg (micrograms) for shortness of breath/COPD - Eliquis 5 mg for blood thinner - fluticasone propionate nasal spray 50 mcg for allergies - gavilax powder 17 gm (gram) for constipation - melatonin 3 mg for other sleep disorders - metoprolol succinate 25 mg for hypertensive heart disease - paliperidone 1.5 mg for schizophrenia - paliperidone palmitate IM (intramuscular) suspension 234 mg/1.5 mL (milliters) for schizophrenia - saline nasal solution for sinus congestion - sennosides docusate sodium 8.6-50 mg for constipation A progress note, dated 7/12/24, indicated Resident 78 was discharged from facility with all medications and belongings. Resident 78's clinical record lacked documentation of a medication release form listing all medications that were sent home with the resident or resident's representative. During an interview on 10/10/24 at 9:17 a.m., the Director of Nursing (DON) indicated that they lacked documentation for the drug dispositions for Resident 77 and Resident 78. On 10/11/24 at 10:35 a.m., the Regional Clinical Consultant (RCC) provided a policy titled Medication Returns, Credits, and Destruction, dated 2/1/18, and indicated it was the current policy being used by the facility. A review of the policy indicated that all items returned to the pharmacy must be logged on a medication return form; the facility was to send the white and yellow copies of the triplicate forms, and they were to keep the pink copy at the facility for their records. 3.1-25(o) 3.1-25(s)

Based on observation, interview, and record review, the facility failed to ensure a current menu was posted for 1 of 1 meal observed. Posted menus were incorrect. Finding includes: During an observation on 10/7/24 at 12:33 p.m., a posted menu was observed on the entry way of the main dining room. The posted menu indicated it was week 4. The menu indicated today's lunch consisted of turkey, carrots, mashed potatoes, and a roll. On 10/7/24 at 12:45 p.m., observed a menu posted on the wall on the entrance to the B wing. The posted menu indicated it was week 3. The menu indicated today's lunch on 10/7/24 consisted of cheesy ham and macaroni, spinach, corn bread, and pineapple tidbits. On 10/7/24 from 12:33 p.m. until 1:00 p.m., observed the facility staff serving the main dining room trays for the noon meal. The meal received by the residents included, brochette chicken, parmesan noodles, green beans, and a dinner roll. During an interview on 10/7/24 at 12:50 p.m., the Staff Scheduler indicated the posted menu's should reflect what was currently being served. During an interview on 10/7/24 at 1:09 p.m., the Dietary Manager indicated the current posted menu should have indicated, day two of week one. The posted menu's should have been changed on 10/5/24. On 10/9/24 at 9:15 a.m., during Resident Council meeting, Resident 48 indicated the residents never knew what they were having for meals until they receive their meal tray. Resident 48 indicated the posted menu was always wrong. On 10/7/24 at 1:43 p.m., the Executive Director provided a policy titled Menus, dated 10/2022, and indicated it was the current policy being used by the facility. A review of the policy indicated .6. Menus will be served as written, unless a substitution is provided in response to preference . 8. Menus will be posted in the Dining Services department, dining rooms and resident/patient care areas . 3.1-20(k)

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity for 1 of 12 residents observed during the noon meal. Staff did not sit to assist residents with their meal. (Resident 60) Finding includes: During a dining observation on 10/7/24 at 12:10 p.m., Unit Manager (UM) 2 assisted Resident 60 with the noon meal while standing over Resident 60. UM 2 was not observed to be seated. During an interview on 10/7/24 at 12:48 p.m., the Director of Nursing (DON) indicated that staff should be sitting at eye level but not standing while assisting residents with meals. During an interview on 10/7/24 at 12:50 p.m., UM 2 indicated staff should be sitting at eye level when assisting residents with meals. On 10/8/24 at 8:50 a.m., Resident 60's clinical record was reviewed. The diagnosis included but was not limited to, Alzheimer's disease. A Quarterly Minimum Data Set (MDS) assessment, dated 9/18/24, indicated the resident had severe cognitive impairment and required extensive assistance with eating. On 10/7/24 at 12:56 p.m., the DON provided a copy of a policy titled Dignity, revised on 1/2/24, and indicated it was the policy currently being followed by the facility. A review of the policy indicated it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. 3.1-3(a)

Based on observation, interview, and record review, the facility failed to provide care and services for a resident diagnosed with PTSD (Post Traumatic Stress Disorder) for 1 of 3 residents reviewed.(Resident D) Finding includes: During an interview on 4/17/24 at 11:23 a.m. Resident F indicated the facility had a major illegal drug and alcohol problem. Resident D drank alcohol in the facility and supplied other resident with alcohol. Resident F reported this to the Administrator. During an interview on 4/17/24 at 12:06 p.m. Resident G indicated Resident G witnessed Resident D offer alcohol to other residents. Resident G reported this to the Administrator. During an interview on 4/18/24 at 1:55 p.m., the Administrator indicated he was aware of allegations of illegal drug and alcohol use in the facility. He indicated the facility had never caught anyone doing drugs inside the facility. Staff did find a bottle of vodka in Resident D's room. At that time, the Administrator pulled a small clear bottle out of his desk drawer. The bottle was unopened, clear, plastic 200 ml (milliliters) container with a red label of [NAME] premium blend Vodka. During an interview on 4/19/24 at 8:23 a.m., Resident D indicated he brought Vodka into the facility and got drunk. During an interview on 4/19/24 at 8:28 a.m., the Social Service Director indicated Resident D was caught with Vodka and the Vodka was removed from his room. After the Vodka was found, Resident D's independent LOA (leave of absence) was discontinued. An independent LOA is not always based on a resident's BIMS (Brief Interview for Mental Status) score. On 3/1/24, Resident D requested to go to the hospital shortly after he had been drinking in the facility and was having increased hallucinations. The clinical record for Resident D was reviewed on 4/19/24 at 9:40 a.m. The diagnoses included, but were not limited to, schizophrenia, major depression, psychoactive substance abuse, and alcohol dependence. An Admission MDS (Minimum Data Set) assessment, dated 2/8/24, indicated Resident D was moderately cognitively impaired. The diagnoses did not include post-traumatic stress disorder. A psychiatric progress note, dated 2/9/24, indicated Resident D's overall history, symptoms, and current presentation appears consistent with post traumatic stress disorder. Established diagnoses list included, but was not limited to, post-traumatic stress disorder. A Quarterly MDS assessment, dated 3/13/24, did not include the diagnosis of post-traumatic stress disorder. Resident D's clinical record lacked a person-centered care plan for post-traumatic stress disorder. During an interview on 4/22/24 at 9:05 a.m., the Administrator indicated Resident D should have had a person-centered care plan for post-traumatic stress disorder. On 4/17/24 at 9:18 a.m., the Director of Nursing provided a copy of a facility policy, titled Mood and Behavior Management, dated 7/2018, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility to provide interventions that are specific to the resident's individualized needs. 3.1-43(a)(1)

Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Survey Agency for 2 of 3 allegations of abuse reviewed. (Resident B, Resident C) Findings include: 1. During an interview on 4/17/24 at 9:05 a.m., the Social Service Director indicated on approximately 4/2/24, Resident B made an abuse allegation that a black, female staff member hit him in the back of the head. The facility was not able to substantiate the allegation. During an interview on 4/18/24 at 1:00 p.m., Resident B indicated a staff member smacked the back of his head after they had an argument. Resident B did not know if the staff was a nurse or CNA (Certified Nursing Aide), was not able to provide a physical description, and was not sure of the date nor time. During an interview on 4/18/24 at 1:55 p.m., the Administrator indicated on 4/1/24, Resident B made an allegation that a staff member hit him. The Administrator indicated the facility investigated the allegation but were not able to substantiate the abuse allegation. The abuse allegation should have been reported to the State Survey Agency but was not. The clinical record for Resident B was reviewed on 4/18/24 at 1:05 p.m. The diagnoses included, but were not limited to, anxiety and depression. A Quarterly MDS (Minimum Data Set) assessment, dated 2/23/24, indicated Resident B was severely cognitively impaired. A progress note, dated 4/1/24 at 4:01 p.m., indicated Resident B reported a staff member hit him. The nurse assessed Resident B. The social worker, Administrator, and DON (Director of Nursing) were notified. On 4/19/24 at 10:15 a.m., the Administrator provided a copy of a document, titled Report a Concern, dated 4/2/24, and indicated the was this was the concern form that was filled out after Resident B made an allegation of abuse. A review of the document indicated the alleged abuse occurred, on 4/1/24 at approximately 4:00 p.m. when a staff member hit Resident B while providing care. 2. During an interview on 4/17/24 at 9:05 a.m., the Social Service Director indicated Resident C made an allegation that a staff member was rough while providing care. RN 1 (Registered Nurse) came to morning meeting and reported the allegation to the Social Service Director and the Social Service Director asked RN 1 to get a statement from Resident C and report the allegation to the Administrator. The Administrator spoke to Resident C, but the Social Service Director did not know the details of that conversation. During an interview on 4/18/24 at 1:55 p.m., the Administrator indicated Resident C made an allegation that a staff member did not provide care in a slow and gentle manner on 3/29/24 at approximately 5:00 a.m. Resident C asked the staff member to slow down but the staff member did not listen. The Administrator indicated the facility was not able to substantiate the allegation of abuse. The clinical record for Resident C was reviewed on 4/19/24 at 9:30 a.m. The diagnoses included, but were not limited to, alcohol abuse, altered mental status, and major depression. An Admission MDS assessment, dated 1/6/24, indicated Resident C was cognitively intact. The electronic medical record did not include sufficient documentation to determine the specific details of the abuse allegation that was made by Resident C on 3/29/24. On 4/19/24 at 10:15 a.m., the Administrator provided a copy of a document, titled Report a Concern, dated 3/29/24, and indicated this was the concern form that was filled out after Resident C made an allegation of abuse. A review of the document indicated the alleged abuse occurred, on 3/29/24 at approximately 5:00 a.m. when a staff member continued to provide care in a manner that was too fast and not gentle enough after Resident C asked the staff member to slow down. On 4/17/24 at 3:05 p.m., the Director of Nursing provided a copy of a facility policy, titled Abuse Prevention Program, dated 3/2021, and indicated this was the current policy used by the facility. A review of the policy indicated when an alleged case of abuse is reported, the Administrator or designee will notify the State certification agency responsible for surveying the facility. This citation relates to Complaints IN00432582 and IN00432713. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner for 3 of 3 kitchen observations. Mouse droppings were in the dry storage room under cereal and crackers boxes, hair nets were not properly covering hair. (Dietary Manager, Staff 6 Findings include: On 11/13/23 from 10:20 a.m. to 10:30 a.m., during the initial kitchen tour with the DM (Dietary Manager) the following was observed: - Staff 6 was observed walking throughout the kitchen where food preparation was being performed, with a hair net on top of her head leaving the hair on the back of her head exposed approximately 1 foot of mixed braided hair uncovered. The DM, while on initial tour was also observed with a hair net on top of his head leaving hair on the back of his head approximately 4 inches long not covered. The DM was observed to return to food preparation with his hair uncovered. - In the dry storage room rodent traps were noted to be in place, while one trap under the cereal and crackers boxes had multiple mouse droppings observed. During an interview at that time, the DM indicated It could very well be mouse droppings. On 11/13/23 at 12:03 p.m., the Executive Director provided the Pest Control Program from, signed and dated 10/17/23 with documentation to pest control activity in facility indicating an ongoing pest control and observations dated from 9/17/23 until 11/12/23. On 11/14/23 at 8:20 a.m., observed mouse droppings in the dry storage area. On 11/14/23 at 8:25 a.m., the DM was observed with a hair net on top of his head leaving the back of his hair uncovered approximately 4 inches. During an interview on 11/14/23 at 8:27 a.m., the Executive Director indicated, Yes, I do see them I will have traps checked and area cleaned. On 11/15/23 at 9:20 a.m., observed the DM walking throughout the kitchen with a hair net on top of his head leaving approximately 4 inches on the back of his head uncovered. During an interview at that time, the District Manager indicated the DM did not have his hair net on properly. On 11/15/23 at 10:12 a.m., the DNS (Director of Nursing Services) provided a copy of the Healthcare Services Group Staff Attire Police, revised 9/2017 and indicated it was the current policy in use by the facility. A review of the policy indicated, .All staff members will have hair off the shoulders, confined in a hair net or cap and all facial hair properly restrained . On 11/15/23 at 10:21 a.m., the DNS provided a copy of the Healthcare Services Group Environment Policy, revised 9/2017 and indicated it was the current policy pin use by the facility, .The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation . The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to verify placement of an enteral tube prior to administering medications for 1 of 2 enteral tube medication administrations observed. (Resident 58) Findings include: On 11/15/23 at 8:40 a.m., Licensed Practical Nurse (LPN) 2 was observed to administer medication to Resident 58 per enteral tube (jejunostomy feeding tube). LPN 2 was observed to not verify the placement of the enteral tube prior to administering the medication. During an interview, at that time, LPN 2 indicated she was not sure if the placement of the tube needed to be verified. On 11/15/23 at 9:00 a.m., the clinical record of Resident 58 was reviewed. The diagnosis included, but was not limited to, gastrostomy. A quarterly Minimum Data Set (MDS) assessment, dated 10/29/23, indicated Resident 58 was moderately cognitively impaired and required a feeding tube. A Physicians order, initiated 5/26/23, indicated check placement of tube [enteral] prior to administration of medications. A care plan, dated 5/26/23 and current through 11/26/23, indicated, Resident 58 is at risk for complications. Resident 58 requires tube feeding, related to NPO (nothing by mouth) status. The interventions included, but were not limited to, tube feeding and water flushes as per physician orders. Check for tube placement and gastric contents per facility protocol and record. On 11/15/23 at 11:22 a.m., the Director of Nursing provided a policy titled, Medication Administration Via Enteral Tube, undated, and indicated it was the current policy being used by the facility. A review of the policy indicated 9. Procedure: h. Enteral tube placement must be verified prior to administering any fluids or medication. 3.1-44(a)(2)

