Every finding on record at Manor Court of Maryville

Based on interview and record review, the Facility failed to ensure residents were free from abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 6. This failure resulted in R1 experiencing physical pain, fear and worry. Findings include:1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including hemiplegia, abnormalities of gait and mobility, and Parkinson's disease. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, used manual wheelchair, and was dependent for transfers. 2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including dementia. R2's MDS dated [DATE] documented R2 was moderately cognitively impaired, used manual wheelchair, and had verbal and physical behaviors. R2's Care Plan dated 8/12/24 documents R2 has verbal and physical aggression toward others. On 7/14/26 at 8:00 AM, V2, Director of Nursing (DON), stated R2 wheeled over to R1 in the dining room, pinned her against the wall, and pulled her arm back behind her. R2 cannot come back to the Facility, because R1 is traumatized. R1's Progress Note by V3, Licensed Practical Nurse (LPN), dated 6/18/26 at 11:08 AM, documents, CNA (Certified Nursing Assistant) reported that a male resident was being ruff with female resident. CNA stated that male resident had put females resident arms behind back and used profanity. On 7/14/26 at 9:29 AM, V3 stated V7 came to her and reported R2 tried to put R1's hand behind her wheelchair. R1 told V3 that R2 did not hurt her, but he tried to put her hand somewhere. The Facility's Undated Written Statement by V7, CNA, documents, I (V7) was emptying dining room. Came back (R2) had (R1)'s arm behind her chair pulled back as far as he could. I intervened (R2) then started screaming, 'Fu** you, you are full of sh**.' I took (R1) to nurse and explained what happened. (R2) was separated from dining room and taken to TV as a redirect. On 7/14/26 at 1:15 PM, V7, CNA, stated R1 and R2 were eating lunch in the dining room when he saw that R2 had R1's arm behind her like they were playing tug of war. V7 told R2 he could not do that, then pushed R2's wheelchair to another area and notified V3. V7 stated he feels much better knowing R2 cannot come back to the Facility for the safety of all residents. R2's Progress Note by V4, Licensed Practical Nurse (LPN), dated 6/18/26 at 11:00 AM documents, This Nurse was made aware that this resident had another resident by her arm with her arm behind her back pushing her up against the dinning {sic} room table in the dinning {sic} area during breakfast. Resident was escorted out by another Nurse away from dinning {sic} area and into the hallway. On 7/14/26 at 1:22 PM, V4 was unavailable for interview by phone. On 7/14/26 at 9:10 AM, R1 stated R2 wanted her to move in the dining room, but she was having trouble moving her feet. R2 kept saying, Back, back, back, then he grabbed her left arm and put it behind her and twisted it. R1 stated, It hurt. He was trying to open my fingers so he could put my hands where he wanted. R1 clarified she thought R2 was going to put her hand on his private parts, but staff intervened before that happened. R1 stated she had bruises that have since resolved. R1 stated she was afraid at the time but now thinks she is alright as long as R2 cannot return to the Facility. R1 stated R2 has been gone from the Facility for a couple months now, but R1 overheard another resident ask about him recently and thought to herself, Why would you bring him up again? R1 stated she tries very hard not to think about R2. R2's Progress Note dated 6/26/26 documents V9, R1's Family, stated she would do anything she could to ensure R2 did not return to the Facility because R1 was very upset by the incident and very frightened by R2. On 7/14/26 at 4:12 PM, V9 stated R1 had never been treated like this before and is worried R1 will have PTSD (Post-Traumatic Stress Disorder) from this incident. The Facility's Final Report sent to IDPH on 6/18/26 documents, (R2) grabbed female resident (R1) by her left arm and bend it behind her back forcefully as she walked by him in the dinning room. (R1) yelled out and staff in dinning room quickly intervened to remove his hand and remove resident from dining room. (R1) had some bruising to her left wrist but no other injuries. (R2) was with staff member until such time as he was transported to (Local Hospital). On 7/15/26 at 10:35 AM, V10, Nurse Practitioner (NP), stated the Facility made her aware of the 6/18/26 incident between R1 and R2. She stated if R2 would ever come back into the Facility there would be a big problem, but R2 is not here and she thinks R1 is doing ok mentally and emotionally. On 7/15/26 at 10:40 AM, V2 stated she expects the Facility to follow its abuse policy. The Facility's Abuse Prohibition and Reporting Policy revised 3/30/26 documents the facility actively prohibits resident abuse. The purpose is to protect residents from any kind of abuse, including verbal, sexual, mental, and physical abuse.

Based on interview and record review, the Facility failed to give the required 30 day notice for involuntary discharge (IVD) and would not allow resident to return to the Facility with a pending appeal for 1 of 6 residents (R2) reviewed for admission, transfer and discharge in the sample of 6.Findings include:1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including dementia. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was moderately cognitively impaired, was dependent for transfer, and had both physical and verbal behaviors. R2's Care Plan dated 8/12/24 documents R2 has verbal and physical aggression to others. R2's Progress Note by V4, Licensed Practical Nurse (LPN), dated 6/18/26 at 11:00 AM documents, This Nurse was made aware that this resident had another resident by her arm with her arm behind her back pushing her up against the dinning {sic} room table in the dinning {sic} area during breakfast. Resident was escorted out by another Nurse away from dinning {sic} area and into the hallway. R2's Progress Note dated 6/18/26 at 1:42 PM documents R2 was sent to (Local Hospital) with an involuntary petition for admission. R2's Progress Note dated 6/23/26 at 1:00 PM documents (Local Hospital) was contacted and informed that R2 would not be able to return to (Facility). R2's Progress Note dated 6/23/26 at 2:12 PM documents V5, R2's Family, was notified that R2 would need new long term placement from the hospital and would not be able to return to the Facility. R2's Progress Note dated 6/27/26 at 8:00 AM documents IVD paperwork was given to R2 at (Local Hospital). R2's Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents dated 6/26/26 documents R2 is being emergently discharged for the physical safety of other residents, the facility's staff, or visitors. The effective date of the proposed discharge was 6/23/26. R2's Discharge Orders dated 6/26/26 document R2 experienced behaviors in the Facility, was sent to (Local Hospital) and is unable to return to the Facility. On 7/14/26 at 8:00 AM, V2, Director of Nursing (DON), stated on 6/18/26, R2 pinned R1 against the wall and pulled her arm back behind her. The Facility sent him to (Local Hospital) and he remains there. V2 gave R2 IVD paperwork a few days after he was admitted to (Local Hospital), and the Facility just cannot take him back. V5 appealed the discharge and there is an upcoming court hearing. On 7/14/26 at 3:23 PM, V8, Ombudsman, stated the Facility should have taken R2 back after the routine three day psychological evaluation. The IVD paperwork was sent to V8 and V5 on 6/26/26, so they were supposed to keep R2 for 30 days after that and not discharge R2 with a pending appeal. The Facility's Transfer of a Resident Policy revised 1/11/23 documents, Should the resident choose to appeal a transfer to another facility, the facility shall not transfer pending the results of the appeal.

Based on interview and record review the facility failed to report an allegation of abuse for 1 of 2 residents (R2) reviewed for abuse in the sample of 9. Findings include: R2's Face Sheet documents she was admitted to the facility 5/4/23 with a pertinent medical diagnosis of Unspecified Dementia, unspecified Severity with Anxiety. R2's Minimum Data Set (MDS) documents (R2) has severe cognitive impairment, no verbal or physical impairment, no rejection and always incontinent of bowel and bladder. On 6/20/25 (R2) reported that Certified Nursing Assistant (CNA) V10 pushed her. The alleged abuse was investigated by facility staff and was unfounded. On 6/26/25 at 3:35 PM (V10) denied pushing (R2) and stated that (R2) pushed her instead. On 7/8/25 at 9:00 AM V1 Administrator stated he was out due to illness, and he was the only one with access to report the abuse. It was investigated but was not reported to Illinois Department of Public Health. The facility's policy on Abuse revised 08/16 documents if the matter involves alleged abuse or neglect of a resident or serious bodily injury the Administrator or designee shall provide the Illinois Department of Public Health with initial notice of the alleged abuse or serious bodily injury as soon as possible but not more than 2 hours after the matter becomes known or no later than 24 hours, if the allegation involves abuse and does not result in serious bodily injury.

Based on interview and record review the facility failed to correctly transcribe and administer discharge orders regarding medications for 1 of 3 residents (R4) reviewed for medications in the sample of 9. The Past Non Compliance occurred 6/10/25 to 6/24/25. Findings include: R4 's Face sheet undated documents an admittance date of 5/27/25 with pertinent medical diagnoses of Osteomyelitis of vertebra Thoracic region, Chronic Systolic (congestive) heart failure (5/27/25) and Chronic Obstructive Pulmonary Disease, Unspecified (5/27/25). R4's Minimum Date Sheet (MDS) dated [DATE] documents R4 is cognitively intact, and the medications taken are in the class of antidepressant, anticoagulants, opioids, and antibiotics. R4's Hospital Medical discharge records from area hospital dated 5/8/25 -5/27/25 documents hospitalized problems as Chronic Midline Thoracic back pain, Bacteremia due to Enterococcus, Osteomyelitis of Thoracic Spine, Pacemaker Infection-(Pacemaker removed), Suspected Heparin Induced Thrombocytopenia (HIT) in hospitalized patient and Fall. R4's hospital medical discharge records dated 5/8/25-5/27/25 documents discharge medications as Albuterol, Ampicillin 100 Milligram/Milliliter injection, Breztri Aerosphere 160-9-4.8 Microgram actuation inhaler, Carvedilol 12.5 Milligram, Ceftriaxone, Cholecalciferol, Famotidine, Ferrous Sulfate, Fluticasone Propionate, Gabapentin, Hydrocortisone 1% cream, Hydroxyzine, Lidocaine 5%, Loraepam, Methocarbamol, Ondansetron, Oxycodone, Polyethylene Glycol, Rosvastatin, Sertraline, Trazadone and Warfarin. Discharge instructions included to stop medications Cyclobenzapine, Furosemide and Spironolactone. The medication Carvedilol was stopped due to low blood pressure but resumed 5/26; Spironolactone was placed on HOLD due to low Blood pressure initially and now to worsening of her renal function. This medication will be resumed as indicated by primary care physician and cardiologist. No reasoning was included for stopping the medication Furosemide. R4's Nurse Progress notes dated 5/27/25 documents R4 was admitted to the facility from a local hospital and was sent back out to an area hospital on 5/28/25 due to complaints of Shortness of Breath (SOB). R4's Hospital Medical discharge records from local hospital dated 5/28/25-6/10/25 documents hospitalized problems as Chronic Midline Thoracic back pain, Bacteremia due to Enterococcus, Osteomyelitis of Thoracic Spine, Pacemaker Infection- (Pacemaker removed), Suspected Heparin Induced Thrombocytopenia (HIT) in hospitalized patient and Fall. R4's hospital discharge medications from area hospital dated 5/28/29-6/10/25 are documented as: Furosemide 40 Milligrams daily, Ampicillin Sodium 2 gram reconstituted solution, Carvedilol 3.125 Milligram tablet daily, Ceftriaxone 2 gram reconstituted solution, Saccharomyces Boulardill 250 Milligram capsule daily, spironolactone 25 Milligram Daily, Sertraline 100 Milligram Daily, 50 Milligram 50 Milligram at bedtime, Famotidine 40 Milligrams daily, Rosuvastatin 40 Milligram, Carvedilol 12.5 Milligram every 12 hours, Diphenhydramine 50 Milligram capsule, Budesonide-Glycopyr-formoterol 160-9-4.9 Micrograms Actuation HFA Aerosol Inhaler, Albuterol Sulfate 90 Micrograms / Actuation, Cyclobenzapine 10 Milligram tablet, Ampicillin 2 gram reconstituted solution, Fluticasone Propionate 50 Micrograms/ Actuation Suspension Spray, Warfarin 4 mg Daily, Hydrocortisone 1% cream, Lidocaine 5% adhesive patch every 12 hours, Polyethylene glycol 3350 17 gras daily, Ceftriaxone 2 gram reconstituted solution, Ferrous Sulfate 325 Milligram Daily, Gabapentin 300 Milligram capsule three times/day, Hydroxzine 10 Milligram every 4 hours as needed, Ondansetron 4 Milligram tablet, disintegrating every 8 hours as needed. Lorazepam 0.5 Milligram (0.25 Milligram every 6 hours as needed, Oxycodone 15 Milligram (7.5 Milligram every 4 hours as needed). HOLD Budesonide-Glycol-Formoterol 160-9-4.8 Microgram/Actuation HFA Aerosol Inhaler until seen by Primary Care Provider (PCP); DISCONTINUE Warfarin 3 Milligram tablet Tuesday-Thursday, 4.5 Milligram Monday, Wednesday, Friday, Saturday, and Sunday. On 7/1/26 at 12:36 PM V2 Director of Nursing (DON) stated they did not have any medication errors in the past 3 months. She did review the orders after the family did complain about R4 not receiving the specific medication Furosemide and did not see the order. On 7/3/25 at 10:00 AM V20 Nurse Practitioner stated the doctor sees the residents first and the nurse practitioners come in next. They try to review medical records prior to seeing the resident but a lot of the times the medical records are not available. We do review the electronic records but that is only helpful if the information has been put into the system. That is what happened with R4. The hospital discharge medications were not entered into the system. She (V20) only became aware that the resident was not receiving Lasix after R4's son brought it to her attention. It was clearly an error. No harm was done, however, the potential for harm was present due to possible fluid overload. Fluid overload can cause lung and/or heart problems. (V20) Nurse Practitioner had not encountered this problem with the facility before and do believe staff do provide good care. On 7/3/25 at 11:30 AM R4's admission nurse (V22) Licensed Practical Nurse stated when a resident is admitted , the hospital records are reviewed with doctor or NP. The facility usually has 2 nurses review the orders to ensure all orders have been entered correctly. We also have another nurse that audit the case to ensure all medications are captured. Uncertain how all R4's medications were not transcribed. On 7/3/25 at 3:30 PM V23 Registered Nurse stated she is the auditing nurse that goes over all orders for admissions or re-admissions. V23 (RN) stated she was on vacation the day that R4 was re-admitted to the facility. It was her understanding that either the Director of Nursing of Assistant Director of Nursing would take care of auditing admissions or re-admissions. Upon her (V23's) return to work R4's was not included in the stack of admissions that needed to be reviewed. On 7/3/25 at 4:30 PM R3 Assistant Director of Nursing stated the facility already had a system in place where 2 nurses would go over the orders during admission and the auditing nurse would review all admissions the next day. That check and balance worked until the auditing nurse went on vacation and this case fell through the cracks. After I became aware of the problem, I agreed to audit the admissions or re-admissions in the absence of the auditing nurse. On 7/8/25 at 1:40 PM V1 Administrator stated the facility instituted a check and balance system to avoid any potential issues of missing medication with 2 nurses being involved in the admission process and the bridge nurse to audit admissions. We have added the Assistant Director of Nursing to that process to cover when the bridge nurse is off work. We did investigate the incident and initiated a Plan of Correction. The facility's policy Medication Administration Using eMAR revised 11/11 documents the objective it to provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident. Prior to the survey date, the facility took the following actions to correct the noncompliance. This tag was corrected on 6/24/25 This Plan of Correction in response to the statement of deficiency demonstrates our good faith and desire to continue to improve the quality of care and services rendered to our residents. This plan of correction constitutes a written allegation of compliance with Federal Medicaid and Medicare requirements. The Following Plan of Corrections was developed to ensure future compliance with all medication orders upon admission. 1) Two nurses will review the discharge orders for all new admissions and readmissions together going line by line of the discharge order summary sheet. 2) The RN Bridge nurse will review all admission and readmission orders within 48 hours of admission and correct any identified issues. 3) The ADON will be clearly designated to perform the reviews of the clinical records within 48 hours of admission if the RN Bridge nurse is unavailable for any reason. 4) The Licensed staff were inservice on 6/24/25 regardig the admission process, including two Licensed nurses to review all discharge orders from hospital. 5) The ADON will perform no less than two audits of the admissions and/or readmissions weekly for no less than 4 weeks. The QAPI will include these audits when they meet monthly and determine if further interventions are necessary.

Based on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination for 4 of 4 residents (R16, R29, R40 and R54) reviewed for food sanitation in the sample of 39. Findings include: On 10/29/2024 at 12:14 PM, in the kitchen off the 300-hall there was a small kitchenette. Inside the kitchenette was a sink for handwashing but the faucet was not in working order and no water would come out. On 10/29/2024 at 12:18 PM, V4, Dishwasher, was wearing gloves and took the following temperatures of the food on the steam table and documented in the Logbook. The mashed potatoes were documented at 114.0 F (Fahrenheit), the meat (chicken) was documented as 113.0 F regular, the pureed meat 132.0 F, the pureed vegetables (lima beans) 132.0 F and the gravy was documented at 113.0 F. V4 then proceeded to serve the food without reheating any of the items that were below 135.0 F. On 10/29/2024 at 12:19 PM, V4 stated he was not sure what temperature the food should be when hot and at the steam table but that is what he got from the kitchen, and he is not a [NAME] but rather a dishwasher. On 10/29/2024 at 12:33 PM, R29 was served mechanical meat (Chicken) covered with gravy on top of it. On 10/29/2024 at 12:39 PM, R16 was served a divided plate with pureed meat, pureed vegetable, both items topped with gravy. On 10/29/2024 at 12:40 PM, R40 was served pureed meat (chicken) covered in gravy and pureed vegetable (lima beans) covered in gravy. On 10/29/2024 at 12:43 PM, R54 was served pureed meat (chicken) covered in gravy and pureed vegetable (lima beans) covered in gravy and was served. On 10/30/2024 at 9:28 AM, the following residents were documented as receiving pureed and/or mechanical diets on the 300-hall: R16, R29, R40 and R54. On 11/1/2024 at 9:59 AM, V37, Dietician stated, I would expect all food temperatures to be taken before the food service and any temperature below 135.0 Fahrenheit, to be taken back to the kitchen and reheated to a temperature of 165 degrees Fahrenheit (F). Any food temperature below 135 degrees can create the perfect environment for bacteria to grow and cause somebody to get sick for food borne illness. All food below 135 degrees should not be served to residents. The Food Service/Holding Temperature Policy dated 7/12/2023 documents, To provide guidelines for safe serving /holding temperatures for foods served in the Dining Services department. Cooked meat 135 degrees (F) or higher, cooked vegetables 135 degrees or higher, soups, gravy or broths 135 degrees or higher.