Based on observation, interview, and record review, the facility failed to ensure tracheostomy supplies were kept at the bedside for 1 of 2 residents reviewed for tracheostomy care. (Resident 231) Finding includes: On 11/15/23 at 10:54 a.m., Resident 231's clinical record was reviewed. The diagnoses included, but were not limited, to the following: tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck, a person with a tracheostomy breathes through a tracheostomy tube inserted in the opening), chronic respiratory failure with hypoxia (not enough oxygen in the blood), and nontraumatic intracranial hemorrhage (damage to the blood vessel walls). Physician orders, effective 10/30/23 with no identified end dates, included but were not limited to the following: - Tracheostomy size 7. - Keep a spare tracheostomy of same size and one size smaller at bedside every shift. - Oxygen at 4 liters per minute via tracheostomy collar every shift. The Admission Minimum Data Set (MDS) assessment, dated 11/12/23, indicated Resident 231 utilized oxygen therapy and tracheostomy care. Resident 231's care plan included, but was not limited to: Resident has a tracheostomy, at risk for complications for impaired breathing mechanics, initiated 10/31/23 and valid through 1/28/24. The interventions included, but were not limited to, size and type of trach tube (Portex 7 disposable) and tracheostomy care as ordered. On 11/15/23 at 10:45 a.m., observed Resident 231 resting in bed with a tracheostomy tube and oxygen, at 4 liters per minute via tracheostomy collar, in place. On 11/15/23 at 11:45 a.m., Unit Manager 3 was observed checking the availability of the required tracheostomy supplies that were to be kept at Resident 231's bedside. Unit Manager 3 found one unused size 7 Portex disposable tracheostomy tube in a box inside a plastic bag hanging on the wall near the resident's headboard. No other tracheostomy tubes were found at the bedside. During an interview on 11/15/23 at 11:50 a.m., Unit Manager 3 indicated Resident 231's tracheostomy size was a 7. At least two spare tracheostomy tubes were to be kept at the bedside. One tracheostomy tube should be the resident's current tracheostomy size and the other one was to be one size smaller. Unit Manager 3 indicated the smaller sized tracheostomy tube was not found in Resident 231's room. On 11/16/23 at 8:30 a.m., the Administrator provided a copy of the [NAME] Care Policy and Procedure: Trach Care policy, dated 5/27/21, and indicated it was the current policy in use by the facility. A review of the policy indicated, .trached patients are to have an unopened next size down tracheostomy tube at the bedside or taped to the head of the bed . 3.1-47(a)(4)

Based on interview and record review, the facility failed to ensure an incident of alleged resident physical abuse was reported to the State Survey Agency for 1 of 1 residents reviewed for reporting resident abuse. (Resident 43) Finding includes: During an interview on 11/13/23 at 9:30 a.m., Resident 43 indicated a CNA (Certified Nurse Aide) 4 had recently smacked her in the head. Resident 43 indicated that she had reported the incident to the charge nurse. During an interview on 11/13/23 at 10:00 a.m., the DON (Director of Nursing), indicated the allegation was not reported to the State Survey Agency and that it should have been reported. On 11/13/23 at 2:30 p.m., Resident 43's clinical record was reviewed. The Quarterly Minimum Data Set (MDS) assessment, dated 10/30/23, indicated Resident 43 was cognitively intact. On 11/14/23 at 11:30 a.m., the DON provided a copy of the facility reportable incident and associated investigation. The incident occurred on 11/7/23 at 6:30 p.m. and it was reported to Administrator and DON on 11/8/23 during morning meeting at 9:00 a.m. It was reported to the State Agency on 11/13/23. On 11/13/23 at 11:00 a.m., the DON provided a copy of abuse policy titled Abuse Prevention Program, dated for March 2021, and indicated that it was the policy currently in use by the facility. A review of the policy indicated, When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility Administrator, DON, or individuals designated will immediately (not to exceed 24 hours if the event does not result in serious bodily injury .notify the following persons or agencies of such [an] incident: 1. The State licensing/certification agency responsible for surveying/licensing the facility 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure a female resident, diagnosed with depression, anxiety, PTSD (post-traumatic stress disorder), and delusions disorder received treatment and services to attain the highest practicable mental and psychosocial well-being for 1 of 3 residents reviewed for mental health treatment. This resulted in the resident requiring inpatient psychiatric treatment. (Resident B) Finding includes: During an interview on 6/19/23 at 10:30 a.m., observed Resident B sitting outside, alone, in the front parking lot of the facility, smoking a cigarette. She had a disheveled appearance with her wig half on and taped to her head. Resident B appeared to be anxious, guarded, and paranoid. At that time, Resident B indicated Resident E was her roommate and Resident E had been putting bed bugs on her. There were multiple residents throwing bed bugs on Resident B outside in the smoking area. There were multiple nights when someone went into Resident B's room at night, while she was sleeping, and threw bed bugs on her. She has not been able to prove it to any staff because by the time she wakes up the bugs are gone. Resident B's son had a fragile X chromosome and she watched him die. Resident B indicated she had never threatened anyone verbally nor physically. Resident B indicated she was getting ready to start medical school. The clinical record for Resident B was reviewed on 6/19/23 at 1:48 p.m. The diagnoses included, but were not limited to, post-traumatic stress disorder, anxiety disorder, and psychotic disorder with delusions. A Quarterly MDS (Minimum Data Set) assessment, dated 3/24/23, indicated Resident B was cognitively intact. A behavioral health progress note, dated 3/13/23 at 12:00 a.m., indicated Resident B had past trauma because she was a hostage. On 11/16/22, a NPIQ (Neuropsychiatric Inventory Questionnaire is a questionnaire that assesses neuropsychiatric symptoms of the resident over the past month) was completed and indicated Resident B had moderate neuropsychiatric symptoms with dysphoria, anxiety, and irritability/lability. On that day, staff reported feeling A Little Stressed when providing care to Resident B. On 3/13/23, another NPIQ was completed and indicated severe neuropsychiatric symptoms with delusions, hallucinations, and agitation. On that day, staff reporting feeling Very Stressed when providing care to Resident B. Resident B's mood was irritable and manic. Resident B was having tactile and visual hallucinations and distressful, persecutorial, and paranoid delusions. Resident B's insight and judgement became severely impaired. Also indicated, Resident B presented in an agitated mood with irritable affect. Resident B expressed delusions, paranoia, and visual hallucinations of bed bugs saying they were in her nose and biting her face. Resident B had multiple sores on her face. Clinician asked Resident B was agitated, verbally aggressive, and endorsed psychosis. Discussed this with the SSD (Social Service Director) and the SSD stated that she was trying to get Resident B into inpatient psychiatric hospital. A progress note, dated 3/13/23 at 11:21 a.m., indicated Resident B noted with significant behavior changes this morning. During conversation with writer Resident B was talking to voices that were not present. When Resident B was asked about these voices she explained that the voices were coming from the kitchen. Resident B stated that the environment was noisy but no one noise was present. She is noted scratching all over her face. She stated that her skin has broken out due to this facility. Resident B has a history of using heavy amounts of make-up which she does not remove daily. Resident B also stated that she believed her hip hardware had come out of place and was causing pain and discomfort. Resident B stood up and requested that writer palpate area at which time writer noted no changes or abnormalities. On 3/12/23 Resident B called emergency services related to hip pain. Resident B was transported to the emergency department where she was evaluated, X-rays were completed, and no fracture or dislocation was noted. Resident B also received Dilaudid and Zofran during the emergency department visit. Resident B returned to facility. Resident B stated that she had been told that she will be discharged to the streets. When writer reassures her that she is not being discharged she then stated that she wanted to leave and discharge to another facility. Writer reassured Resident B that we want to make sure she is safe and comfortable, provided personal space. Resident B purchased an energy drink and went to her room. The Nurse Practitioner and Psych services were notified of behavior changes. Social Services noted of request to transfer facilities A progress note, dated 3/13/23 at 11:38 a.m., indicated Resident B with psychosis type behavior this morning. She was going down the hallway on A Wing and then to B Wing with raised voice. Multiple staff members attempted to redirect and calm down without success. Resident B went outside to smoke. She returned to the A wing nurse's station with shrilled voice saying that there were bugs in her room that were eating her, and she just needed somewhere to relax and be left alone to call. She claimed that staff burst in on her in the bathroom and started pouring diarrhea water on her head and wig. Resident B stated that someone confiscated her cigarettes, and she wanted them back. Resident B had cigarettes within the last hour because she had gone out to smoke. She was noted by the Executive Director that she was talking with someone that was not present about I am not going to throw up, just leave me alone. When approached Resident B stated that she was talking with someone who told her it was okay to puke. She insisted on going to the hospital over the weekend because her hip popped out. Nursing attempted to treat in house, and she was insistent. SSD has spoken with her several times and expressed that she might need inpatient treatment. SSD standing with resident and placed hand on handle of wheelchair, and Resident B said, please don't do that. She expressed that she was unhappy here and a staff member expressed that if she was unhappy there were women's shelters that could help her. She then started talking about her handicapped son that she can't care for because of her condition and that his dad is abusing him. SSD expressed to her that she needed to notify authorities to assist because of her current condition and she said that she had. Resident B recently told the psychologist that she was in the witness protection program. A behavioral health progress note, dated 3/23/23 at 1:00 a.m., indicated Resident B was assessed in room. She continues to fidget. Staff reported Resident B told another patient that she was going to shoot all the nursing staff with a gun. When asked Resident B about this, she denied accusation. Stated she has never told anyone anything like that. Staff reported Resident B's behavior has become more erratic. Encouraged staff to monitor patients behaviors. A progress note, dated 4/10/23 at 5:31 p.m., indicated Resident B noted to have hallucinations and hearing voices. Resident B stated that someone was messing with her hair and her earbuds. Resident B also was seen yelling at someone stating get the F off of me when there was no one there. Writer attempted to reassure Resident B that no one was there. A progress note, dated 4/11/23 at 3:28 p.m., indicated Resident B was observed in hallway talking to pictures on the wall. When asked Resident B stated, I know them. Resident B continued conversation for 3-5 minutes with the pictures. Then, Resident B went outside. A behavioral health progress note, dated 4/12/23 at 1:00 a.m., indicated during the session Resident B presented as anxious, with anxious/worried affect. Staff requested this appointment for Resident B due to reported visual hallucinations. Resident B described a hole in her wall and something from the hole as eating the top of my head. She complained of bed bugs despite staff denying her having the bugs after investigating for the pests. Resident B denied visual hallucinations stating, If so, I'd say something. She reported rekindling her relationship with her adoptive son and wanting to leave the facility in 2-3 weeks. Will follow up with staff SSD. A progress note, dated 5/9/23 at 2:47 p.m., indicated Resident B was seen walking down the hallway yelling at the wall. When asked what's wrong, Resident B replied, They need to stop touching me. No one was present nor touched her. Resident B continued to have loud outburst throughout the day and was not able to be redirected. A progress note, dated 5/9/23 at 3:19 p.m., indicated Resident B approached writer in social service office. Resident B stated she didn't feel. Resident B was very tearful and anxious and not easily altered with 1:1. Writer observed Resident B talking to people not in the room. Resident B stated, stop bothering me and No, I don't want to do an AB workout right now. Resident B continues to ramble non sensical. Resident B has been noted with ongoing episodes of delusions and hallucinations. The Unit Manager was made aware and Resident B agreed to possible inpatient psychiatric care. SSA contacted a psychiatric facility with referral. A behavioral health progress note, dated 5/24/23 at 1:00 a.m., indicated during session Resident B presented as anxious, with congruent affect. Resident B discussed moving rooms due to perceived issues with her roommate. Resident B was delusional throughout the session and stated she had called the FBI over perceived injustices and bed bugs in her room. Diagnosis updated to reflect Delusional Disorder, Persecutory type. During an interview on 6/20/23 at 8:32 a.m., the Unit Manager indicated she was not sure what Resident B's diagnosis of PTSD was from nor what any triggers were. Resident B's behaviors have been ongoing for over a month. During an interview on 6/20/23 at 8:35 a.m., the Social Service Director indicated she wasn't sure why Resident B was diagnosed with PTSD. She believed Resident B had been raped several times. The Social Service Director was not sure of any triggers. Resident B was suffering from psychosis back in March of 2023. A referral was sent to a psychiatric facility, but Resident B was never sent to a psychiatric facility. The Social Service Director did not have any denial from the psychiatric facility, so she was not sure why Resident B was not sent to the psychiatric facility, but should have been followed up on. The Social Service Director was not aware of any treatment changes at that time back in March of 2023 when Resident B was suffering from the delusions and hallucinations. On 6/19/23 at 2:17 p.m., the Administrator provided a copy of a facility policy, titled Mood and Behavior Management, dated April 2022, and indicated this was the current policy used by the facility. A review of the policy indicated it is the policy of the facility to provide interventions for all residents with behavioral and or mood indicators that may be problematic or distressing. Residents are provided interventions that are specific to the resident's individualized needs. 3.1-43(a)(1)