Based on interview and record review the Facility failed to prevent resident physical abuse for 1 of 3 residents (R54) reviewed for abuse in the sample of 39. Findings include: R54's Physician Order Sheet (POS) dated February 2024 documents a diagnosis of Alzheimer disease with late onset, wedge compression fracture vertebrae, subsequent encounter for fracture with routine healing, atherosclerotic heart disease of native coronary artery without angina pectoris, stent 1999 & 2004, unspecified dementia, unspecified severity without behavioral disturbances, psychotic disturbance and anxiety, conductive hearing loss, age related osteoporosis. R54's Minimum Data Set (MDS) dated [DATE] documents R54 was severely impaired for cognition for activities of daily living. R54's Care Plan dated 11/9/2022 documents Problem: (R54) has chosen to receive Hospice care from (Hospital) Hospice related to Alzheimer's. R54's Care Plan does not address abuse. R54's Incident Report dated 2/20/2024 at 10:15 AM, Notified by (V6, Licensed Practical Nurse), notified me that she observed a hospice aide strike resident (R54) across the head with both hands and she yelled at the hospice aide to stop, and the aide stated, 'I was pushing her head away to keep her from biting me.' 10:20 AM, V7, Hospice aide, that was identified as the alleged perpetrator was instructed not to go back into the resident care area, and a statement obtained from (V7) that stated she was providing assistance for resident and she was trying to bite me, and I insistently was pushing her way from me although I know (V6) thinks I was slapping (R54) but I wasn't'. I asked for her contact information, (V7's phone number) was given to me as a phone number and she was instructed to leave and not return until such time as I contact her and allow her back into the facility. 10:40 Resident assessed for injuries and no injuries noted. Resident unable to communicate but has no signs or distress on her face and appears calm currently. 10:55 was informed by (V6) that she notified the POA (Power of Attorney) and the Physician, no injuries were noted per assessment she stated and to her the resident does not look upset or having any distress. 10:45 AM, Notified (Local Police Department) of allegation, at approximately 11:10, an Officer came to the facility and interviewed staff and took statements from staff, information was provided about the alleged perpetrator, and case number was documented. Written statement by V6 undated documents, Call light was on and entered the room. When I entered the room (V7) slapped resident on both sides of her head simultaneously by each ear creating a 'slapping' sound. I yelled, 'Hey' Hospice CNA looked up and said, 'she bit me.' Another facility nurse and CNA came into the room. Stayed with the resident while I left to report to management. A statement undated from V7 documents, (R54) was biting me when nurse walked in the room, and I was pushing her head away from my arm. On 10/30/2024 at 9:00 AM, V6, Licensed Practical Nurse stated, I remember the CNA hospice aide (V7). (R54's) call light was going off that day and I went into her room and when I entered the room I saw (V7) slap (R54) with an open hand on both sides of her head and when she saw me she jumped back and said (R54) bit me, she bit me, like she was trying to make it okay what she had done. R54's Police Report documents, On Tuesday February 20, 2024, at approximately 11:48 A.M. I, (V11, Local Police Officer) responded to (Facility) in reference to an aggravated battery that occurred earlier that day. Upon my arrival I made contact with the site manager, identified as: (V1). (V1) stated that at approximately 10:15 A.M. a nurse witnessed a contract hospice CNA employed by (Hospice Company) smack a patient on both sides of the head above her ears with enough force to make a crack sound. (V1) identified the nurse and hospice CNA as (V7). I spoke with (V6) who stated she noticed the call light on for patient she identified as (R54). (V6) stated that (R54) is physically unable to activate the call light. (V6) stated she went to check on (R54) and upon entering the room witnessed (V7) smacking (R54) on both sides of her head above the ears with an open palm with enough force to make a crack sound. (V6) shouted, 'Hey'. The Abuse Policy with a revision date of 1/2017 documents, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or mental anguish. Abuse also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and/or physical conditions, cause physical harm, pain and mental abuse including abuse facilitated or enabled through the use of technology. Physical abuse means the infliction of injury on a resident that occurs other than by accidental means, whether or not the injury required medical attention, Physical abuse must include, but is not limited to such acts as: hitting, slapping, kicking, hair pulling and pinching, etc.

Based on record review, observation, and interview the facility failed to perform a diagnostic test in a timely manner to diagnose and treat a Urinary Tract Infection for 1 out of 7 residents (R8) reviewed for a Urinary Tract Infections. Findings include: According to the electronic health record (EHR) dated 6/27/2024. R8 EHR documents diagnose of Dementia, Type 2 diabetes, displaced of medial Condyle of left tibia closed fracture, chronic obstructive pulmonary disease, cirrhosis of liver, abnormalities of gait and mobility, muscle weakness, atrial fibrillation, cognitive communication deficit, osteoporosis, overactive bladder, gastro-esophageal reflux disease, hyperlipidemia, encephalitis, encephalomyelitis, spinal stenosis, anemia, vitamin D and B12 deficiency, depression, and anxiety. MDS (minimum data set) dated 5/14/2024 documents R8 having a BIMS (brief interview of mental status) of 15 and dependent of functional abilities and goals. Requires maximal/substantial assist with ADLs (activities of daily living). Care Plan dated 5/14/2024 documents that R8 requires substantial maximum assistance with ADLs related to dementia. The EHR review of the progress notes documented by V23, RN (Registered Nurse) on 06/23/2024 09:40 PM interview with V10, R8's spouse, at length concerning resident's confusion would like to see ensure or some shake given or medication to help with her appetite be started to help lessen confusion. On 6/26/2024 V6, LPN (Licensed Practical Nurse) documented 06:12 PM, Resident has some confusion noted for some days now. POA, (Power of Attorney) V10 has also stated to Nurse that confusion observed. Resident repeating same questions and not usually like resident. MD (Medical Doctor) has orders to collect urinary analysis/urine. On 06/27/2024 11:57 AM, V6, LPN documented that urine specimen obtained this shift due to confusion. Urine placed on main floor in lab fridge for collection. V6 documented the resident continues to show confusion this shift with staff and spouse. Urine obtained. V6 documented on 07/02/2024 at 1:58 PM, 2nd urine specimen obtained this shift for STAT collection. R8's Urinalysis dated 7/5/24 for specimen collected 7/3/24 documents the following abnormal results: Clarity: Turbid, Protein: 1+. Urobilinogen: 2+, Nitrates: Positive, Leukocytes: 1+, Bacteria: Few, Amorphous: Present, and Mucous: Present. At 10:45 AM observed V16, CNA and V15, CNA perform perineal care related to incontinence on R8. V16 wiped back (buttocks) to front (vaginal) area of R8, was unable to obtain all of stool from inner buttocks. V16 and V15 placed a new brief on R8. On 7/2/2024 at 9:20 AM, Interview with V6, LPN stated the urine was collected 6/27/2024 and that she will check it today to see if the results of urinalysis are in yet. On 7/2/2024 at 12:30 PM, V3 LPN stated about lab results of R8's urinalysis results are needed. V3 stated she would check into that. On 7/2/2024 at 1:00 PM, V2 DON (Director of Nursing) stated that the specimen was never picked up due to the lab technician was off that day and never came to get it. V2 DON stated that another urine specimen will be obtained today. On 7/2/2024 at 2:55 PM, V10 R8's husband, stated the nurse V6, LPN came in and obtained another urine for collection this afternoon. V10 stated he noticed R8 is more confused and disoriented than normal. V10 stated the confusion and disorientation started a week ago I told V6, and she did agree. V10 stated that R8 is forgetful but not this confused. On 7/3/2024 at 11:45 AM, V22 technician stated the urine for the urinalysis was received today about an hour ago and someone will be out there to pick up the specimen sometime today. Received extension to supervisor, at the lab will follow up in 30 minutes. On 7/3/2024 At 1:32 PM, spoke to V21, Supervisor stated no orders were submitted for any labs for R8 between 6/25/2024 through 6/30/2024 at this time. Policy: It is a policy of the facility to provide means of quality diagnostic lab services for the residents. Purpose: To provide residents a means of diagnostic service promptly and conveniently. Staff Responsible: 1. Director of Nursing 2. Staff Nursing 3. Procedure: 1. Provision for Diagnostic Services a. Provision has been made for promptly and conveniently obtaining required clinical laboratory, X-ray and other diagnostic services from a clinical laboratory or diagnostic service, physician's office, or hospital. b. All diagnostic services are provided only on the order of a Physician, a Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist (if practitioners are acting in accordance with state law, scope of practice law and facility policy). The facility will follow the standards set by the Laboratory, Radiology, or other Diagnostic service in setting the Normal, Abnormal, and Critical result reference ranges for the Labs and Diagnostics ordered. Revised: 11/28/17

Based on observation, interview and record review, the facility failed to initiate progressive interventions to prevent falls after a resident had a fall with a fracture for 1 of 4 residents (R1) reviewed for falls in the sample of 11. Findings include: On 7/3/24 at 1:15 PM, V15 Certified Nursing Assistant (CNA) and V16 CNA provided incontinent care for R1. R1 was able to bring her own legs up onto the bed after sitting on side of bed and laying down. There was a healed scar on R2's right knee from previous surgery (no surgery after recent fall). R1 did not appear to have any pain when lifting her legs onto bed before incontinent care started. R1's undated Care Plan documents her diagnoses as: Unspecified Fracture of Left Patella, Cerebrovascular Accident (CVA), Hypertension (HTN), Dysphagia; Chronic Kidney Disease (CKD)-Stage 3, Unspecified Dementia, Urinary Tract Infection (UTI) on 4/4/24, Rash and other Non-Specific Skin Eruption (1/18/24), Dysuria, Hemiplegia Affecting Left Non-Dominant Side, and Major Depressive Disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and is dependent for toileting hygiene, positioning and transfers, she does not walk and is dependent for wheel chair (w/c) mobility and she is always incontinent of bowel and bladder. R1's Progress Note dated 05/02/2024 at 6:03 AM documents, Resident found on the floor near bed laying underneath her covers. When this nurse ask resident what happen, she stated that I just fell out of the bed. Resident is c/o (complaining of) pain to her left knee, also c/o back pain and stated that she did hit head. Some bruising was also noted under residents left eye. Resident was sent to (local hospital) for treatment and evaluation. All parties have been notified. R1's Progress Note dated 5/02/2024 at 6:52 AM documents, Report received from (hospital staff) with (local hospital). Resident has a small fracture noted to L (left) Kneecap and will return with an Immobilizer. Follow up with Ortho. Will return to facility shortly. R1's Care Plan dated 5/5/21 documents, Resident at risk for falling R/T (related to) recent illness/hospitalization and new environment, orthostatic hypotension, TIA (Transient Ischemic Attacks) , femur fracture, impaired cognition, vision loss, CVA. The goal for this care plan documents, Resident will have decreased risk for injury related falls this quarter. Interventions for this care plan include: 7/10/23: When resident in high traffic areas, offer/assist resident into chairs from wheelchair. 5/6/21: Orientate resident to room, surrounding areas, and use of call light system. 5/6/21: Encourage resident to use side rails/enablers as needed. 5/6/21: Provide resident with specialized equipment as deemed necessary per therapy 5/6/21: Assist resident with activities of interest. There was no updated interventions on care plan for most recent fall of 5/2/24 after R1's fall resulting in fractured patella (knee cap). On 7/2/24 at 10:52 AM, V8 Care Plan Coordinator, stated she was not aware R1 had a fall with a fracture on 5/2/24. She stated she checks the Events tab in residents' medical records to check for falls. She stated she tries to watch their progress notes also, but doesn't always see all progress notes. She stated R1's Care Plan was not updated with a progressive intervention after her fall on 5/2/24 and it should have been. The facility's policy, Accidents and Incidents dated 8/2014 documents, 2. All accidents and incidents should be documented, by creating and event and attaching a progress note. Progress notes will be documented in the resident record every shift until the event is closed by the DON (Director of Nursing). All accidents/incidents need to be investigated to determine the possible cause, to assist in future reoccurrences. When a resident has been identified as a high risk of accidents/incidents, interventions will be put into place per the individual resident assessment and care plan.

Based on observation, interview, and record review, the Facility failed to ensure staff appropriately use PPE (Personal Protective Equipment) to prevent the spread of infectious disease including COVID-19. This has the potential to affect all 93 residents living in the Facility. Findings include: 1. On 12/12/23 at 7:15 AM, there was a sign on the door of the Facility entrance documenting Positive Covid Cases and Masks Are Required In The Building. An additional copy of the sign was placed on the door leading into the residential part of the Facility. On 12/12/23 at 7:24 AM, V5, Registered Nurse (RN), was working at the medication cart on Bounce Back Lane without a mask. On 12/12/23 at 7:30 AM, V6, Licensed Practical Nurse (LPN), and V7, V8, and V9, Certified Nurse Aides (CNAs), were all working in the Memory Lane unit and were not wearing masks. On 12/12/23 at 12:58 PM, V7, CNA, stated she was not wearing a mask because there was no COVID in that unit. On 12/12/23 at 8:35 AM, V3, Minimum Data Set (MDS) Coordinator/ Licensed Practical Nurse (LPN), provided a list of residents that have tested positive for COVID since the outbreak began on 10/28/23. V3 stated R1 was the only resident isolated at that time. V3 stated residents must isolate for ten days after a positive COVID test result. The Facility's List of COVID Positive Residents documents R1 tested positive for COVID on 12/5/23. 2. On 12/12/23 at 10:04 AM, V13, CNA, exited room [ROOM NUMBER] with a surgical mask worn around her neck. The mask was not covering her nose or mouth. On 12/12/23 at 10:24 AM, V13, CNA, entered room [ROOM NUMBER] and spoke with R4 while still wearing the mask around her neck. On 12/12/23 at 10:26 AM, there were two signs on R1's door documenting Contact and Droplet precautions. There was a rack on the door containing gowns, masks, and gloves. V13, CNA, entered R1's room wearing a surgical mask. V13 was not wearing a gown, gloves, N-95 mask, or protective eyewear. On 12/12/23 at 10:28 AM, V3, entered R1's room wearing appropriate PPE and pointed to the sign on R1's door. V13, CNA, stated, I don't think (R1) has COVID. V13 stated Nobody told me. On 12/12/23 at 2:30 PM, V3, stated she expects staff to wear surgical masks any time they go beyond the double doors to the patient care area in the Facility. V3 stated if staff are going into a COVID positive room, they need to wear N-95 masks, gowns, and gloves. On 12/13/23 at 9:25 AM, V1, Administrator, stated he expects staff to wear surgical masks in all patient care areas and wear appropriate PPE in COVID positive rooms. The Facility's COVID-19 Policy revised 8/28/23 documents, Facility will follow current CDC (Centers for Disease Control)/CMS (Centers for Medicare and Medicaid Services) recommendations regarding masking while in an outbreak. The policy adds, Any residents that are determined to have new onset of symptoms will have the following initiated: Contact/Droplet precautions (N95 respirator) with eye protection will be initiated. Staff will wear N95 respirators, eye protection, gowns and gloves when caring for residents with COVID-19. The Facility's Resident Census and Conditions of Residents Form, CMS-672, dated 12/12/23 documents there are 93 residents living in the Facility.