Based on interview and record review, the facility failed to provide transportation to and from dialysis for 7 of 7 residents reviewed. Four residents missed dialysis appointments and required emergency care due to decline in condition. (Resident B, Resident C, Resident F, Resident G, Resident H, Resident J, Resident K) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, [DATE] at approximately 8:00 a.m. when the facility failed to provide transportation to and from dialysis for 2 residents. The Administrator and the Regional Nurse were notified of the Immediate Jeopardy on [DATE] at 1:30 p.m. The Immediate Jeopardy was removed on [DATE] at 9:45 a.m., but noncompliance remained at a lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During an interview on [DATE] at 11:36 a.m., the Administrator indicated the transportation company that was supposed to transport Resident C to dialysis called the facility to let them know they had a staff member call off of work so they would not be able to transport Resident C. Resident C required a stretcher for transport. The facility was unable to reschedule transportation for Resident C to go to dialysis. Resident C died at the emergency department. During an interview on [DATE] at 12:32 p.m., Bus Driver 1 indicated Resident C required a stretcher for his transportation so she would not have been able to transport Resident C in the facility bus. The clinical record for Resident C was reviewed on [DATE] at 1:15 p.m. The diagnoses included, but were not limited to, heart failure, diabetes mellitus, and chronic kidney disease. An Admission MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident C was cognitively intact and was receiving dialysis while a resident at the facility. The Physician's Orders included, but were not limited to: Hemodialysis, five times a week, Monday through Friday, initiated [DATE]. No discontinue date. Appointment on [DATE] for hemodialysis. A progress note, dated [DATE] at 11:17 a.m., indicated Resident C's daughter was contacted to notify her that resident does not have transportation set up for dialysis and did not attend dialysis today. The plan to be set up for dialysis was Monday, Wednesday, and Friday for the next two weeks, beginning Wednesday [DATE]. A progress note, dated [DATE] at 10:58 a.m., indicated Resident C denied any nausea this morning and did not show signs or symptoms of not receiving dialysis. A progress note, dated [DATE] at 5:46 a.m., indicated Resident C complained of upset stomach and lower back pain. As needed medication given, but no change. Resident C's vitals were checked oxygen saturation was 88 percent at 3 LPM (liters per minute of supplemental oxygen), bumped oxygen up to 4 LPM. Oxygen saturation at 99 percent on 4 LPM upon first check. Rechecked 2 hours later oxygen saturation at 93 percent on 4 LPM, then oxygen saturation dropped to 88 percent on 4 LPM. Resident C was pale with bluish lips. A progress note, dated [DATE] at 8:45 a.m., indicated Resident C complained of upset stomach. This writer went to Resident C's room to administer morning medications and medication for upset stomach. Resident C took all of his medications without issues, followed by 8 ounces of water. This writer noticed Resident C was very pale in color and mottling (discoloration to the skin when the body starts directing blood to the vital organs) had started in Resident C's bilateral lower extremities. Vitals taken oxygen saturation at 90 percent on 2 LPM, respirations were labored at 14 per minute, the head of bed was raised, and findings reported to the Unit Manager. Upon Unit Manager assessing Resident C, the decision was made to call 911 for evaluation. This writer went back to Resident C's room with crash cart and to stay with Resident C until paramedics arrived. While waiting for the paramedics to arrive, Resident C stopped breathing. CPR (cardiopulmonary resuscitation) began immediately until paramedics, and fire department arrived. Code blue was called, care passed on to paramedics upon their arrival. Resident C's family notified of condition. Resident C did not receive a dialysis treatment, on [DATE], [DATE], [DATE]. Resident C was sent to the emergency department, on [DATE], where he died . 2. During an interview on [DATE] at 11:01 a.m., Family Member 1 indicated she believed her husband had missed one or two dialysis treatments. She asked why the facility bus didn't take Resident B to the dialysis treatment, but she didn't get an answer. Resident B had been receiving dialysis Monday through Friday at the facility. On [DATE], Family Member 1 went to the nurse to ask about Resident B not receiving the dialysis treatment and was told Resident B was going to be sent to the emergency department when he returned from another appointment. At the hospital, the hospital doctor told her Resident B had 4 liters of fluid removed. Normally Resident B had 1 liter of fluid removed at each dialysis treatment. She indicated Resident B was still at the hospital on that date ([DATE]). During an interview on [DATE] at 11:36 a.m., the Administrator indicated the transportation company that was supposed to transport Resident B did not show up on the morning of [DATE]. She indicated the facility attempted to contact them for a reason but did not get an answer. She indicated the facility attempted to find transportation for Resident B but was unsuccessful. During an interview on [DATE] at 12:32 p.m., Bus Driver 1 indicated she had not been asked to transport Resident B to dialysis until [DATE]. Resident B was sent to the hospital and admitted a couple days before that, so she didn't transport Resident B on [DATE]. Bus Driver 1 worked the morning of [DATE]. She had to leave at 10:00 a.m., to take another resident to an appointment. She was never asked to transport Resident B to dialysis on [DATE]. The clinical record for Resident B was reviewed on [DATE] at 12:45 p.m. The diagnoses included, but were not limited to, heart failure, diabetes mellitus, and end stage renal disease. An Admission MDS assessment, dated [DATE], indicated Resident B was cognitively intact and received dialysis while a resident at the facility. The Physician's Orders, included, but were not limited to: Hemodialysis, 5 times a week, Monday through Friday, dated [DATE] through [DATE]. Hemodialysis, three times a week, Tuesday, Thursday, Saturday, initiated [DATE]. A progress note, dated [DATE] at 6:23 a.m., indicated staff called transportation company due to Resident B had a scheduled pick up time of 6:00 a.m., and transport had not arrived. The transport company was not able to provide an estimated time of arrival for transportation. A progress note, dated [DATE] at 4:24 p.m., Resident B returned from appointment and was complaining of shortness of breath. The Nurse Practitioner was notified and gave verbal order to send Resident B to the emergency department. Resident B did not receive a dialysis treatment on [DATE] and [DATE]. Resident B was transferred to the emergency department on [DATE]. 3. During an interview on [DATE] at 8:35 a.m., the MDS Coordinator indicated Resident F missed dialysis treatments because the facility could not get transportation nor an appointment for his dialysis treatments. Resident F was discharged to another facility to receive routine dialysis treatments there. The clinical record for Resident F was reviewed on [DATE] at 9:27 a.m. The diagnoses included, but were not limited to, end stage renal disease and heart failure. An Annual MDS assessment, dated [DATE], indicated Resident F was cognitively intact. The Physician's orders, included, but were not limited to: Hemodialysis 5 times a week Monday through Friday, initiated on [DATE] and discontinued on [DATE]. A progress note, dated [DATE] at 3:32 p.m., indicated Resident F did not receive a dialysis treatment. A progress note, dated [DATE] at 3:34 p.m., indicated Resident F's mother was contacted, but there was no answer. Voicemail was left to inform her that as of now Resident F didn't have a dialysis chair. A progress note, dated [DATE] at 11:30 a.m., indicated Resident F was showing signs and symptoms of not receiving the dialysis treatments. A progress note, dated [DATE] at 2:00 p.m., indicated Resident F was transported to the emergency department via ambulance. A progress note, dated [DATE] at 11:11 p.m., Resident F returned from the emergency department. Resident F did not receive a dialysis treatment. Resident F did not receive a dialysis treatment on [DATE], [DATE], and [DATE]. Resident F was transferred to another facility to receive routine dialysis treatments on [DATE]. 4. During an interview on [DATE] at 8:35 a.m., the MDS Coordinator indicated Resident G missed dialysis treatments. Resident G's normal schedule for dialysis treatments was on Mondays, Wednesdays, and Fridays. The clinical record of Resident G was reviewed on [DATE] at 10:00 a.m. The diagnoses included, but were not limited to, acute kidney failure, chronic respiratory failure, and heart failure. A Brief Interview For Mental Status (BIMS), dated [DATE], indicated Resident G was severely cognitively impaired. The Physician's orders included, but were not limited to: Hemodialysis 3 times weekly Monday through Friday, initiated on [DATE] and discontinued on [DATE]. A Physician's progress note, dated [DATE] at 4:37 p.m., indicated Resident G had a half run of hemodialysis completed on [DATE]. Resident G had not been dialyzed since [DATE]. Today Resident G feels positive for cough and feels getting fluid up with heavy breathing and having back pain. Resident G had fluid overload with acute respiratory failure due to last half run hemodialysis was on [DATE]. Will plan for transfer to the emergency department for further management. Resident G did not receive dialysis treatments on [DATE], [DATE], and [DATE]. 5. During an interview on [DATE] at 8:35 a.m., the MDS Coordinator indicated Resident H missed dialysis treatments due to not having an appointment available. Resident H was transferred to another facility to receive routine dialysis treatments. The clinical record for Resident H was reviewed on [DATE] at 10:06 a.m. The diagnoses included, but were not limited to, heart failure, end stage renal disease, and acute respiratory failure. A Quarterly MDS assessment, dated [DATE], indicated Resident H was cognitively intact. The Physician's orders, included, but were not limited to: Hemodialysis 5 times a week Monday through Friday, initiated on [DATE] and discontinued on [DATE]. Resident H did not receive dialysis treatments on [DATE], [DATE], [DATE], and [DATE]. Resident H was discharged to another facility to receive routine dialysis, on [DATE]. 6. During an interview on [DATE] at 8:35 a.m., the MDS Coordinator indicated Resident J missed dialysis treatments. Resident J was discharged to another facility to receive routine dialysis treatments. The clinical record for Resident J was reviewed on [DATE] at 9:45 a.m. The diagnoses included, but were not limited to, dependence on renal dialysis and acute respiratory failure. A BIMS, dated [DATE], indicated Resident J was severely cognitively impaired. The Physician's orders included, but were not limited to: Hemodialysis Monday through Friday, initiated on [DATE] and discontinued on [DATE]. Resident J did not receive a dialysis treatment on [DATE], [DATE], and [DATE]. Resident J was discharged to another facility on [DATE]. 7. During an interview on [DATE] at 8:35 a.m., the MDS Coordinator indicated Resident K missed dialysis treatments because he had a tracheostomy (a tube that enters the front of the neck and into the windpipe to allow air to fill the lungs). Resident K was discharged to another facility to receive routine dialysis treatments. The clinical record for Resident K was reviewed on [DATE] at 9:13 a.m. The diagnoses included, but were not limited to, heart failure and end stage renal disease. A Quarterly MDS assessment, dated [DATE], indicated Resident K was cognitively intact. The Physician's orders included, but were not limited to: Hemodialysis 3 times a week on Mondays, Wednesdays, and Fridays, initiated on [DATE]. A progress note, dated [DATE] at 3:47 p.m., indicated Resident AK's wife was notified the facility was not able to accommodate dialysis due to Resident AK having a tracheotomy. Resident AK would have to go to another facility for dialysis. Resident AK did not receive a dialysis treatment on [DATE] and [DATE]. Resident AK discharged to another facility on [DATE]. During an interview on [DATE] at 8:35 a.m., the MD'S Coordinator indicated dialysis was not provided in the facility after [DATE]. On [DATE] at 11:30 a.m., the Administrator provided a copy of a facility policy, titled Dialysis Care, dated ,d+[DATE], and indicated this was the current policy used by the facility. A review of the policy indicated the facility will assure that each resident that requires dialysis services, receives such services that are consistent with the professional standards. The Immediate Jeopardy, that began on [DATE], was removed on [DATE] when the facility inserviced the staff on dialysis care, adverse effects of missed dialysis treatments, and implemented a plan for dialysis residents when transportation does not arrive, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaint IN 00409435 3XXX,d+[DATE](a)

Based on observation, interview, and record review, the facility failed to ensure staff were properly securing the bus safety latch before transporting residents for 3 of 3 residents reviewed for accidents hazards. Resident D sustained fractures to both legs. Resident B sustained minor injuries. (Resident D, Resident B, Resident E) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began, on 12/29/22 at approximately 5:00 p.m. when the facility failed to secure a resident's wheelchair prior to transporting that resident in the facility bus. The Administrator was notified of the Immediate Jeopardy on 5/30/23 at 4:40 p.m. The Immediate Jeopardy was removed on 5/31/23 at 3:30 p.m., but noncompliance remained at a lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. During an interview on 5/30/23 at 12:12 p.m., Resident D indicated the Maintenance Director was driving the facility bus when Resident D was being transported. The Maintenance Director stopped the bus and Resident D fell forward out of his wheelchair and the wheelchair moved forward. Resident D's legs were pinned between his motorized wheelchair and the bus seat. He indicated his wheelchair wasn't secured to the floor either. Resident D indicated the Maintenance Director was in a hurry. Resident D indicated he didn't put his wheelchair seat buckle on because he was used to being strapped in once on the bus. Resident D thought his right leg looked like the bone was going to come out. The Maintenance Director did not secure Resident D's motorized wheelchair to the bus floor. The Maintenance Director did not put the seat belt on Resident D. During an interview on 5/30/23 at 12:49 p.m., the Maintenance Director indicated Resident D was sitting in his motorized wheelchair while being transported in the facility bus. The Maintenance Director was driving and came to a stop. Resident D flipped out of the wheelchair. This was not the Maintenance Director's first time driving the facility bus to transport residents. The clinical record for Resident D was reviewed on 5/30/23 at 3:13 p.m. The diagnoses included, but were not limited to, paraplegia and post traumatic stress disorder. A Quarterly MDS (Minimum Data Set) assessment, dated 4/12/23, indicated Resident D was cognitively intact. A hospital progress note, dated 12/29/22 at 6:19 p.m., indicated Resident D presented to the emergency department after he fell forward from his wheelchair because he was not secured in the transport van. Noted twisted legs. A hospital progress note, dated 1/1/23 at 11:16 a.m., indicated Resident D sustained a right tibial shaft fracture (right lower leg), a left femur fracture (left upper leg), and a left tibial fracture just below the knee. 2. During an interview on 5/26/23 at 11:01 a.m. Family Member 1 indicated she was with Resident B, on the facility bus, when the bus driver crossed a median and Resident B fell out of his wheelchair. Resident B hit his head, had a cut on his elbow, and a cut on his finger. Resident B also told Family Member 1 that his neck was hurt. The bus driver didn't have Resident B strapped in. The bus driver told her the straps didn't work. During an interview on 5/26/23 at 12:32 p.m., Bus Driver 1 indicated she was transporting Resident B on 5/15/23 when he slid out of his wheelchair when she made a wide turn. Resident B's wheelchair was secured to the floor but the seat belt that was supposed to secure Resident B was broken so she did not apply the seatbelt. The bus driver thought the seat belt was fixed, on May 17 or 18, 2023, when she used the bus again for transportation. The clinical record for Resident B was reviewed on 5/26/23 at 12:45 p.m. The diagnoses included, but were not limited to, heart failure and end stage renal disease. An Admission MDS assessment, dated 5/4/23, indicated Resident B was cognitively intact. A progress note, dated 5/15/23 at 4:13 p.m., indicated skin assessment was completed on Resident B. A skin tear was noted on Resident B's right elbow and his right 5th finger. A progress note, dated 5/15/23 at 4:59 p.m., indicated Resident B had an appointment and was being transported by the facility bus. When the bus came to a construction site, the bus driver had to make a u turn and Resident B's wheelchair fell over. Resident B indicated that he hit his head and that he was having neck pain. The Nurse Practitioner was notified, and a physician's order were received for a cervical spine x-ray. Staff educated on importance of making sure residents are properly secured on bus during transports. 3. On 5/30/23 at 1:43 p.m., Resident E was sitting in a wheelchair on the facility bus. Bus Driver 1 was observed to attempt to secure Resident E and the wheelchair in the facility bus. First, Bus Driver 1 moved Resident E's wheelchair into position to be secured. Second, she pulled a strap, with a hook at the end, up from the floor and attached the hook to the wheelchair's wheel. Then, she tightened the strap. This was repeated for each wheel until the wheelchair was secured to the bus floor. Next, she pulled a seat belt from above Resident E's left side down across his chest and another seat belt up from the floor on Resident E's right side. Each seat belt had a buckle attached to the end. She connected the buckles near Resident E's right thigh. After that she indicated Resident E was secured with the seat belts and ready for transport, observed the seat belt that came up from the floor, easily, come apart when slight pressure was applied. At that time, Bus Driver 1 indicated the seat belt was not broken. The clinical record for Resident E was reviewed on 5/30/23 at 3:31 p.m. The diagnoses included, but were not limited to, paraplegia and post traumatic stress disorder. A Quarterly MDS assessment, dated 3/30/23, indicated Resident E was cognitively intact. On 5/30/23 at 4:32 p.m., the Administrator provided a copy of an undated document, titled employee training orientation, and indicated this was the employee training completed to transport residents in the facility bus. A review of the document indicated the safety gear on the facility van is to be inspected before and after each use. Ensure the resident is secure and double check all locks and restraints. The Immediate Jeopardy, that began on 12/29/22, was removed on 5/31/23 when the facility inserviced the staff on transporting residents in the facility bus via wheelchair to ensure they are secured properly, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. 3.1-45(a)(1)