Based on observation, interview and record review, the Facility failed to implement progressive fall interventions to prevent accidents/falls for 1 of 3 residents (R4) reviewed for supervision to prevent accidents in the sample of 7. Findings include: R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, idiopathic peripheral autonomic neuropathy, chronic pain, abnormalities of gait and mobility, lack of coordination, muscle weakness, and muscle spasms. R4's Minimum Data Set (MDS) dated [DATE] documented R4 was cognitively intact and used wheelchair for mobility. The MDS did not further evaluate R4's functional abilities. R4's Care Plan initiated 1/7/19 documents, (R4) at risk for falling r/t (related to) impaired mobility, use of psychoactive medications, use of diuretic medication, dx (diagnosis) of htn (hypertension), dx of insomnia, and dx of neuropathy. R4's Fall Report dated 1/31/23 documents R4 had an unwitnessed fall in the bathroom while trying to reach for a grab bar next to the toilet. The interventions added were therapy evaluation and application of new cushion and (non-slip pad) to wheelchair. R4's Fall Risk assessment dated [DATE] documented R4 was at high risk of falls. R4's Progress Note by V25, Registered Nurse (RN) on 12/11/23 at 6:30 PM documents, found pt (patient) sitting on floor in the bathroom no call light on and brake wasn't locked on the w/c (wheelchair) pt (patient) states she isn't injured no sores bruises noted to hip. Pt states that she wheeled into bathroom and slide out of w/c on to the floor. R4's Fall Report dated 12/11/23 documents R4 had unwitnessed fall wheeling into bathroom from wheelchair. R4 did not sustain any injuries. The intervention added was therapy evaluation for wheelchair positioning and cushion. On 12/13/23 at 9:35 AM, R4 stated she was transferring herself from her wheelchair to the toilet the other night when the pad on her seat slid out from the chair and she fell . On 12/13/23 at 9:37 AM, V24, Director of Rehab, entered R4's room with a cushion and (non-slip pad). V24 stated the previous (non-slip pad) might have been displaced, but she has a new one to place in R4's chair. R4 stated she had never seen that (non-slip pad) in her wheelchair before. On 12/13/23 at 1:15 PM, V1, Administrator, stated he expects the Facility to implement and follow progressive interventions and feels they always do. The Facility's Accidents and Incidents Policy dated 8/2014 documents, When a resident has been identified as a high risk for accident/incidents, interventions will be put into place per the individual resident assessment and care plan. All accidents/incidents need to be investigated to determine the possible cause, to assist in future recurrences. All staff should be part of the identification of and intervention process to assist in fall prevention.

Based on interview and record review, the Facility failed to provide advance written notice of a room change in 1 of 3 residents (R3) reviewed for room changes in the sample of 7. Findings include: The Facility's Census History from 9/12/23 through 12/12/23 documents R3 changed rooms on 11/14/23. On 12/12/23 at 4:05 PM, V22, R3's Power of Attorney (POA), stated she was not informed that R3 would not be returning to her previous room after she was isolated for COVID-19. V22 stated she came in to visit R3 and discovered R3 was no longer in the same room. On 12/12/23 at 2:30 PM, V3, Minimum Data Set/MDS Coordinator/ Licensed Practical Nurse, LPN, stated she was unable to locate documentation that R3's family were notified of R3's room change. On 12/13/23 at 9:25 AM, V1, Administrator, stated the Facility does not have any documentation that R3's family was notified of the room change. On 12/13/23 at 10:57 AM, V3 stated the Facility does not have a policy regarding room change notifications.

Based on interview and record review, the facility failed to obtain urine cultures to ensure that the appropriate antibiotic was utilized or necessary to treat urinary tract infections (UTIs) for 4 of 4 residents (R12, R57, R65, R91) reviewed for antibiotic stewardship in the sample of 35. Findings include: 1. The Facility Infection Control Log documents R12 had a UTI, and the hospital stated the culture was negative. R12's Progress Note, dated 3/16/23 at 1:47 PM, documents report was called from the hospital and R12 would be returning to the facility and was treated for an abnormal urinalysis (UA), but the urine culture came back negative but R12 would be continuing three more days of antibiotics. R12's Progress Note, dated 3/20/23 at 12:12 PM, documents R12 completed the antibiotic on 3/19/23 related to an abnormal UA/UTI. R12's Physician Order Sheet (POS), documents an order dated, 3/16/23, for Cefdinir 300 milligrams (mg) twice daily (BID) with an end date of 3/19/23. 2. The Facility Infection Control Log documents R57 had two UTIs with no organism identified on the log. R57's Progress Note, dated 4/17/23 at 3:06 PM, documents the root cause analysis related to a fall on 4/16/23 was that R57 attempted to get herself out of bed and fell . The intervention is as follows: Hospice in the building to assess resident, resident is anxious and fidgety. Resident is moving around in chair. Hospice Nurse states that he suspects that the resident has a UTI and will be starting her on an antibiotic. R57's Progress Note, dated 9/4/23 at 6:16 PM, documents that the facility talked with R12's family and they do not want the resident catheterized to obtain a urine specimen because it wouldn't be comfortable for R12, who is on hospice. Called hospice care nurse and received a new order for Cipro 500 mg BID for 10 days. R57's POS, documents an order dated, 4/18/23, for Cipro 500mg BID with an end date of 4/27/23. R57's POS, documents an order dated, 9/4/23, for Cipro 500mg BID with an end date of 9/15/23. There was no documentation in R57's record that a urine culture was obtained prior to the antibiotics ordered on 4/18/23 and 9/4/23 to ensure the antibiotic was necessary or susceptible to the organism/infection. 3. The Facility Infection Control Log documents R65 had a UTI, resulted at the urologist, results not available. R65's Progress Note, dated 10/21/22 at 5:59 PM, documents R65 was out for a urology appointment, during the appointment the catheter was changed, and a UA was obtained with no findings noted. R65's Progress Note, dated 10/24/22 at 11:42 AM, documents Urologist called and stated R65 had a UTI and started resident on Macrobid 100mg BID for 7 days. R65's POS documents an order, dated 10/24/23, for Macrobid 100mg BID with an end date of 10/31/22. There was no documentation in R65's medical record what the results of the UA/Urine culture results were to ensure that the antibiotic was necessary or was susceptible to the antibiotic prescribed. 4. The Facility Infection Control Log, documents R91 had a UTI and there was no documentation on the log that a urine culture was obtained or that an organism was identified. R91's Progress Note, dated 9/5/23 at 1:40 PM, documents the hospice nurse came to see the resident. New orders received to start Macrobid 100mg BID for 7 days for UTI. R91's last urine culture report, dated 8/10/23, documents normal skin flora. There was no documentation that a urine culture was obtained prior to R91 starting the antibiotic on 9/5/23 to ensure the antibiotic was necessary or was susceptible to the organism/infection. On 10/6/23 at 9:20 AM, V4, Infection Control Preventionist, stated she would expect that a UA/Urine culture would be obtained prior to the initiation of an antibiotic for a UTI to ensure the antibiotic is necessary and if so, the antibiotic prescribed is susceptible to the organism. The Antibiotic Stewardship policy, dated 12/18/19, documents the purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events.

Based on interview and record review, the facility failed to staff enough Certified Nursing Assistants (CNA) to provide care to the residents for 5 of 8 residents (R3, R36, R54, R79, R80) reviewed for adequate staffing in the sample of 35. This failure has the potential to affect all 102 residents residing in the facility. Findings include: 1. On 10/4/23 at 1:54 PM, R54 stated the facility needs more CNAs, especially on the weekends. R54 stated a lot of times they only have one CNA on her hall. R54 stated her roommate is at risk for falls and when her alarm goes off, she (R54) will turn her call light on to get help for her roommate. R54 stated no one comes so she (R54) has to call the nurse's station on her phone to get help. R54's filed a grievance, dated 2/28/23, documenting that there are low staff on the weekends. The corrective action from the facility was they have hired eight nurse aides, changed the schedule to spread staffing out throughout the weekend more effectively with a team effort from all department heads to assist with scheduling and staffing on the weekends. R54's Minimum Data Set (MDS), dated [DATE], documents R54 is cognitively intact. 2. During the group meeting on 10/4/2023 at 3:00 PM, R80 stated the staff that are here are great and they work hard but the truth of the matter is we need more staff. R80 stated It's really bad at nights. I am not sure what is going on in the world, but the truth of the matter is we need more staff working here. I am not sure what has happened, but it is not enough, and I think some of the staff get burnt out because they do not have enough help and then quit. I do not like to complain but they need more help. Our needs are not always met because there is not enough help. R80's MDS dated [DATE] document R80 was cognitively alert for decision making of activities of daily living. 3. During the group meeting on 10/4/2023 at 3:00 PM, R36 stated, My biggest complaint is that they need more help. Especially in the evenings. I have to wait and wait for staff because there is not enough help. I need help getting to the bathroom and I have had accidents for waiting for staff to come and help me. They need more help here it really is a big problem at nights. R36's MDS dated [DATE] document she is cognitively intact for decision making for activities of daily living. 4. During the group meeting on 10/4/2023 at 3:00 PM, R3 stated, This is a great place to live if you have to be in a nursing home. My biggest complaint is that they need more help. Especially in the evenings. I have to wait and wait for staff because there is not enough help. I need help getting to the bathroom and I have had accidents for waiting for staff to come and help me. They need more help here, it really is a big problem at nights. R3's MDS dated [DATE] document she is cognitively intact for decision making for activities of daily living. 5. During the group meeting on 10/4/2023 at 3:00 PM, R79 stated there is not enough help especially at night. The facility needs more staff because resident needs are not being met during the night. R79's MDS dated [DATE] document she was cognitively alert and orientated for decision making of activities of daily living. On 10/3/23 at 2:23 PM, V7, Licensed Practical Nurse (LPN), stated all of healthcare needs more staff, a lot quit during COVID and never came back. On 10/3/23 at 2:30 PM, V5, LPN, stated they have staff, but they call off, so it causes the CNAs that do come in to have to do extra work. On 10/4/23 at 2:35 PM, V13, CNA/Shift Coordinator, stated they decide how many CNAs are needed on each hallway and each shift by reviewing the census and acuity/needs of the residents. V13 stated if there are call offs, she will work the floor or call another CNA in to work. V13 stated if they have call offs and can't replace them, they work short and make it work. On 10/4/23 at 2:35 PM, V2, Director of Nurses (DON) stated call offs are a problem with CNAs. On 10/5/23 at 8:10 AM, V14, CNA, stated they are short on CNAs on day shift and it's hard to care for the facility. V14 stated the facility is hiring but they don't show up. On 10/5/23 at 8:15 AM, V15, CNA, stated some days they are short on CNAs and when they are short it makes it harder to provide care. V15 stated they have a lot of call offs or staff that don't call or show up for their shift. On 10/5/23 at 8:18 AM, V16, CNA, stated they are short on CNAs, and it makes it hard to provide care to the residents. V16 stated the facility just doesn't have enough CNAs. The Staffing policy, dated 9/18, documents staffing shall be based on the number, acuity, and diagnoses of the residents in the facility in accordance with the facility assessment, and shall be determined by figuring the number of hours of nursing time that each resident needs on each shift of the day.

Based on observation, record review and interview the facility failed to ensure residents' drug regimen was free for unnecessary psychotropic drug use for 1 of 5 residents (R13) reviewed for unnecessary psychotropic medications in the sample of 35. Findings include: On 10/6/2023 at 10:50 AM, R13 was sitting in television area, R13's facial features would slightly twitch/jerk as she was sitting in her wheelchair watching the dancing on the television. On 10/6/2023 at 9:05 AM, V20, Registered Nurse (RN) stated, I know (R13) has some lip smacking and facial twitches. I do not think it is getting worse. I have been here for about 8 months now. I am not aware of her having any behaviors. On 10/6/2023 at 9:11 AM, V10, RN stated, When (R13) was in the Memory Care Unit I provided care for her. She has some facial twitching in her neck and face. I am not aware of her having any behaviors. There were times she refused her medication but no behaviors that I can think of. R13's Physician Order Sheet (POS) document a diagnosis of Unspecified dementia, unspecified severity with anxiety, type 2 diabetes mellitus with diabetic neuropathy, shortness of breath, emphysema, conversion disorder with seizures or convulsions, constipation, unspecified abnormalities of gait and mobility, cognitive communication deficit, muscle weakness, gastro-esophageal, hypertension, pain, vitamin deficiency, long term care use of aspirin, depression. R13's POS documents an order for quetiapine 25 milligrams (mg), amount 1 tablet oral. Diagnosis of Dementia in other diseases classified elsewhere mild, with anxiety at bedtime, 8:00 PM. R13's Care Plan does not address quetiapine or the use of psychotropic medication. R13's Minimum Data Set, dated dated dated [DATE] documents R13 has memory problems, moderately impaired for decision making. Mood: Little interest in doing things; No behaviors, and document R13 was receiving antipsychotic, antidepressants, and hypnotic medications. On 10/5/2023 at 2:32 PM, Behavior Tracking was requested for R13. On 10/5/2023 at 3:31 PM, V1, Administrator stated, We do not have any behavior tracking for (R13). (R13) came into the facility with the quetiapine and remember some issues with the family wanting her on the medication. There is no behavior tracking for (R13). R13's Progress Notes dated 6/7/2023 at 10:40 AM, documents Resident currently having Tardive Dyskinesia. Resident is sitting in wheelchair and states not feeling well. Involuntary twitching movement noted in intervals. R13's Admission Note dated 4/17/2023 at 4:16 PM, document, admitted to the facility via private car accompanied by daughter from Home. She is alert and oriented. She is here for long term placement in memory care for worsening Dementia. The Pharmacy Note To Attending Physician/ Prescriber, Pharmacist Recommended does reduction to Quetiapine 25 milligrams (mg): take 1/2 tablet (12.5) at bedtime. The Physician (V21) disagreed and marked an x in the box, Behavior interventions continue to be attempted, except in emergency situations, and are included in the plan of care. However, dose reductions at this time would likely impair resident's function or increase distressed behavior while continuing to pose a danger to the resident or others as supported by the following CLINICAL RATIONALE AND EVIDENCE OF THE FOLLOWING SYMPTOMS: Nothing was documented in this area. The Facility Psychopharmacological Drug Usage Procedure with a revision date of 09/08 documents, A Psychopharmacological Drug is any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. This includes the following types of drugs: antipsychotic, antidepressants, anti-anxiety meds, and sedatives/hypnotics. Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis, as well as medication response and adverse consequences. Unsuccessful reductions of medication must be substantiated by documentation, including rationale from the physician as to why the medication cannot be reduced further.