Based on interview and record review, the facility failed to provide care as directed by the physician for a resident receiving dialysis and had MRSA (methicillin resistant staphylococcus aureus) bacteremia (blood infection). A central venous catheter was not removed, antibiotics were not administered, and laboratory tests were not completed for 1 of 3 residents reviewed for quality of care. This deficient practice resulted in the resident being readmitted to the hospital and died . (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began, on [DATE], when the staff failed to follow physician's orders for a resident diagnosed with MRSA bacteremia the required labs were not drawn, antibiotics were not given, and the central venous catheter was not removed. The resident was readmitted to the hospital and died on [DATE]. The Administrator and DON (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 4:09 P.M. The Immediate Jeopardy was removed on [DATE] at 5:00 p.m., but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: During an interview on [DATE] at 9:28 a.m., the Director of Nursing indicated the physician's order for daptomycin (intravenous antibiotic) for Resident B was originally supposed to stop on [DATE] but was updated to stop on [DATE]. The reason for the change was unknown. Resident B's labs were not completed nor was the central line removed on [DATE]. The clinical record for Resident B was reviewed on [DATE] at 10:40 a.m. The diagnoses included, but were not limited to, acute kidney failure and dependence on renal dialysis. An Admission MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident B was cognitively intact, did not have a multi-drug resistant organism, and had received dialysis prior to and after admitting to the facility. A care plan, dated [DATE] and current through [DATE], indicated Resident B required intravenous antibiotics due to bacteremia. The interventions included, but were not limited to, administer intravenous antibiotics as ordered and observe for adverse side effects, and keep site clean and dry, and labs as ordered A care plan, dated [DATE] and current through [DATE], indicated Resident B required hemodialysis. The interventions included, but were not limited to, Dialysis Days: Monday through Friday (in house), and check and change dressing daily at access site and document. A progress note, dated [DATE] at 9:34 a.m., indicated Resident B was crying out with neck pain that feels like spasms. On call NP (Nurse Practitioner) notified. New order received for a muscle relaxant. A progress note, dated [DATE] at 2:06 p.m., indicated Resident B continued to have severe neck pain resident showed no signs of relief. NP requested Resident B to be sent out to the emergency room . A Nurse Practitioner progress note, dated [DATE] at 7:09 p.m., indicated Resident B was seen for extreme pain. Resident B was visited and was yelling in pain. Resident B remarked pain was located in her neck. Also nursing noting oxygen saturation was 74 percent and oxygen was needed to bring oxygen saturation up. Resident was sent to emergency room for evaluation. A hospital progress note, dated [DATE] at 3:57 p.m., indicated Resident B presented to the emergency department with complaints of neck pain and hypoxia. Resident B had positive blood cultures secondary to MRSA. An Infectious Disease progress note, dated [DATE] at 9:39 a.m., indicated the impression/plan was for the following: 1. MRSA bacteremia with fever on admission and positive blood cultures on [DATE], [DATE], [DATE], and [DATE]. Concern for tunneled dialysis catheter as probable source. The dialysis catheter was removed on [DATE] with thick exudate, and the tip culture was positive. Blood cultures were negative on [DATE], [DATE], [DATE], and [DATE]. A transthoracic echocardiogram (ultrasound of the heart through the chest) negative for vegetations. A transesophageal echocardiogram (a probe inserted into the esophagus that provides a picture of the heart using sound waves) valves normal. Hospital lab results, dated [DATE] at 5:10 a.m., indicated white blood cell count was 10.8 (normal range ,d+[DATE]) A hospital discharge medication list, dated [DATE] at 3:02 p.m., indicated to start daptomycin (an antibiotic) 8 mg (milligrams)/kg (kilogram) equals 750 mg in sodium chloride 50 ml (milliliters) intravenous piggyback every other day for 10 days. Start on [DATE]. The current physician's orders included, but were not limited to: Start [DATE], daptomycin infuse 750 mg intravenously every other day for infection. Give 8 mg/kg in 50 ml sodium chloride IVPB (intravenous piggyback) for 10 days. This order was updated on [DATE] at 9:54 a.m., by the Medical Records Coordinator to include: Start [DATE], daptomycin infuse 750 mg intravenously every other day for infection until [DATE]. Give 8 mg/kg in 50 ml sodium chloride IVPB for 10 days. A fax transmission of a hand written prescription from the Infectious Disease Physician, dated [DATE] at 12:26 p.m., indicated, 1. Daptomycin 750 mg Q [every] 48 after HD [hemodialysis] end of therapy [DATE]. 2. Weekly labs Q [every] Monday fax to [Infectious Disease fax number] cbc w/diff [complete blood count with differential], cmp [comprehensive metabolic panel], cpk [creatinine phosphokinase]. 3. Tunneled small bore line in L [left] IJ [internal jugular] will need removed by Interventional Radiology. Orders placed for removal after [DATE]. Will ask IR [Interventional Radiology] staff to call nursing staff. Please do not leave in place after ,d+[DATE]! DX [diagnosis] MRSA Bacteremia. If no one calls from IR [Interventional Radiology] for tunneled cath [catheter] removal, please call our office at [Infectious Disease phone number] and we will assist you. The [DATE] Medication Administration Record indicated Resident B received daptomycin 750 mg intravenously on [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] and [DATE], the daptomycin was on order. A Pharmacy Drug Regimen Review Progress Note, dated [DATE] at 4:59 p.m., indicated a full chart review was completed. An SBAR (situation, background, assessment, recommendation) note, dated [DATE] at 9:33 a.m., indicated there had been a change in condition, shortness of breath and oxygen saturation of 88 percent while on oxygen via nasal cannula. Resident sent to emergency room for evaluation and treatment as indicated. Hospital lab results, dated [DATE] at 11:00 a.m., indicated white blood count 19.6 (normal range ,d+[DATE]). A hospital progress note, dated [DATE] at 11:01 a.m., indicated chief complaint was shortness of breath. While at dialysis Resident B became short of breath 1 hour into treatment. Medic stated dialysis usually runs for 3 hours. Staff placed Resident B on 4 liters of oxygen by nasal cannula due to oxygen saturation in the 80's. Right tunneled central venous catheter with loose dressing. A hospital history and physical progress note, dated [DATE] at 2:30 p.m., indicated discharged from hospital 3 weeks ago after episode of Staphylococcus septicemia. discharged with central venous catheter and antibiotics. Patient was sent to emergency department from her dialysis today due to severe dyspnea. Central venous catheter was still present. A hospital discharge summary, dated [DATE] at 4:30 a.m., indicated Resident B's primary admission diagnosis was MRSA bacteremia. Resident B presented to the hospital with a chief complaint of shortness of breath and was admitted for MRSA bacteremia. Initially found to be hypoxic. Blood cultures collected on admission and became positive for MRSA. Transesophageal echocardiogram performed on [DATE] and revealed multiple mitral valve vegetations. On [DATE] at 1:54 a.m., respirations ceased. Preliminary cause of death was MRSA bacteremia, infective endocarditis, and multiple embolic strokes. The clinical record lacked a physician's order to administer daptomycin 750 mg intravenously after [DATE] and for the central venous catheter to remain in place after [DATE]. The clinical record lacked documentation of physician notification for [DATE] and [DATE] when the daptomycin was on order from the pharmacy and not administered. The clinical record lacked lab results from [DATE] and [DATE] and lacked documentation that lab results were faxed to the Infectious Disease doctor. The clinical record lacked pharmacy recommendation after the drug regimen review on [DATE]. During an interview on [DATE] at 2:16 p.m., the Medical Records Coordinator indicated she was the Medical Record Coordinator at the time Resident B was readmitted with the physician's order for daptomycin. She did not remember changing or updating the daptomycin order. She had updated physician's orders from the facility's physician but had not changed or updated orders from an outside physician. On [DATE] at 10:05 a.m., the Regional Nurse provided a copy of an undated facility policy, titled Medication Orders, and indicated this was the current policy used by the facility. A review of the policy indicated medications should be administered only upon the signed order of a person lawfully authorized to prescribe. The Immediate Jeopardy, that began on [DATE], was removed on [DATE] when the facility inserviced the facility staff following physician orders and following policies and procedures for transcribing physician orders, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaint IN00392014. 3XXX,d+[DATE](a)

Based on interview and record review, the facility failed to provide basic emergency life support immediately to 1 of 1 resident reviewed for death. This resulted in the resident being declared deceased by EMS. (Resident B). This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at approximately 7:15 a.m., when the facility failed to provide basic emergency life support (CPR) to a resident who had a full code status. The Administrator and Unit Manager were notified of the Immediate Jeopardy on [DATE] and 4:12 p.m. The Immediate Jepoardy was removed on [DATE] at 3:08 p.m., but non-compliance remained at a lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: On [DATE] at approximately 7:15 a.m., LN (Licensed Nurse) 1 found Resident B lying next to his bed, unresponsive, and without a pulse. LN 1 then went out into the hall to call 911. There was no attempt at CPR prior to the arrival of EMS (Emergency Medical Services). Upon arrival of EMS, (no time or paperwork was available) EMS began CPR. The clinical record for Resident B was reviewed on [DATE] at 10:30 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The POST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Burial Transfer Form, dated [DATE], indicated Resident B was declared deceased at 8:00 a.m. During an interview with CNA 1 on [DATE] at 12:48 p.m., she indicated although she was not one of Resident B's aides on [DATE], she did question why CPR was not performed. During an interview with CNA 2 on [DATE] at 1:05 p.m., she indicated no CPR was performed on Resident B until EMS arrived. During an interview with CNA 3 on [DATE] at 1:15 p.m., she indicated LN 1 told her she had just checked on Resident B and was going to get something from her car. When she came back, she went into Resident B's room and found him on the floor, came running out into the hallway screaming, grabbing a staff members cell phone to call 911. She indicated LN 1 did not perform CPR on Resident B. During an interview with LN 1 on [DATE] at 2:02 p.m., she indicated she went into Resident B's room around 7:20 a.m. and found the resident on the floor, unresponsive, and without a pulse. She called 911 from another CNA's cell phone at 7:26 a.m. She did not initiate CPR, or see any other staff initiate CPR. LN 1 indicated she panicked. She indicated Resident B had a full code status. CPR should have been initiated. During an interview with RN 1 on [DATE] at 2:55 p.m., RN 1 indicated, she didn't remember hearing anyone call code blue (the need for CPR to be initiated) on the morning of [DATE]. RN 1 also indicated she didn't remember doing CPR on any resident on that day ([DATE]). On [DATE] at 10:30 a.m., the Administrator provided a copy of a facility policy, dated ,d+[DATE], titled Cardiopulmonary Resuscitation (CPR), and indicated this was the current policy used by the facility. A review of the policy indicated, the facility must provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel related to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy, that began on [DATE], was removed on [DATE] when the facility inserviced the facility staff on basic emergency life support and resident code status, but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because a systemic plan of correction had not been developed and implemented to prevent recurrence. This Federal tag relates to Complaint IN 735. 3.1-(4)(f)(7)