Based on observation, interview and record review the facility failed to monitor food intake, assess insidious weight loss and effectiveness of interventions, and implement progressive interventions based upon this assessment to prevent continued weight loss for 1 of 5 residents (R75) reviewed for nutrition and weight loss in the sample of 42. This failure resulted in R75's severe weight loss of 28.41% in 3 months. Findings include: R75's Undated Face Sheet, documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R75's Care Plan, dated 8/31/2021, documents R75's current body weight was 109 pounds. R75's Care Plan documents R75's acceptable body weight is 114-146 pounds. The Goal documents Resident will achieve desired weight of 114-146 pounds. R75's Approaches documented the following approaches with the following start dates: Pureed diet start 9/22/21; Encourage oral intake of food and fluids start 8/13/21; Monitor/record weight weekly, notify physician and family of significant weight change start 8/13/21; and provide supplement of high protein supplement with fortified pudding at all times start 8/13/21. R75's Nurse's Note, dated 5/15/2022 at 6:42 PM documents resident arrived via ambulance at 5:37 PM. Resident was transferred 3 assist from stretcher to bed by EMS (emergency medical services) and staff. NG (nasogastric) feeding tube, 8 FT in place with [MEDICATION(S)] 1.5 Cal 45 ml (milliliters)/hr (hour) continuous. No s/s (signs and symptoms) of pain or discomfort noted during assessment. R75's Nurse's Note, dated 5/16/2022 at 2:15 PM documents Hospice nurse removed NG tube per family and order from MD (physician). Resident tolerated removal well. R75's Practitioner Order for Life-Sustaining (POLST) form dated 5/16/2022, had no documentation in the section regarding medically administered nutrition section. This section was not completed. R75's Significant Change Minimum Data Set (MDS), dated [DATE] documents R75 is severely cognitively impaired, no swallow disorder, height 66 inches weight 97 pounds. R75's MDS documents R75 requires extensive assistance with one-person physical assist for eating. R75's MDS documents R75 had no weight loss and was on a mechanically altered diet. R75's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R75's POS dated 5/25/2022, documents [MEDICATION(S)] ([MEDICATION(S)] appetite stimulate) 125 mg (milligrams)/5 ml every day. R75's Progress Note, dated 6/8/2022 at 11:02 AM documents, resident alert and very talkative during breakfast. With help of staff resident consumed around 30% of breakfast and drank approximately 1 cup of water and half apple juice. Within 5 minutes of resident telling aide 'no more,' resident had small emesis (vomit) that resulted in what she had eaten and drank. R75's POS, dated 6/8/2022 documents high protein supplement with meals. R75's Progress Note, dated 6/12/2022 at 6:30 PM, documents, Resident refused meds and a drink of water this shift. CNA (Certified Nurse Aide) tried to feed resident at dinner, and she also refused to eat and drink. R75's Progress Note, dated 6/14/2022 at 3:18 PM documents, Resident ate about 5% of breakfast and drank 1 cup apple juice and refused all drinks and food for lunch. R75's Monthly Weight dated, 6/15/2022, documents R75 weighed 111.6 pounds. R75's Progress Note, dated 6/17/2022 at 1:02 PM, documents, Resident ate 1 pudding for breakfast with 2 cups ice water and refused all food for lunch but drank 1 cup water. R75's Progress Note, dated 6/20/2022 at 6:03 PM, documents, Poor appetite for supper, refused to let staff feed her. R75's Progress Note, dated 6/21/2022 at 6:45 PM, documents, Resident has refused all meals from help or staff. R75's Monthly Weight dated, 7/1/2022, documents R75 weighed 108 pounds. R75's Monthly Weight dated, 8/2/2022, documents R75 weighed 92 pounds. R75's Progress Note, dated 8/7/2022 at 8:52 AM, documents, Resident ate about 50% of breakfast and drank 25% of liquids this morning. Staff encouraged resident to drink more of her liquids, resident continued to put blanket on top of her head and refused to drink anymore. Writer of this note will continue to encourage fluids during all mealtimes. R75's Dietitian Assessment, dated 8/9/2022 at 5:09 PM documents, on a Pureed diet as tolerates with High Protein Supplement. Fortified Pudding at meals. Intakes poor. Refuses assistance at meals and refuses food and fluids. On [MEDICATION(S)] which can stimulate appetite. Weights: (8/2): 92, (7/1): 108, (5/4): 97, and (2/1): 111. Current weight is down 16# (14.8%) x/1 month and down 19# (17.1%) x/6 months. Below IBW Range 114-146. Body Mass Index: 14.85 (Underweight). History of [CONDITION(S)], on (2) diuretics (diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Fluids encouraged and dietary offers 15+ servings/day. Skin free of open areas. No new labs to review. On Iron Supplement. Estimated Needs: 1260 calories (30 kilo-calories per kg), 1260 cc (cubic centimeters) fluids (1 cc per kilo-calories), and 42-50 gram protein (1.0-1.2 injury factor). History of weights up and down. Monitor. R75's Progress Note, dated 8/9/2022 at 4:55 PM, documents, this nurse left voicemail to resident's family to return call to facility in regards to unplanned weight loss. R75's POS dated, 8/10/2022 documents weekly weight related to unplanned weight loss. R75's Care Plan, dated 8/10/2022 documents resident has unplanned weight loss. Goal resident will have no weight changes +/- 2 pounds during this quarter. Approaches monitor weight, serve diet as ordered R75's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R75's Dietitian/Quarterly Assessment, dated 8/16/2022 at 1:45 PM documents, on a Pureed diet with High Protein Supplement. Comfort feedings if alert. Fortified Pudding at meals. Intakes poor. Refuses assistance at meals and refuses food and fluids at times. On [MEDICATION(S)] which can stimulate appetite. Weights: (8/2): 92, (7/1): 108, (5/4): 97, and (2/1): 111. Current weight is down 16# (14.8%) x/1 month and down 19# (17.1%) x/6 months. Below IBW Range 114-146. Body Mass Index: 14.85 (Underweight). History of [CONDITION(S)], on (2) diuretics (diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Fluids encouraged and dietary offers 15+ servings/day. Skin free of open areas. Labs (4/27/22): Glucose 60(L), Sodium 134(L), Potassium 5.0, Blood Urea Nitrogen 57(H), Creatinine 1.9(H), Total Protein 6.5, [MEDICATION(S)] 3.2(L), Hemoglobin 9.5(L), and Hematocrit 28.2(L). On Iron Supplement. Estimated Needs: 1260 calories (30 kilo-calories per kg), 1260 cc fluids (1 cc per kilo-calories), and 42-50 gram protein (1.0-1.2 injury factor). History of weights up and down. Monitor. R75's MDS, dated [DATE] documents R75 is severely cognitively impaired, no swallow disorder, height 66 inches weight 92 pounds. R75's MDS documents R75 is totally dependent with one person physical assist for eating has had no weight loss and is receiving mechanically altered diet and feeding tube (nasogastric or abdominal). R75's MAR, dated 8/17/2022 documents she weighed 94 pounds. R75's Progress Note dated, 8/22/2022, documents, resident continues with poor appetite. Resident did however take around 4 bites of breakfast but then told aide that she was full and done eating. Half cup water drank. R75's MAR, dated 8/24/2022 documents she weighed 94 pounds. R75's Progress Note dated, 9/1/2022 at 6:56 PM, documents, Poor appetite continues. Resident stated she wanted some candy or cookies, but when given some soft candy resident refused saying 'I'm not hungry'. R75's Progress Note dated, 9/6/2022 at 1:04 PM, documents, resident ate approximately 5-6 bites of breakfast and 5-6 bites of lunch, 1 cup of apple juice for breakfast with half cup of water, and for lunch 1 cup apple juice. R75's Dietitian Assessment, dated 9/7/2022 at 5:20 PM documents, on a Pureed diet with High Protein Supplement. Comfort feedings as alert. Fortified Pudding at meals. Intakes poor. Refuses assistance at meals and refuses food and fluids at times. On [MEDICATION(S)] which can stimulate appetite. Weights: (9/6): 86, (8/2): 92, (6/15): 111.6, and (3/1): 108. Current weight is down 6# (6.5%) x/1 month, down 25# (22.9%) x/3 months, and down 22# (20.4%) x/6 months. Below IBW Range 114-146. Body Mass Index: 13.88 (Underweight). History of [CONDITION(S)], on (2) diuretics (diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Fluids encouraged and dietary offers 15+ servings/day. Skin free of open areas. No new labs to review. On Iron Supplement. Estimated Needs: 1170 calories (30 kilo-calories per kg), 1170 cc fluids (1 cc per kilo-calories), and 39-47 gram protein (1.0-1.2 injury factor). Continue with diet Rx and encourage intakes. Monitor. R75's MAR, dated 9/7/2022, documents R75 weighed 87 pounds. R75's Progress Note dated, 9/8/2022 at 8:55 PM, documents, resident refused all meals this day stating 'I'm not hungry.' Resident would hold head down and staff could only get resident to take few sips of a drink. R75's MAR, dated 9/14/2022, documents R75 weighed 86 pounds. R75's Progress Note dated, 9/20/2022 at 8:12 PM, documents, resident continues with poor appetite for all meals this day. Approximately 5% total eaten this day with resident also denying most fluids. Family (who is aware of resident's decline and not eating) has called up to check on resident and was told no change in eating habits. On 9/20/2022 at 12:15 PM, staff were feeding R75 pureed food with fortified pudding and fortified milk. R75 sat in a geri chair with her head was half way under the blanket. Staff encouraged her to eat and drink. R75 ate less than 5% of the meal. On 9/21/2022 at 8:50 AM staff pureed food with fortified pudding and fortified milk. R75 sat in a geri chair, her head was under the blanket. Staff encouraged her to eat and drink. R75 ate less than 5% of the meal. On 9/21/2022 at 12:30 PM, staff were feeding R75 pureed food with fortified pudding and fortified milk. R75 sat in a geri chair, her head was laying against the chair and half under the blanket. Staff encouraged her to eat and drink. R75 ate less than 5% of the meal. R75's Progress Note dated, 9/21/2022 at 1:01 PM, documents, Appetite continues to be poor with aide of staff. Resident took around 5-6 bites for breakfast and same for lunch. Fluids encouraged with taking very little sips. Resident continued to hang down and again encouraged to lift head to eat and drink Resident would lift head a little but kept wanting head covered stating she was cold. On 9/21/2022 at 1:35 PM V24, Certified Nurse's Aide (CNA) and V11, CNA transferred R75 to bed using a full body lift to weigh R75. R75's weigh was 79.9 pounds. V24 and V11 stated they are familiar with R75, she doesn't ever eat well but lately R75 is eating less and less they feed her at all meals as much as she will eat. V24 and V11 both stated they don't offer R75 snacks in between meals because no one told them to do that. R75's Electronic Medical Record dated 6/15/2022 documents she weighed 111.6 pounds and 9/22/2022 documents she weighed 79.9 pounds which resulted in R75 had a 28.41% weight loss in 3 months. R75's EMR during this time period has no documentation R75's physician was notified of the significant weight loss and no additional interventions/recommendations were added from the licensed dietitian and R75's care plan was not updated during this time. On 9/21/2022 at 2:00 PM, V6, Licensed Practical Nurse (LPN), stated R75 was on weekly weights in the past and then her weight was stable so they discontinued her weekly weights and reordered weekly weights in August 2022. V6 stated she documents the weekly weights in the computer. V6 stated R75 was on hospice for one day in May 2022 but the family didn't want her on hospice so it was discontinued. R75's Progress Note dated, 9/21/2022 at 6:04 PM, documents, Notified family of weight loss and continued poor appetite. Discussed options and conditions. Family would like to see if resident is a candidate for G (gastrostomy) -Tube placement. MD (physician) notified of weight loss and continued poor appetite, gave OK for GI (gastrointestinal) consult. R75's Progress Note dated, 9/21/2022 at 8:51 PM, documents, resident ate 50% of meal during dinner. Resident consumed all her mashed potatoes and chocolate pudding. On 9/21/2022 at 3:20 PM, V2, Director of Nursing (DON), stated R75 is on dietary supplements ordered by the physician of fortified foods and staff feed her as much as she will eat. V2 stated every day is different with R75, some days she eats more than others. V2 stated she expects staff to document in the nurse's notes when R75 doesn't eat well. V2 stated she didn't know if staff document meal intake for R75. V2 stated the Dietary Manager does a weight report that documents 5% or more weight loss in a month and she reviews it. V2 stated the Registered Dietitian (RD) comes in weekly to review residents that have weight loss. V2 stated R75's physician recommended hospice but (R75's) family doesn't want her to be on hospice. V2 stated R75's physician would be responsible to discuss a G-Tube with R75's family and she wasn't sure if it was discussed or not. V2 stated R75 had an NG tube when she was readmitted from the hospital in May 2022, but they had to discontinue it because the facility doesn't allow NG tubes at the facility. On 9/22/2022 at 9:00 AM, V2, DON stated staff are not documenting how much R75 eats per meal. V2 stated if she doesn't eat well for a meal V2 expected staff to document that in the nurse's notes. V2 stated she doesn't know if staff are offering R75 comfort food/snack between meals, but they should and if R75 eats the snack staff should document how much of the snack she ate in the nurse's notes. R75 was on weekly weights in the past but she gained weight and the weekly weights were discontinued and were reordered in 8/2022. V2 stated R75 was on hospice for a few days but her family didn't want her on hospice, so it was discontinued. V2 stated she expected staff to follow the facility weight monitoring policy. On 9/22/2022 at 1:00 PM, V2 stated she called R75's POA to update her on R75's weight loss and asked if she wanted R75 to have a G-Tube if her physician would clear her for surgery and the POA stated she would agree to a G-Tube. On 9/22/2022 at 1:55 PM, V40, R75's Power of Attorney (POA) stated she wanted R75 to have a G-Tube for a long time. V40 stated R75 was hospitalized in May 2022, and she was readmitted to the facility a few days later with a naso-gastric tube. V40 stated R75's NG tube was removed at the facility the next day she was readmitted staff took her NG tube out because she couldn't stay at the facility with it. V40 stated she asked multiple staff about R75 getting a G-Tube, but it fell on deaf ears, no one wants to do their job. V40 stated the DON called her in the evening on 9/21/2022 and told her R75 was losing more weight and asked her if she would be ok with R75 getting a G-Tube and she said yes. On 9/23/2022 at 9:00 AM, V34, Licensed Dietitian, stated R75 she comes to the facility every two weeks. V34 stated R75 is on [MEDICATION(S)] to increase her appetite and on high protein supplement of fortified milk and pudding. V34 stated the facility doesn't document how much the residents eat so it's hard to tell how many calories she's getting. V34 stated she talks to staff when she is at the facility to see how much residents are eating. V34 stated R75 has a history of not eating well. V34 stated her weight was stable a few months ago and now she's losing weight again. V34 stated she hasn't recommended a G-Tube for R75 and she didn't have a reason why she hasn't recommended it. V34 stated she expected staff to feed R75 between meals and a bedtime snack to ensure she is getting as many calories as possible. V34 was not aware R75's current weight is down to 79.9 pounds. The facility's Weight Monitoring Policy, revised 6/2021 documents, Objective to consistently assess residents for significant weight loss or gain. Procedure record weight in the proper place in the resident's clinical record, weekly and monthly weights are recorded by dietary in Electronic Medical Record (EMR.) Licensed staff will notify the physician of the following: 5% loss in a 30-day period, 7.5% loss in a 90-day period, 10% loss in a 180-day period. Notification to the physician must be documented, and also whether or not new orders were received. Families/POA must be notified of significant weight loss. The weight committee will review all residents with significant weight losses and other residents of concern and refer to the RD (registered dietitian) as needed. The RD will review significant weight losses and any other residents referred by the weight committee on a monthly basis and make recommendations to physician as necessary. Residents that are confined to bed may be weighed with a lift scale. Responsible staff include licensed staff, CNAs, food service supervisor and the RD.