Based on record review and interview, the facility failed to provide the necessary care and services for a resident, in that when a resident had [MEDICAL CONDITION] activity which required nursing intervention, physician and family notification, the nursing staff failed to protect the resident from potential injury from additional [MEDICAL CONDITION] activity which resulted in a subdural hematoma and eventual death, for 1 of 3 residents reviewed for [MEDICAL CONDITION] and or head injury in a sample of 4. (Resident "B"). Findings include: 1.a. The record for Resident "B" was reviewed on 10-19-12 at 11:50 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] after recent surgery, which included a mitral valve replacement. At the time of discharge to the facility the resident had physician orders which included [MEDICATION NAME] (a medication used in the treatment of [REDACTED]. Review of the resident's current plan of care, originally dated 08-30-12, indicated the resident was "at risk for Neurological deficiencies related to: [MEDICAL CONDITION] diagnosis." Interventions to this plan of care included "Administer meds (medications) per physician orders. If [MEDICAL CONDITION] activity occurs, place on side, maintain open airway. Remove obstacles to ensure safe environment, Neurochecks per facility guidelines. Obtain labs as ordered and notify physician of results. Obtain vital signs as needed, report presence of [MEDICAL CONDITION] activity. Note duration, characteristic of tonic/clonic movement LOC (level of consciousness) etc. Report signs or symptoms of tremors, rigidity, dizziness, changes in level of consciousness, slurred speech." The record indicated while the resident received [MEDICAL TREATMENT] treatment on 08-07-12 at the local outpatient [MEDICAL TREATMENT] center, [MEDICAL CONDITION] activity was observed and the resident was transported to the emergency department of the local area hospital and subsequently admitted to the hospital. The resident was discharged from the hospital on 08-16-12 and had a physician order for [REDACTED]. The September 2012 and October 2012 physician re-writes instructed the nursing staff to continue with the dosage of [MEDICATION NAME] as prescribed at the time the resident was discharged from the hospital on 08-16-12. Review of the medication reconciliation of returned medication, provided by the pharmacy and reviewed on 10-22-12 at 1:30 p.m., indicated the facility received 60 tablets, 200 mg each tablet, on 08-17-12 and a subsequent delivery of 60 tablets on 09-24-12. The Pharmacy documentation indicated 50 tablets were returned to them on 10-06-12. A reconciliation of the medications scheduled to be dispensed, with verification by Registered Nurse employee #4, the Assistant Director of Nurses, from 08-17-12 through 10-01-12 indicated only 28 tablets should have been returned to the pharmacy and not the 50 as indicated. b. In addition, the resident had a physician order, dated 08-30-12, which included [MEDICATION NAME] 4 mg daily. A subsequent current plan of care, originally dated 08-07-12, indicated "anticoagulant therapy to treat recent mitral valve replacement" at risk for adverse effects." Interventions to this plan of care included "Administer per physician orders, obtain labs as ordered and notify physician or results, report adverse effect such as blood in urine/stool, gums/nose, bleeding, bruising." Interview on 10-22-12 at 12:00 p.m., Licensed Practical Nurse employee #8 indicated that on 10-01-12, "(name of resident) had the call light on around 8:00 p.m. or 8:30 p.m. and when I went in there (resident name) was postictal (observation of resident after the [MEDICAL CONDITION] occurred) laying on the right side like (resident) had been sitting in bed. There was brown drainage out of (resident) mouth. The other nurses helped me and we positioned (resident name) to the middle of the bed on back. I had to start oxygen because the oxygen saturation level I think was in the 70's. I called the doctor and was told to just monitor and when (resident) started to come out of it (the [MEDICAL CONDITION] activity) (resident) was incontinent. I called (resident's family member) and told what had happened and at that time (resident) was making a snoring noise after the [MEDICAL CONDITION]. (Family member) asked if we were going to send (resident) to the hospital and I said that if it happened again we probably would send (resident) out for an evaluation. When I finally left the room (resident) when talking to (family member) on the telephone. I went back a little later and (resident) seemed alert, the vital signs were normal and I took off the oxygen. (Resident) told me (resident) was fine but just tired. When I left (resident) was in bed in a normal position. (Resident) was not a fall risk and there was no mat and the bed was not in a low position. We don't use siderails here so there is nothing to pad. I know (resident) had a [MEDICAL CONDITION] a few months earlier at the [MEDICAL TREATMENT] clinic but nothing recently. Around 11:00 p.m., the CNA yelled for the nurses and we found (resident name) on the floor laying on the right side of the bed but on (resident) left side. The nightstand was on the right side of the bed and (resident) head was up against the front of the nightstand and there was bleeding from (resident) mouth. After the first [MEDICAL CONDITION] we didn't move any furniture back or out of the way. (Resident) seemed alert just drowsy. The other nurse called 911 and we sent (resident) out." Review of the Progress Notes, dated 10-01-12 at 23:15 (9:15 p.m.) indicated the following:"Pt. (patient) found beside bed, face down with head near the night stand approx. (approximately) 1 foot. Pt. not reonsive (sic). Post ictal (sic) breathing. Call placed to 911 to request transport pt to ER (emergency room ). M.D. (Medical Doctor) office notified and order was obtained for pt. to go to (name of local area hospital) for eval. (evaluation). At 2308 (9:08 p.m.) O2 (oxygen) SAT (saturation) was 52 and HR (heart rate) = 123. O2 was applied and O2 SAT 70 %, and HR = 127. At 2311 (9:11 p.m.) O2 SAT = 80 % and HR = 101. At 2313 (9:13 p.m.) O2 SAT 88 % and HR = 117, and B/P (blood pressure) = 188/144. Pt's (family member) was notified of pt. going to (name of local area hospital) ER." Review of the hospital record on 10-19-12 at 8:30 a.m., indicated the resident was transported to the local hospital emergency room and was diagnosed with [REDACTED]. The emergency room notes also indicated that prior to taking a chest x-ray the "pt. (patient) in active grand mal [MEDICAL CONDITION] just prior to taking portable chest x-ray." In addition, the emergency room notations indicated the resident "had 2 [MEDICAL CONDITION] today, has no recollection of the events, apparently woke up on the floor or was found on the floor face down. (Resident) has a contusion to the forehead to the right of midline, and another contusion to the left brow, and was given 1000 PE equivalents of [MEDICATION NAME] for a subtherapeutic [MEDICATION NAME]." The hospital record indicated the resident's [MEDICATION NAME] level was "5.6 "L" (low), with a reference range of 10 - 20." The last [MEDICATION NAME] level drawn at the facility also indicated the resident's [MEDICATION NAME] level was low at "3" with a reference range of 10 - 20. While in the emergency room , due to the resident's low [MEDICATION NAME] level received "1000 mg (milligrams) of [MEDICATION NAME] in the emergency room " and in addition the resident's PT/INR ([MEDICATION NAME]/International Normalization Ratio)was 5.1/50.9 (sic) (with reference ranges to include (2.5 - 3.5/8.9 - 11.9). The record indicated the received "Vitamin K 2.5 mg by a cardiologist" while the resident was in the emergency room . At the time of admission to the emergency room a head CT (cat scan) was performed and indicated the resident had a "small subdural in the left temporal lobe that is approximately 0.7 cm (centimeters) by 3.5 cm." The hospital notation indicated the resident was transferred to the Intensive Care Unit from the emergency room but "seems to be getting more somnolent. (Resident) is not waking up or following commands in any meaningful way with intermittent airway obstruction - with loud snores and grunts." An addendum to the Hospital History and Physical, dated 10-02-12 indicated "the (Resident) had a generalized tonic-clonic [MEDICAL CONDITION] at ECF (extended care facility) around 9:00 p.m. 10-01-12 and subsequently had several "smaller" [MEDICAL CONDITION] after that. Around 11:00 p.m. was found on the floor face down by the ECF staff and was transferred to (name of local area hospital) for further evaluation. (Resident) is chronically on [MEDICATION NAME] for [MEDICAL CONDITION] fib. (fibrillation) and mechanical mitral valve." A subsequent CT scan was completed (10-02-12) "in the morning, after the patient became more and more somnolent, showed significant enlargement of the subdural hematoma, now with about a 2 cm (centimeter) midline shift." "Impression: significant increase in the size of the acute left frontoparietal subdural hemorrhage now measure approximately 2 cm in thickness in the left frontal region. Significant mass effect 18 mm of left to right midline shift at the level lateral ventricle is noted. Mass effect with deformity and distortion of the mesencephalon is observed. Mild partial entrapment of the right lateral ventricle is present." The Hospital Discharge Summary indicated "Cause of Death: Left frontal contusion with left subdural hematoma after a fall with Contributing Causes Include 1. A [MEDICAL CONDITION] due to above." Interview on 10-22-12 at 9:20 a.m., the Director of Nurses provided documentation of Inservice Education, as indicated above, in regard to [MEDICAL CONDITION], dated 10-03-12. The Director of Nurses indicated the Inservice Education was conducted due to the [MEDICAL CONDITION] activity and subsequent transportation to the hospital in regard to (name of Resident "B"). Review of a facility policy on 10-22-12 at 9:20 a.m., and dated 01-2011 indicated the following:"[MEDICAL CONDITION] PRECAUTIONS: GUIDELINES FOR CARE - PURPOSE (bold type and underscored): To protect patient from injury during a [MEDICAL CONDITION] and to evaluate and document observations prior to, during and after a [MEDICAL CONDITION]." "PROCEDURE (bold type and underscored) - Care During a [MEDICAL CONDITION] (bold type and underscored): 1. Note the signs of impending [MEDICAL CONDITION] - change in behavior or unusual sensations (aura). 2. Maintain airway and safety of patient - Position the patient on side if on a flat surface (bed or floor). Do not put anything in the patient's mouth. If sitting, turn patient's head to side. Loosen patient's clothing around neck. Do not restrain; protect the patient from injury. 3. Record time of onset, duration and termination of [MEDICAL CONDITION] - Extremity or extremities where [MEDICAL CONDITION] started (bilateral or unilateral). Was there an aura (yelling, bizarre smell). Head and eye movement and changes in pupils. Type of muscle response (tonic/clonic - marked by alternate contraction and relaxation of muscle). Respiratory status or change. Urinary/bowel incontinence. Loss of consciousness. Ability to control movements. Any injuries that occurred. Post [MEDICAL CONDITION] Care (bold type and underscored) - 8. Position the patient on their side unless contraindicated. 9. Observe the patient for post [MEDICAL CONDITION] symptoms, headaches or confusion. 10. Check the patient's neurological status - level of consciousness, pupil reactions, vital signs, movement and extremity strength (left or right weakness, etc), increased oral secretions - patient may need suctioning. 11. Notify physician of [MEDICAL CONDITION]: have available - Events leading to, during and after [MEDICAL CONDITION]. List of anticonvulsant's, any missed anticonvulsant's or refusals, also any pertinent laboratory results especially most recent anticonvulsant level." The record lacked the resident's neurochecks, ensure the resident remained on side and documentation the physician was notified of the subtherapeutic [MEDICATION NAME] level as outlined in the policy. Review of the facility policy on 10-24-12 at 8:30 a.m., the "NEUROLOGICAL: NEUROLOGICAL EVALUATION," policy dated 3/2010 indicated the following: "PURPOSE (bold type and underscored) a neurological evaluation is used to establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined." "PROCEDURE (bold type and underscored) 4. After the completion of initial neurological evaluation with vital signs, continued evaluations every 30 minutes times 4, then every 1 hour times 4, then every 8 hours times 9 for the next 72 hours." When interviewed on 10-22-12 at 12:50 a.m. the Director of Nurses indicated the Neurochecks were not completed as directed per policy by the nursing staff. This Federal tag relates to Complaint IN 826. 3.1-37(a)

Based on record review and interview, the facility failed to ensure supervision and/or assistive devices to alert the nursing staff of unassisted ambulation, movement or safe transfer which resulted in a head injury (hematoma) which required transport to the local area hospital for evaluation, skin tear which required treatment and bruising (Resident "A") for 3 of 3 resident's reviewed for falls in a sample of 4. (Residents "A", "C" and "D"). Findings include: 1.a. The record for Resident "A" was reviewed on 10-19-12 at 11:45 a.m. [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set assessment, dated 07-17-12, indicated the resident's balance was not steady and only able to stabilize with staff assistance when moving from a seated to a standing position, moving on/off the toilet and surface to surface transfers. Review of the resident's current Plan of care, originally dated 12-20-11, indicated the resident was "at risk for falls due to unsteady gait, cognitive impairment, poor safety awareness, a history of falls, history of left hip fracture [DIAGNOSES REDACTED] and cerebral edema." Interventions to this plan of care included "Assess for fall risk upon admission and reassess as needed." The record indicated the facility updated the resident's plan of care on 06-25-12 with a "scoop mattress," and on 07-09-12 with "low bed with mats." However the record indicated on 08-20-12 at 9:00 a.m., the resident "was sitting in wheelchair out in hallway when (resident) leaned over trying to reach (resident) shoe, when inadvertently slipped out of wheelchair landing on the left side of body. See nurses notes." The nursing progress notes, dated 08-20-12 at 9:00 a.m., in regard to the resident's fall indicated "Extrinsic factors: (resident) posture by leaning forward." Review of the plan of care lacked a "focus problem" to identify the resident's posture, leaning forward or any "intervention." Review of the incident report, dated 09-13-12 at 11:00 a.m., the writer "heard loud thud coming from res. (resident) room. Resident found on floor on left side. Head facing doorway. ST (skin tear) to left elbow - cleaned with NS (normal saline) xeroform applied, wrap (sic) in Kerlix. Bruising to left side of head/face and bilateral knees." The section of the incident report titled "documentation" indicated "Writer heard loud thud coming from res. (resident) room. When entering the res. was on the left side on floor head facing the door. W/C (wheelchair) to the right side of res. with unlocked W/C brakes unlocked (sic). ST to left elbow and bruising to left side of face/bilateral knees already appearing (sic). Resident c/o (complains of) dizziness and stiffness." Review of the plan of care lacked a "focus problem" to ensure the resident's brakes were locked when leaving the resident unattended, and failed to develop or document an intervention. The 10-03-12 progress notes at 7:35 a.m., indicated the resident was "sitting in W/C at nurses station eating breakfast when fell forwards onto floor, hitting forehead on floor. P (pulse) 49, R (respirations) 18, B/P (blood pressure 174/110. Muscle strength and mobility poor but that is WNL (within normal limits) for res. Res. does have small hematoma on right aspect of forehead from where head hit floor. MD (Medical Doctor) notified and rec'd (received) order to send to ER (emergency room ) due to abnormal VS if family agrees." Review of the Incident report also dated 10-03-12 at 8:03 a.m., indicated the resident had a "fall and hit head on floor. Resident has a history falls (sic)and CA (cancer) wiuth (sic) mets (metastasis) to the brain." The nurses progress notes, dated 10-03-12 at 8:35 a.m., indicated the resident "is noted to be more lethargic at this time. Awaiting transport to ER (emergency room )." The resident was sent to a local area hospital and [DIAGNOSES REDACTED]." The progress notes indicated that at the time the resident returned to the facility the resident had a "hematoma remains on "R" (right) aspect of forehead." The resident's plan of care indicated a Broda chair was placed as an intervention on 10-04-12, after the resident fell from the wheelchair and sustained injuries during two of the three falls. Review of the physician progress notes [REDACTED]. was leaning forward in w/c and fell out causing redness to right knee and forearm. Cont. (continue) fall precautions." The physician progress notes [REDACTED]." The physician progress notes [REDACTED]. (evaluation). Pt. (patient) overall prognosis poor, pt increased risk for falls secondary to CNS (central nervous system) [DIAGNOSES REDACTED]." Interview on 10-23-12 at 9:48 a.m., an interested family member indicated that a staff member said that when (name of resident) fell from the wheelchair while in room (09-13-12), it sounded like a watermelon hit the floor. Sometimes (name of resident) sees things on the floor and will reach out for it. The nursing staff should know that by now and should have done something to keep (resident) from falling face first out of the wheelchair." The resident had four falls from the wheelchair without the facility staff providing additional interventions to protect the resident from injury. 2. The record for Resident "C" was reviewed on 10-19-12 at 1:25 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. Review of the Hospital Progress Notes, dated 09-20-12 and received via fax (facsimile) on 10-16-12, indicated the resident had "Falls - Family report multiple falls at home and Alzheimer's dementia with family "reported difficulty managing care. Suspect stair step progression of dementia." The record indicated the resident was admitted to the facility on [DATE] at 12:15 p.m., and on 10-18-12 at 6:30 a.m., the resident was found on the floor in the bathroom by the CNA (certified nurses aide). "Resident stated was going to bathroom et (and) attempting to return to w/c. Res. (resident) stated right elbow hurt et was reddened upon inspection. Res. was supporting weight on that arm while on floor. Once up in w/c et able to move extremity res. stated discomfort had decreased." The resident record contained two "Fall" assessments, both dated 10-18-12 at 18:15 (6:15 p.m.), over 24 hours after the admission and 12 hours after the resident was found on the floor of the bathroom. Both assessments contained the same information related to physical performance limitations, medications, disease and conditions, laboratory test, and environmental factors. The section titled "documentation" on both assessments and indicated "[DIAGNOSES REDACTED]. Accucheck at time of incident was 67. Res. given dinner along with cookie and juice. Instructed res. to push call light when needing assistance. Call light within reach. Res. to be toileted every 2 hours." During interview on 10-22-12 at 2:00 p.m., the Director of Nurse indicated one of the "Fall" assessments was the initial assessment and the other was the assessment after the fall on 10-18-12. Interview on 10-24-12 at 8:30 a.m., the Director of Nurses provided a subsequent "Fall" admission assessment, dated 10-17-12 at 15:20 p.m. (3:20 p.m.). This assessment indicated the resident used a wheelchair, had bowel and bladder incontinence a history of falls, had moderately impaired decision making skills with poor decision making skills with cues and supervision required. The resident's ability for "functional status' was not completed, and lacked any additional "documentation" by the nursing staff to include observations or comments "not captured in the previous questions. When further interviewed the Director of Nurses indicated the nursing staff provided a low bed and mats to the floor, but failed to included additional interventions including a toileting program for a cognitively impaired resident to assist with toileting needs. Although the resident was admitted to the facility with a history of falls with noted concerns by the family members, the record lacked MD notification/intervention on behalf of the resident and the facility's failure to do a thorough assessment and planned interventions. 3. The record for Resident "D" was reviewed on 10-22-12 at 11:00 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The resident's current plan of care, originally dated 09-27-12, indicated the resident "at risk for falls due to arthritis, impaired mobility, DX. (diagnosis) of MR (mental retardation) and involuntary movements." Interventions to this plan of care with the original initiation date of the intervention included "2 person transfer with showers 09-28-12." The admission "Fall" assessment indicated the resident did not have physical performance limitations, did not have impulsivity or poor safety awareness, cognitive impairment or chronic or acute condition resulting in instability, laboratory testing. However; further review of the record indicated the resident required extensive assistance and two staff members with transfer, bed mobility and bathing. The resident was only able to maintain balance with staff assistance when moving from seated to standing position, on/off toilet and surface to surface transfer. A Falls assessment, dated 09-28-12 at 15:38 (3:38 p.m.) indicated the "intervention begun of 2 per person assist at all times." Review of the Progress notes, dated 09-29-12 at 00:05 (12:05 a.m.) "Resident was in shower room and was being transferred to chair when the CNA could no longer hold (resident) up and was lowered to the floor. Intervention put in place to use assist times 2 when transferring res. (resident) Will monitor." The incident report indicated the following "date of incident 09-26-12 (sic) at 9:45 a.m. (sic) "resident was attempting to self transfer self in shower room and was lower (sic) to this floor by staff." Interview on 10-24-12 at 8:30 a.m., the Director of Nurses provided a subsequent "Fall" admission assessment, dated 09-26-12 at 8:30 p.m. This assessment indicated the resident used a wheelchair, lacked documentation the resident had a catheter, had severely impaired decision making skills, but lacked the resident had a history of [REDACTED]. completed, and lacked any additional "documentation" by the nursing staff to include observations or comments "not captured" in the previous questions. When further interviewed the Director of Nurses indicated the nursing staff provided a low bed and mats to the floor, but failed to included safe transfer interventions used for this resident. Although the resident was admitted to the facility with a history of accidental falls, the record lacked MD notification/intervention on behalf of the resident and the facility's failure to do a thorough assessment and planned interventions. 4. Review of the facility "Falls Practice Guide Flowchart," on 10-22-12 at 9:20 a.m., prompted the nursing staff to "assess" the resident. If the resident had a history of [REDACTED]."Practice Guidelines also prompted the nursing staff to develop a "plan" and revise the initial or interdisciplinary care plan as applicable." After the "implementation" of the plan the nursing staff was instructed to "evaluate" the interventions for effectiveness. This Federal tag relates to Complaint IN 709. 3.1-45(a)(2)

Based on record review and interview the facility failed to ensure a resident's physician was kept current on a resident's condition, in that when a resident fell and sustained a head injury and later had a change of condition which included massive bleeding, nausea/vomiting, complaints of headache and inability to verbalize, the licensed nurse (employee #8) failed to continue to update the physician for emergent intervention. The licensed nurse (employee #8) waited over four hours before transferring the resident to the local hospital emergency room for evaluation and/or treatment, at which time the resident arrived at the hospital with pupils pinpoint and fixed and was assessed with [REDACTED]. This deficient practice affected 1 of 2 residents reviewed for falls and who sustained a head injury which required additional physician intervention in a sample of 5. (Resident "A"). Findings include: The record for Resident "A" was reviewed on [DATE] at 10:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The hospital discharge summary, dated [DATE], indicated the resident had acute [MEDICAL CONDITION], cardiomegaly and was identified as a fall risk. The hospital fall scale, dated [DATE], prior to admission to the facility indicated "confusion, provide regular reality orientation, give directions one step at a time to allow time for comprehension, purposeful rounding every 30 minutes and document check, DO NOT leave resident unattended in bathroom or on bedside commode, attempt room placement close to nursing station, use bed check alarms and chair alarm." The preadmission Physician Certification for Long Term Care Services, 450B assessment, dated and signed by the physician on [DATE], indicated the resident was "confused/disoriented, and high fall risk due to confusion and unsteady gait." The resident record indicated the following incidents. "[DATE] at 8:11 a.m. Found resident laying supine position on bedside mat. Dx. (diagnoses) Alzheimer's, unable to follow direction to use call light even though given frequent reminders and cueing since admission. Resident may have been attempting to get to toilet <sic>. No injury found. Neuro checks WNL (within normal limits)." The resident's physician was notified. "[DATE] 11:30 p.m. Writer went to check on resident and found resident sitting at the edge of the bed with a raised area on the upper right eye, slightly purple in color. Area measuring 9 cm (centimeters) by 7 cm. Resident states ... fell early, when going to kitchen to get a drink and hit his <sic> head on floor ... " "Ice pack was applied to the raised area on the upper right eye, helpful." The resident's physician was notified. The nurses notes, documented by Licensed Nurse employee #8, and dated [DATE] at 4:41 a.m., indicated, "Note Test: F/U (follow up) continues for fall. No new injuries noted. Scant amount of blood noted in toilet and brief dx. (diagnosis) hemorrhoids. Vital sign <sic> @ (at) 12 a.m. (blood pressure),[DATE], (pulse) 89, (respirations) 18, T (temperature) 98.2, O2 (oxygen saturation level) 94% ra (room air) resident denies pain early at start of shift. At 2:30 a.m. resident c/o (complained of) headache, lethargy, diaphoretic. BP (blood pressure) ,[DATE], (pulse) 75, (respirations) 16, O2 saturation 94% RA. Resident unable to swallow prn (as needed) Tylenol c/o headache. MD (Medical Doctor) notified, no new order at this time." Interview on [DATE] at 5:15 a.m., Licensed Nurse employee #8 indicated the following;"I came in and got report and was told to watch (resident) because (resident) kept trying to get up. The CNA (certified nurses aide employee #9) called me in. He said (name of resident) was in the bathroom and is bleeding - it was hemorrhoids. There was blood in the toilet. (Name of resident) was sitting on the toilet. The CNA (employee #8) put (resident) back to bed and the vital signs were ok. (Resident) slept. The CNA called after a few hours and said 'I need you in here' and I went to the room. (Resident) was sitting on the side of the bed) and said (resident) had a headache. I checked the vital signs and they were different. The blood pressure was 98 over something, but the O2 and respirations were ok. (Resident) was sweating and temperature was spiking. I got Tylenol and (resident) took ,[DATE] of it. I waited a little bit and then called the doctor. I called the office (in regard to the physician's office) and the lady, the nurse, gave me an order for [REDACTED]. She told me to ask the family. I called the Unit Manager (Licensed Nurse employee #3) before the family call. She (the Unit Manager) told me since the resident was a DNR call, and ask the family what they want. She asked me if I called the Doctor and I said 'yes' and I told her the office (lady nurse) wouldn't give me an order to send the resident out since the resident is a DNR. I gave the Tylenol suppository. When I talked to (resident) she tried to respond but couldn't. I waited for family to call. When I talked to (name of Unit Manager) she told me to do as the family and Doctor say and 'there's nothing we can do.' (Name of resident) didn't have any other bruises other than what was on the face." Interview on [DATE] at 5:45 a.m. CNA employee #9 indicated, "The evening shift CNA told me (resident) had fallen and was constantly getting up without supervision and that (resident) was a fall risk. That is when all the craziness started. The call light came on because the roommate needed to go to the bathroom. (Resident "A") was already on the toilet. There was massive blood and clots in the toilet, almost like when a women has a period (menses). Every time I changed (resident) there were clots in the brief (incontinent). They (in reference to the nurses) told me it was just hemorrhoids and they gave me a cream to put on the hemorrhoid. I was in that room a lot for both (resident) and the roommate. The roommate called for assistance to go to the bathroom and when I went in there was a trail of blood from the bathroom to the bed. (Resident "A") was half on the bed. There was blood on the sheets and I had to change (resident), the bed and then pulled (resident) up in bed. (Name of Licensed Nurse employee #8) helped me. Then later (name of CNA employee#10) came down to help me with call lights. She went to help (name of Resident "A") roommate - that's when I could see that (Resident "A") was not normal. I got (name of Licensed Nurse employee #8) to come down. There was bruising on (resident) face and arms - and didn't look good. (Name of CNA employee #10) sat with (resident) and I went to get (name of Licensed Nurse employee #8) again. (Name of resident) was laying on stomach and shivering." Interview on [DATE] at 5:55 a.m. CNA employee #10 indicated, I was working on TCU (Transitional Care Unit). I walked down here (in reference to the area where CNA employee #9) was working. She (CNA employee #9) was taking care of (name of resident "A"). I had (Resident "A") 2 days earlier and when I walked in (name of Resident "A") was naked and lying face down on the bed. (Resident "A") was dry heaving and there was a lot of saliva under (resident). (Resident "A") was burning up. (Resident "A") was shaking like having a [MEDICAL CONDITION]. I told (name of Licensed Nurse employee #8) to check (resident) out. (Resident) told me 'something's wrong, my head hurts, something's wrong.' (Resident) was drooling mucousy saliva. I told (name of Licensed Nurse employee #8) that if (resident) says something's wrong, then something is wrong (emphatic). The first night I had (Resident "A") had a fall. (Resident) didn't know where (resident) was at, confused and anxious. The complete side of the face was purple black and blue. It looked like someone beat (resident) up." The record indicated the resident was transported to the local area hospital at approximately 7:15 a.m. on [DATE], over 4 hours after the resident displayed signs and symptoms of a change in condition and lacked any additional assessments of the resident's condition or decline since the original noted decline in condition at 2:30 a.m. The local area hospital emergency room record, reviewed on [DATE] at 2:00 p.m., indicated the resident had "[MEDICAL CONDITION], subdural hemorrhage and altered mental status with increase respiratory rate and fever, pupils pinpoint and non reactive (to light), with extensive bruising noted to the right side of head." The hospital Discharge Summary, dated [DATE] indicated the resident was "admitted from nursing home after a fall and acute loss of consciousness and found to have a large subdural hematoma at admission." The record further indicated the resident was then admitted to the hospital Hospice, where on [DATE] at 2250 (10:50 p.m.) the resident expired. Further interview on [DATE] at 6:15 a.m., Licensed Nurse employee #8 indicated she did not contact the physician when the resident was found with copious amounts of saliva and inability to communicate and continued clots of blood found in the incontinence brief when changed. The facility "Clinical Services FYI (for your information) - Post Fall Evaluation, dated [DATE], provided by the Interim Director of Nurses, indicated the following" "Falls are a common source of patient injury. A comprehensive clinical evaluation by the nurse supervisor is important to determine the extent of injury and the need for additional intervention. The licensed nurse is responsible for completing this evaluation and reporting changes in condition to the attending physician whenever any symptom, sign or apparent discomfort is sudden in onset, a marked change in relation to usual symptoms or unrelieved by initial interventions." This Federal deficiency relates to Complaint IN 794. 3XXX,[DATE](a)

Based on record review and interview the facility failed to ensure a resident received prompt medical intervention, in that when a resident had a fall and sustained a head injury which resulted in change in condition, the nurse failed to provide a resident with emergent care. The resident displayed a change in condition which included massive bleeding, nausea/vomiting, complaints of headache and inability to verbalize, and the licensed nurse (employee #8) waited over four hours before sending the resident to the local hospital emergency room for evaluation and/or treatment. The resident arrived at the hospital with pupils pinpoint and fixed and was assessed with [REDACTED]. This deficient practice effected 1 of 2 residents who sustained a head injury as a result of a fall and had a change of condition, in a sample of 5. (Resident "A") Findings include: The record for Resident "A" was reviewed on [DATE] at 10:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] after a brief hospitalization for a urinary tract infection [MEDICAL CONDITION]. The hospital discharge summary, dated [DATE] indicated the resident had acute [MEDICAL CONDITION], cardiomegaly and was identified as a fall risk. The hospital fall scale, dated [DATE], prior to admission to the facility indicated "confusion, provide regular reality orientation, give directions one step at a time to allow time for comprehension, purposeful rounding every 30 minutes and document check, DO NOT leave resident unattended in bathroom or on bedside commode, attempt room placement close to nursing station, use bed check alarms and chair alarm." The preadmission Physician Certification for Long Term Care Services, 450B assessment, dated and signed by the physician on [DATE] indicated the resident was "confused/disoriented, and high fall risk due to confusion and unsteady gait." The admission physician orders [REDACTED]. The Initial Clinical Assessment, dated [DATE] indicated the resident was "severely cognitively impaired, had difficulty in focusing attention, with disorganized thinking which "fluctuates (comes and goes in severity), with shortness of breath, a history of falls, an unsteady gait, and required frequent reminders and cueing due to demenia <sic> with alzhemiers. Frequent attempts to get up due to confusion, frequently re-oriented to facility protocol, call light use and safety issues." The resident record indicated the following incidents. "[DATE] at 8:11 a.m. Found resident laying supine position on bedside mat. Dx. (diagnoses) Alzheimer's, unable to follow direction to use call light even though given frequent reminders and cueing since admission. Resident may have been attempting to get to toilet <sic>. No injury found. Neuro checks WNL (within normal limits)." The nurses started the neurological evaluation flow sheet on [DATE] at 5:30 a.m. The directions at the top of this form instructed the nursing staff to "complete neurological evaluation with vital signs initially, then every 30 minutes times 4, then every hour times, 4, then every 8 hours times 9 (72 hours). More frequent evaluation may be necessary. More frequent evaluations may be necessary. Use both sides of this form and additional forms if necessary. Complete episodic charting for at least 72 hours including any pertinent evaluation findings related to the neurological evaluation. Review the most recent evaluation on the medical record and notify the Physician of any changes from previous evaluation." "[DATE] 11:30 p.m. Writer went to check on resident and found resident sitting at the edge of the bed with a raised area on the upper right eye, slightly purple in color. Area measuring 9 cm (centimeters) by 7 cm. Resident states ... fell early, when going to kitchen to get a drink and hit his <sic> head on floor ... " "Ice pack was applied to the raised area on the upper right eye, helpful." The Licensed Nurses continued the neurological checks as directed including when the resident was found with the raised area to the right side of the head. During interview on [DATE] at 10:30 a.m. the Unit Manager Licensed Nurse employee #3 indicated the nursing staff "should have started the neuro checks over once the discovered the bump." The Rehabilitation progress notes, dated [DATE] indicated the resident was "seen today for skilled physical therapy. Pt had a fall on [DATE] and has bruises multiple locations on her body (R) (right) face, forehead (R) arm, around the eye to count the major ones. (Resident) is very confused today ... is high fall risk and needs assistance with all ADL's (activities of daily living) transfers/walking." The nurses notes, documented by Licensed Nurse employee #8, and dated [DATE] at 4:41 a.m., "Note Test: F/U (follow up) continues for fall. No new injuries noted. Scant amount of blood noted in toilet and brief dx. (diagnosis) hemorrhoids. Vital sign <sic> @ (at) 12 a.m. (blood pressure),[DATE], (pulse) 89, (respirations) 18, T (temperature) 98.2, O2 (oxygen saturation level) 94% ra (room air) resident denies pain early at start of shift. At 2:30 a.m. resident c/o (complained of) headache, lethargy, diaphoretic. BP (blood pressure) ,[DATE], (pulse) 75, (respirations) 16, O2 saturation 94% RA. Resident unable to swallow prn (as needed) Tylenol c/o headache. MD (Medical Doctor) notified, no new order at this time." Interview on [DATE] at 5:15 a.m., Licensed Nurse employee #8 indicated the following;"I came in and got report and was told to watch (resident) because (resident) kept trying to get up. The CNA (certified nurses aide employee #9) called me in. He said (name of resident) was in the bathroom and is bleeding - it was hemorrhoids. There was blood in the toilet. (Name of resident) was sitting on the toilet. The CNA (employee #8) put (resident) back to bed and the vital signs were ok. (Resident) slept. The CNA called after a few hours and said 'I need you in here' and I went to the room. (Resident) was sitting on the side of the bed) and said (resident) had a headache. I checked the vital signs and they were different. The blood pressure was 98 over something, but the O2 and respirations were ok. (Resident) was sweating and temperature was spiking. I got Tylenol and (resident) took ,[DATE] of it. I waited a little bit and then called the doctor. I called the office (in regard to the physician's office) and the lady, the nurse, gave me an order for [REDACTED]. She told me to ask the family. I called the Unit Manager (Licensed Nurse employee #3) before the family call. She (the Unit Manager) told me since the resident was a DNR, call and ask the family what they want. She asked me if I called the Doctor and I said 'yes' and I told her the office (lady nurse) wouldn't give me an order to send the resident out since the resident is a DNR. I gave the Tylenol suppository. When I talked to (resident) she tried to respond but couldn't. I waited for family to call. When I talked to (name of Unit Manager) she told me to do as the family and Doctor say and 'there's nothing we can do.' (Name of resident) didn't have any other bruises other than what was on the face." Interview on [DATE] at 5:45 a.m. CNA employee #9 indicated, "The evening shift CNA told me (resident) had fallen and was constantly getting up without supervision and that (resident) was a fall risk. That is when all the craziness started. The call light came on because the roommate needed to go to the bathroom. (Resident "A") was already on the toilet. There was massive blood and clots in the toilet, almost like when a women has a period (menses). Every time I changed (resident) there were clots in the brief (incontinent). They (in reference to the nurses) told me it was just hemorrhoids and they gave me a cream to put on the hemorrhoid. I was in that room a lot for both (resident) and the roommate. The roommate called for assistance to go to the bathroom and when I went in there was a trail of blood from the bathroom to the bed. (Resident "A") was half on the bed. There was blood on the sheets and I had to change (resident), the bed and then pulled (resident) up in bed. (Name of Licensed Nurse employee #8) helped me. Then later (name of CNA employee#10) came down to help me with call lights. She went to help (name of Resident "A") roommate - that's when I could see that (Resident "A") was not normal. I got (name of Licensed Nurse employee #8) to come down. There was bruising on (resident) face and arms - and didn't look good. (Name of CNA employee #10) sat with (resident) and I went to get (name of Licensed Nurse employee #8) again. (Name of resident) was laying on stomach and shivering." Interview on [DATE] at 5:55 a.m. CNA employee #10 indicated, I was working on TCU (Transitional Care Unit). I walked down here (in reference to the area where CNA employee #9) was working. She (CNA employee #9) was taking care of (name of resident "A"). I had (Resident "A") 2 days earlier and when I walked in (name of Resident "A") was naked and lying face down on the bed. (Resident "A") was dry heaving and there was a lot of saliva under (resident). (Resident "A") was burning up. (Resident "A") was shaking like having a [MEDICAL CONDITION]. I told (name of Licensed Nurse employee #8) to check (resident) out. (Resident) told me 'something's wrong, my head hurts, something's wrong.' (Resident) was drooling mucousy saliva. I told (name of Licensed Nurse employee #8) that if (resident) says something's wrong, then something is wrong (emphatic). The first night I had (Resident "A") had a fall. (Resident) didn't know where (resident) was at, confused and anxious. The complete side of the face was purple black and blue. It looked like someone beat (resident) up." The record indicated the resident was transported to the local area hospital at approximately 7:15 a.m. on [DATE], over 4 hours after the resident displayed signs and symptoms of a change in condition and lacked any additional assessments of the resident's condition or decline since the original noted decline in condition at 2:30 a.m. The local area hospital emergency room record, reviewed on [DATE] at 2:00 p.m., indicated the resident had "[MEDICAL CONDITION], subdural hemorrhage and altered mental status with increase respiratory rate and fever, pupils pinpoint and non reactive (to light), with extensive bruising noted to the right side of head." The hospital CT scan of the resident's head without contrast, dated [DATE], indicated "There is a large acute right subdural hemorrhage present measuring 3 cm (centimeters) in greatest thickness. Approximately 16 mm (millimeters) of right to left midline shift of the lateral ventricles is noted as described above. There is entrapment of left lateral ventricle. Significant impression and slight rotation of the brainstem due to mass affect is observed. Within the hemorrhage is noted which may reflect areas of unclotted blood. The hemorrhage extends into the right temporal lobe region and along the anterior inferior aspect of the right anterior cranial fossa. In the inferior temporal lobe region, the hemorrhage measures approximately 2 cm (centimeters) in thickness. Dilation of the left lateral ventricle is noted consistent with entrapment." The hospital Discharge Summary, dated [DATE] indicated the resident was "admitted from nursing home after a fall and acute loss of consciousness and found to have a large subdural hematoma at admission." The record further indicated the resident was then admitted to the hospital Hospice, where on [DATE] at 2250 (10:50 p.m.) the resident expired. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of "The Nursing Spectrum Drug Handbook," on [DATE] at 2:30 p.m., indicated [MEDICATION NAME] was an anticoagulant with "precautions" which included "adverse reactions of headache, confusion, dizziness, nausea, vomiting, bleeding tendency, hemorrhage, and bruising. The section of the handbook related to "monitoring" included "watch for signs and symptoms of bleeding or bruising, and was "contraindicated in active major bleeding." The medication [MEDICATION NAME] also inhibited platelet aggregation and "adverse reactions" included dizziness, headache, and GI (gastrointestinal) bleeding." "Patient Monitoring" included to monitor the patient for unusual bleeding or bruising as the drug significantly increases risk of bleeding. Further interview on [DATE] at 6:15 a.m., Licensed Nurse employee #8 indicated she would continue to follow the same set of instructions when a resident was identified as a DNR - "call the Doctor first, the Unit Manager and follow the orders. We only send a resident out to the hospital as 911 if they are a full code." The facility "Clinical Services FYI (for your information) - Post Fall Evaluation, dated [DATE], provided by the Interim Director of Nurses, indicated the following" "Falls are a common source of patient injury. A comprehensive clinical evaluation by the nurse supervisor is important to determine the extent of injury and the need for additional intervention. Do not move the patient prior to completing the evaluation. Mental status - patients with suspected head or neck injury should not be moved until evaluated by emergency personnel. Motor function - acute head and neck injuries require additional evaluation. Skin integrity, laceration, abrasion, bruises - Patients with significant injuries may require transfer to an acute care facility for evaluation and treatment. Changes in communication when compared to baseline may be indicative of impending stroke, cardiovascular compromise or other neurological involvement. Medication - Anticoagulant therapy combined with a head injury increases the risk for intracranial bleeding. In the event of a fall with suspected head, neck or spinal injury, staff should keep the patient warm but not move the patient until emergency personnel arrive or head, neck or spinal injury has been ruled out. The licensed nurse's evaluation of a patient's condition after a fall, identification of changes in condition and recognition of emergent situations is critical to achieving positive patient outcomes. The licensed nurse is responsible for completing this evaluation and reporting changes in condition to the attending physician whenever any symptom, sign or apparent discomfort is sudden in onset, a marked change in relation to usual symptoms or unrelieved by initial interventions." Review of the Encyclopedia and Dictionary of Medicine, Nursing and Allied Health - Second edition on [DATE] at 3:00 p.m., indicated the following related to the need for monitoring of a resident who sustained a head injury as the result of a fall. "Continuous monitoring of the vital signs and assessment of the neurological status are essential to the care of the resident with a head injury. Any one of the following symptoms should be reported to the physician (1) changes in the blood pressure, pulse or respiratory rate, especially slowing of the pulse with a rising blood pressure, (2) extreme restlessness or excitability following a period of comparative calm. (3) deepening stupor of intensity, (5) vomiting, especially persistent, projectile vomiting (6) unequal size of pupils, (7) inability to move one or more extremity." This Federal deficiency relates to Complaint IN 794. 3XXX,[DATE](a)

Based on observation, interview and record review the facility failed to ensure supervision and assistive devices for residents, in that when residents had a history of [REDACTED]. This deficient practice resulted where resident ("A") sustained a head injury with extensive bruising and continued to displayed a decline in condition which included massive bleeding, complaints of a headache, inability to verbalize and nausea/vomiting and eventual death. This effected 1 of 1 resident's identified with dementia/confusion and a history of falls at the time of admission, and 1 of 1 residents reviewed for a history of falls and the potential of fall with injury in a sample of 5. (Residents "A" and "D"). Findings include: 1. The record for Resident "A" was reviewed on [DATE] at 10:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] after a brief hospitalization for a urinary tract infection and sepsis. The hospital discharge summary, dated [DATE] indicated the resident had acute delirium, cardiomegaly and was identified as a fall risk. The hospital fall scale, dated [DATE], prior to admission to the facility indicated "confusion, provide regular reality orientation, give directions one step at a time to allow time for comprehension, purposeful rounding every 30 minutes and document check, DO NOT leave resident unattended in bathroom or on bedside commode, attempt room placement close to nursing station, use bed check alarms and chair alarm." The preadmission Physician Certification for Long Term Care Services, 450B assessment, dated and signed by the physician on [DATE] indicated the resident was "confused/disoriented, and high fall risk due to confusion and unsteady gait." The admission physician orders [REDACTED]. The Physical Therapy Evaluation dated [DATE] indicated the resident was "oriented to person and at high risk for falls, presents with decreased strength, decreased balance, difficulty with bed mobility, transfer and ambulation high risk for fall." The Occupational Therapy Evaluation, dated [DATE] indicated the resident had "decreased independence with self care, decreased safety, decreased cognition high risk for falls." The resident record indicated the following incidents. "[DATE] at 8:11 a.m. Found resident laying supine position on bedside mat. Dx. (diagnoses) Alzheimer's, unable to follow direction to use call light even though given frequent reminders and cueing since admission. Resident may have been attempting to get to toilet <sic>. No injury found. Neuro checks WNL (within normal limits)." "[DATE] 11:30 p.m. Writer went to check on resident and found resident sitting at the edge of the bed with a raised area on the upper right eye, slightly purple in color. Area measuring 9 cm (centimeters) by 7 cm. Resident states ... fell early, when going to kitchen to get a drink and hit his <sic> head on floor ... " "Ice pack was applied to the raised area on the upper right eye, helpful." The Rehabilitation progress notes, dated [DATE] indicated the resident was "seen today for skilled physical therapy. Pt had a fall on [DATE] and has bruises multiple locations on body (R) (right) face, forehead (R) arm, around the eye to count the major ones ... is very confused today ... is high fall risk and needs assistance with all ADL's (activities of daily living) transfers/walking." During the daily exit conference on [DATE] at 12:45 p.m., the Administrator indicated that once the resident fell , the room was changed to be closer to the nurses station. Interview on [DATE] at 10:05 a.m. the Unit Manager Licensed Nurse employee #3 indicated if a resident fell and there is an injury, a body assessment is suppose to be done, once the area was found, a head to toe assessment is completed. Interview on [DATE] at 10:35 a.m. CNA employee #5 indicated (name of Resident "A") would get up by self a lot (emphatic). Interview on [DATE] at 10:30 a.m. the Interim Director of Nurses verified a completed body assessment was not conducted on Resident "A" after the falls. The nurses notes, documented by Licensed Nurse employee #8, and dated [DATE] at 4:41 a.m., "Note Test: F/U (follow up) continues for fall. No new injuries noted. Scant amount of blood noted in toilet and brief dx. (diagnosis) hemorrhoids. Vital sign <sic> @ (at) 12 a.m. (blood pressure),[DATE], (pulse) 89, (respirations) 18, T (temperature) 98.2, O2 (oxygen saturation level) 94% ra (room air) resident denies pain early at start of shift. At 2:30 a.m. resident c/o (complained of) headache, lethargy, diaphoretic. BP (blood pressure) ,[DATE], (pulse) 75, (respirations) 16, O2 saturation 94% RA. Resident unable to swallow prn (as needed) Tylenol c/o headache. MD (Medical Doctor) notified, no new order at this time." Interview on [DATE] at 5:15 a.m., Licensed Nurse employee #8 indicated the following;"I came in and got report and was told to watch (resident) because (resident) kept trying to get up. The CNA (certified nurses aide employee #9) called me in. He said (name of resident) was in the bathroom and is bleeding - it was hemorrhoids. There was blood in the toilet. (Name of resident) was sitting on the toilet. The CNA (employee #8) put (resident) back to bed and the vital signs were ok. (Resident) slept. The CNA called after a few hours and said 'I need you in here' and I went to the room. (Resident) was sitting on the side of the bed) and said (resident) had a headache. I checked the vital signs and they were different. The blood pressure was 98 over something, but the O2 and respirations were ok. (Resident) was sweating and temperature was spiking. I got Tylenol and (resident) took ,[DATE] of it. I waited a little bit and then called the doctor. I called the office (in regard to the physician's office) and the lady, the nurse, gave me an order for [REDACTED]. She said since the resident is DNR (Do Not Resuscitate) I cannot give you an order to send (resident) out. She told me to ask the family. I called the Unit Manager (Licensed Nurse employee #3) before the family call. She (the Unit Manager) told me since the resident was a DNR call and ask the family what they want. She asked me if I called the Doctor and I said 'yes' and I told her the office (lady nurse) wouldn't give me an order to send the resident out since the resident is a DNR. I gave the Tylenol suppository. When I talked to (resident) she tried to respond but couldn't. I waited for family to call. When I talked to (name of Unit Manager) she told me to do as the family and Doctor say and 'there's nothing we can do.' (Name of resident) didn't have any other bruises other than what was on the face." Interview on [DATE] at 5:45 a.m. CNA employee #9 indicated, "The evening shift CNA told me (resident) had fallen and was constantly getting up without supervision and that (resident) was a fall risk. That is when all the craziness started. The call light came on because the roommate needed to go to the bathroom. (Resident "A") was already on the toilet. There was massive blood and clots in the toilet, almost like when a women has a period (menses). They (in reference to the nurses) told me it was just hemorrhoids and they gave me a cream to put on the hemorrhoid. Every time I changed (resident) there were clots in the brief (incontinent). I was in that room a lot for both (resident) and the roommate. The roommate called for assistance to go to the bathroom and when I went in there was a trail of blood from the bathroom to the bed. (Resident "A") was half on the bed. There was blood on the sheets and I had to change (resident), the bed and then pulled (resident) up in bed. (Name of Licensed Nurse employee #8 helped me. Then later (name of CNA employee#10) came down to help me with call lights. She went to help (name of Resident "A") roommate - that's when I could see that (Resident "A") was not normal. I got (name of Licensed Nurse employee #8) to come down. There was bruising on (resident) face and arms - and didn't look good. (Name of CNA employee #10) sat with (resident) and I went to get (name of Licensed Nurse employee #8) again. (Name of resident) was laying on stomach and shivering." Interview on [DATE] at 5:55 a.m. CNA employee #10 indicated, I was working on TCU (transitional care unit). I walked down here (in reference to the area where CNA employee #9) was working. She (CNA employee #9) was taking care of (name of resident "A"). I had (Resident "A") 2 days earlier and when I walked in (name of Resident "A") was naked and lying face down on the bed. (Resident "A") was dry heaving and there was a lot of saliva under (resident). (Resident "A") was burning up. (Resident "A") was shaking like having a seizure. I told (name of Licensed Nurse employee #8) to check (resident) out. (Resident) told me 'something's wrong, my head hurts, something's wrong.' (Resident) was drooling mucousy saliva. I told (name of Licensed Nurse employee #8) that if (resident) says something's wrong, then something is wrong (emphatic). The first night I had (Resident "A") had a fall. I went and got a mat and put the bed down in the low position. (Resident) didn't know where (resident) was at, confused and anxious. The complete side of the face was purple black and blue. It looked like someone beat (resident) up." The record lacked documentation of a fall on the evening shift of [DATE]. The resident was transported to the local area hospital at approximately 7:15 a.m. on [DATE], over 4 hours after the resident displayed signs and symptoms of a change in condition at 2:30 a.m. The local area hospital emergency room record, reviewed on [DATE] at 2:00 p.m., indicated the resident had "intracranial hemorrhage, subdural hemorrhage and altered mental status with increase respiratory rate and fever, pupils pinpoint and non reactive (to light), with extensive bruising noted to the right side of head." The hospital CT scan of the resident's head without contrast, dated [DATE], indicated "There is a large acute right subdural hemorrhage present measuring 3 cm (centimeters) in greatest thickness. Approximately 16 mm (millimeters) of right to left midline shift of the lateral ventricles is noted as described above. There is entrapment of left lateral ventricle. Significant impression and slight rotation of the brainstem due to mass affect is observed. Within the hemorrhage is noted which may reflect areas of unclotted blood. The hemorrhage extends into the right temporal lobe region and along the anterior inferior aspect of the right anterior cranial fossa. In the inferior temporal lobe region, the hemorrhage measures approximately 2 cm (centimeters) in thickness. Dilation of the left lateral ventricle is noted consistent with entrapment." The hospital Discharge Summary, dated [DATE] indicated the resident was "admitted from nursing home after a fall and acute loss of consciousness and found to have a large subdural hematoma at admission." The record further indicated the resident was then admitted to the hospital Hospice, where on [DATE] at 2250 (10:50 p.m.) the resident expired. The Medication Administration Record ([DATE]) indicated the resident continued to receive the Lovenox on [DATE], and the Plavix on [DATE] and again on [DATE]. Review of "The Nursing Spectrum Drug Handbook," on [DATE] at 2:30 p.m., indicated Lovenox was an anticoagulant with "precautions" which included "adverse reactions of headache, confusion, dizziness, nausea, vomiting, bleeding tendency, hemorrhage, and bruising. The section of the handbook related to "monitoring" included "watch for signs and symptoms of bleeding or bruising, and was "contraindicated in active major bleeding." The medication Plavix also inhibited platelet aggregation and "adverse reactions" included dizziness, headache, and GI (gastrointestinal) bleeding." "Patient Monitoring" included to monitor the patient for unusual bleeding or bruising as the drug significantly increases risk of bleeding. 2. The record for Resident "D" was reviewed on [DATE] at 10:35 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The local area hospital transfer papers, dated [DATE] indicated the resident was a "fall risk." Interview on [DATE] at 10:20 a.m. Licensed Nurse employee #13 indicated the resident had recently been admitted to the facility and had a history of [REDACTED]. I had to give Phenergan for the nausea and vomiting. Yesterday was a good day, today not so much. I was told (resident) was a fall risk when admitted - I was told in report. No the bed isn't in a low position or is there a mat next to the bed." Observation on [DATE] at 11:30 a.m., the resident was observed seated upright in bed. The bed was in a high position and there was no mat on the floor adjacent to the bed. 4. During the Initial Tour of the facility on [DATE] at 9:15 a.m., with the Interim Director of Nurses and Unit Manager in attendance, the Unit Manager indicated if a resident is admitted to the facility and is known fall risk "we immediately place the bed in a low position and place a mat next to the bed." This Federal deficiency relates to Complaint IN 794. 3XXX,[DATE](a)(2)

Based on observation, record review and interview, the facility failed to ensure residents were free from unnecessary medications, in that when resident had falls and sustained head injuries, the nursing staff continued to administer anticoagulation therapy. The residents sustained bruising to the face and temple area. The nursing staff continued to dispense anticoagulation therapy to the residents which inhibited platelet formation for to 2 of 3 resident's reviewed for falls and a head injury, which resulted in the death of 1 resident in a sample of 5. (Resident "A" and "C"). Findings include: The record for Resident "A" was reviewed on 07-03-12 at 10:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] after a brief hospitalization for a urinary tract infection [MEDICAL CONDITION]. The hospital discharge summary, dated 06-19-12 indicated the resident had acute [MEDICAL CONDITION], cardiomegaly and was identified as a fall risk. The hospital fall scale, dated 06-19-12, prior to admission to the facility indicated "confusion, provide regular reality orientation, give directions one step at a time to allow time for comprehension, purposeful rounding every 30 minutes and document check, DO NOT leave resident unattended in bathroom or on bedside commode, attempt room placement close to nursing station, use bed check alarms and chair alarm." The preadmission Physician Certification for Long Term Care Services, 450B assessment, dated and signed by the physician on 06-19-12 indicated the resident was "confused/disoriented, and high fall risk due to confusion and unsteady gait." The admission physician orders [REDACTED]. The resident record indicated the following incidents. "06-20-12 at 8:11 a.m. Found resident laying supine position on bedside mat. Dx. (diagnoses) Alzheimer's, unable to follow direction to use call light even though given frequent reminders and cueing since admission. Resident may have been attempting to get to toilet <sic>. No injury found. Neuro checks WNL (within normal limits)." The nurses started the neurological evaluation flow sheet on 06-20-12 at 5:30 a.m. The directions at the top of this form instructed the nursing staff to "complete neurological evaluation with vital signs initially, then every 30 minutes times 4, then every hour times, 4, then every 8 hours times 9 (72 hours). More frequent evaluations may be necessary. Use both sides of this form and additional forms if necessary. Complete episodic charting for at least 72 hours including any pertinent evaluation findings related to the neurological evaluation. Review the most recent evaluation on the medical record and notify the Physician of any changes from previous evaluation." "06-20-12 11:30 p.m. Writer went to check on resident and found resident sitting at the edge of the bed with a raised area on the upper right eye, slightly purple in color. Area measuring 9 cm (centimeters) by 7 cm. Resident states fell early, when going to kitchen to get a drink and hit his <sic> head on floor ... " "Ice pack was applied to the raised area on the upper right eye, helpful." The Licensed Nurses continued the neurological checks as directed including when the resident was found with the raised area to the right side of the head. During interview on 07-05-12 at 10:30 a.m. the Unit Manager Licensed Nurse employee #3 indicated the nursing staff "should have started the neuro checks over once they discovered the bump." The nurses notes, documented by Licensed Nurse employee #8, and dated 06-22-12 at 4:41 a.m., "Note Test: F/U (follow up) continues for fall. No new injuries noted. Scant amount of blood noted in toilet and brief dx. (diagnosis) hemorrhoids. Vital sign <sic> @ (at) 12 a.m. (blood pressure)137/84, (pulse) 89, (respirations) 18, T (temperature) 98.2, O2 (oxygen saturation level) 94% ra (room air) resident denies pain early at start of shift. At 2:30 a.m. resident c/o (complained of) headache, lethargy, diaphoretic. BP (blood pressure) 98/66, (pulse) 75, (respirations) 16, O2 saturation 94% RA. Resident unable to swallow prn (as needed) Tylenol c/o headache. MD (Medical Doctor) notified, no new order at this time." Interview on 07-06-12 at 5:15 a.m., Licensed Nurse employee #8 indicated the following;"I came in and got report and was told to watch (resident) because (resident) kept trying to get up. The CNA (certified nurses aide employee #9) called me in. He said (name of resident) was in the bathroom and is bleeding - it was hemorrhoids. There was blood in the toilet. (Name of resident) was sitting on the toilet. The CNA (employee #8) put (resident) back to bed and the vital signs were ok." Interview on 07-06-12 at 5:45 a.m. CNA employee #9 indicated, "The evening shift CNA told me (resident) had fallen and was constantly getting up without supervision and that (resident) was a fall risk. That is when all the craziness started. The call light came on because the roommate needed to go to the bathroom. (Resident "A") was already on the toilet. There was massive blood and clots in the toilet, almost like when a women has a period (menses). Every time I changed (resident) there were clots in the brief (incontinent). They (in reference to the nurses) told me it was just hemorrhoids and they gave me a cream to put on the hemorrhoid. I was in that room a lot for both (resident) and the roommate. The roommate called for assistance to go to the bathroom and when I went in there was a trail of blood from the bathroom to the bed. (Resident "A") was half on the bed. There was blood on the sheets and I had to change (resident), the bed and then pulled (resident) up in bed." Interview on 07-06-12 at 5:55 a.m. CNA employee #10 indicated, I was working on TCU (transitional care unit). I walked down here (in reference to the area where CNA employee #9) was working. She (CNA employee #9) was taking care of (name of resident "A"). I had (Resident "A") 2 days earlier and when I walked in (name of Resident "A") was naked and lying face down on the bed. The complete side of the face was purple black and blue. It looked like someone beat (resident) up." The record indicated the resident was transported to the local area hospital at approximately 7:15 a.m. on 06-22-12, over 4 hours after the resident displayed signs and symptoms of a change in condition at 2:30 a.m. The local area hospital emergency room record, reviewed on 07-03-12 at 2:00 p.m., indicated the resident had "[MEDICAL CONDITION], subdural hemorrhage and altered mental status with increase respiratory rate and fever, pupils pinpoint and non reactive (to light), with extensive bruising noted to the right side of head." The hospital CT scan of the resident's head without contrast, dated 06-22-12, indicated "There is a large acute right subdural hemorrhage present measuring 3 cm (centimeters) in greatest thickness. Approximately 16 mm (millimeters) of right to left midline shift of the lateral ventricles is noted as described above. There is entrapment of left lateral ventricle. Significant impression and slight rotation of the brainstem due to mass affect is observed. Within the hemorrhage is noted which may reflect areas of unclotted blood. The hemorrhage extends into the right temporal lobe region and along the anterior inferior aspect of the right anterior cranial fossa. In the inferior temporal lobe region, the hemorrhage measures approximately 2 cm (centimeters) in thickness. Dilation of the left lateral ventricle is noted consistent with entrapment." The hospital Discharge Summary, dated 06-23-12 indicated the resident was "admitted from nursing home after a fall and acute loss of consciousness and found to have a large subdural hematoma at admission." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of "The Nursing Spectrum Drug Handbook," on 07-12-12 at 2:30 p.m., indicated [MEDICATION NAME] was an anticoagulant with "precautions" which included "adverse reactions of headache, confusion, dizziness, nausea, vomiting, bleeding tendency, hemorrhage, and bruising. The section of the handbook related to "monitoring" included "watch for signs and symptoms of bleeding or bruising, and was "contraindicated in active major bleeding." The medication [MEDICATION NAME] also inhibited platelet aggregation and "adverse reactions" included dizziness, headache, and GI (gastrointestinal) bleeding." "Patient Monitoring" included to monitor the patient for unusual bleeding or bruising as the drug significantly increases risk of bleeding. 2. The record for Resident "C" was reviewed on 07-05-12 at 1:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident had physician orders [REDACTED]. During the initial tour of the facility on 07-03-12 at 9:30 a.m., the Unit Manager Licensed Nurse employee #3 indicated the resident had fallen, hit head and had an injury related to the fall. The nurses notes indicated the resident fell on [DATE] at 12:15 p.m. "Called to resident's room per CNA (certified nurses aide), resident found on floor lying on left side with left side of head against base of table. Alert and responsive. Small amount of blood noted on floor, next to residents head. Laceration measuring .5 cm (centimeters) in length noted above left eye, small amount of active bleeding. Two steri-strips applied to approximate wound edges. Ace applied to forehead, bleeding subsided." The facility Incident Report, dated 06-28-12 at 10:30 a.m. indicated the resident was "found lying on floor, left side of head on base of table. small amount of blood noted on floor." Observation on 07-05-12 at 11:00 a.m., Resident "C" was observed seated in the wheelchair. The resident indicated a fall occurred "a few days ago" but didn't know what had happened. The resident pulled the hair from the forehead a large bruised area was noted above the left eye, hair line and temple area. The Nurses notes dated 07-05-12 at 05:05 a.m. indicated the resident "con't (continued) to have multi-bruising area and to left upper eye ... ." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of "The Nursing Spectrum Drug Handbook," on 07-12-12 at 2:30 p.m., indicated the medication [MEDICATION NAME] inhibited platelet aggregation and "adverse reactions" included dizziness, headache, and GI (gastrointestinal) bleeding." "Patient Monitoring" included to monitor the patient for unusual bleeding or bruising as the drug significantly increases risk of bleeding. The medication Aspirin had and antiplatelet effect and "precautions" included to "use in extreme in caution in elderly patients, with "adverse reactions" to include GI bleeding, nausea, vomiting and bruising. "Patient Monitoring" indicated to "watch" for adverse reactions, especially bleeding tendency, incoherent speech, confusion, lethargy" and the need to report unusual bleeding and bruising. This Federal deficiency relates to Complaint IN 794. 3.1-48(a)(5)