Based on observation, interview and record review the facility failed to provide treatment in accordance with professional standards of care for a fall resulting in injury for 1 of 16 residents (R65) reviewed for quality of care in the sample of 42. This failure resulted in R65 falling and sustaining a fractured arm which was not treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: R65's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/23/2022 at 10:58 AM, R65's was residing on the dementia unit. R65 had a soft cast to her right arm. R65's Care Plan dated 8/15/2022 documents (R65) has dementia with behaviors. On 9/23/2022 at 10:59 AM, V38, Registered Nurse stated, (R65) is on the dementia unit and has poor safety awareness. She is easily confused. R65's Progress Notes dated 8/29/2022 at 4:16 PM, documents Resident had witnessed fall, playing game in dayroom with other residents, resident began walking backwards and tripped over her own feet and tried to catch herself and landed on her Right wrist, resident did not hit her head. Right wrist swelling noted. PRN (as needed) Acetaminophen administered, wrapped in ace wrap, Ice pack placed alternating on/off for 20 minutes. MD (Medical Doctor) notified, received orders to wrap/immobilize, and get STAT (right away) x-ray. R65's Progress Note dated 8/29/2022 at 8:00 PM, documents x-ray technician here at this time, x-ray done. R65's X-ray Report dated 8/29/2022 document R65 had an acute fracture of the distal radius and ulna styloid of the wrist. (2 long bone fractures close to the wrist). R65's Progress Note dated 8/30/2022 at 5:41 AM, documents Resident's bruise to Right side of eye is healing well, no swelling or redness to resident Left Knee, resident had a fall on 8/29 resulting in a Right wrist injury, resident denies any pain or discomfort at this time, this writer notices that Right wrist swollen with some redness and dark blue bruising, continuing to wait on results of x-ray related to wrist injuries. R65's Progress Notes dated 8/30/2022 at 11:25 AM, documents [CONDITION(S)] continues to be noted to right wrist. Pain noted to area with movement. Resident currently has an ace wrap in place to area. Current x-ray results pending at this time. Resident also continues to have swelling to Left knee at this time. Resident denies pain to area. MD (Medical Doctor) previously made aware of knee. Resident able to ambulate normally and expresses no pain. Family in at this time to sit with resident. R65's Progress Notes dated 8/30/2022 at 2:29 PM, documents Power of Attorney (POA), Medical Doctor has been made aware of fracture. R65's Progress Notes dated 8/31/2022 at 11:13 AM, documents Assistant Director of Nursing (ADON) in unit at this time and advises Nurse to send resident out to ER (emergency room ) to be further evaluated. Resident wrist continues to have swelling and is painful with movement. Movement to area currently limited and radial pulse very faint. This Nurse contacted ems (Emergency Medical System) at 11:17 AM to send to ER (emergency room ) for evaluation of fracture to area. POA (Power of Attorney) contacted and made aware of concerns. On 9/22/2022 at 8:58 AM, V2, Director of Nursing (DON), stated, If a STAT (Immediately) x-ray was ordered I would expect the turnaround time to be minimum of 3 hours. I would expect staff after three hours to be following up with the lab and finding out where the results are. Typically, the form is faxed back to us at the nurse's station. I would expect the x-ray company to call us to alert us of any critical care including a fracture. I reviewed the notes and saw that there was a delay in reporting the fracture for (R65). I am not sure what exactly happened and why it was not caught earlier. On 9/23/2022 at 10:06 AM, V36, Former Assistant Director of Nursing (ADON), stated, I use to be the ADON but no longer work in the facility. I remember (R65) she was in the dementia unit and had poor safety awareness and was really confused. I remember I came in on a Wednesday morning and (V2, Director of Nursing) told me (R65) had a previous fall a few days later and then she just walked away. (V2) told me they took and x-ray, but she was not sure if there was any injury. I talked with the nurse, and she told me nobody got an x-ray. I went and checked on (R65) her wrist was swollen, and she had a low pulse, so I wanted them to send her (R65) next door to the hospital to get an x-ray. I sent her out and then she had two fractures. When I told (V2) she just told me 'I guess we will just take the tag for that one.' On 9/23/2022 at 11:07 AM, V37, Medical Director stated, I am not sure when I got the x-ray results or when I was notified of (R65) having pain and swelling in her wrist. The facility is usually good about notifying me. I have another patient I cannot talk. The Change of Condition Policy with a revision date of 12/02 documents, The resident is involved in any accident or incident that results in an injury including injuries of unknown source notification will be made within twenty-four hours of a change occurring in residents' condition or status.

Based on interview, observation, and record review, the facility failed to wear personal protective equipment (PPE) appropriately to aid in the prevention and spread of the Coronavirus (COVID-19). This failure has the potential to affect all 104 residents residing in the facility. Findings include: 1. On 9/20/22 at 9:09 AM, V1, Administrator, states they have had a staff member test positive for COVID over the weekend, the facility is now in outbreak status. On 9/20/22 at 9:20 AM, V5, Licensed Practical Nurse (LPN) was observed at the nurses station with no eye protection on. On 9/20/22 at 9:20 AM, V6, LPN, was observed at the nurses station with eye protection on the top of her head, not covering her eyes. On 9/21/22 at 12:10 PM, V9, Dietary Assistant, was observed in the 300 hall dining room/kitchenette serving the lunch meal with no eye protection on. On 9/21/22 at 12:30 PM, V12, Housekeeper/Laundry, was observed outside of room [ROOM NUMBER] with her mask down below her nose and no eye protection on. On 9/21/22 at 12:35 PM, V10, Certified Nurses Assistant (CNA), and V11, CNA, were observed in the 200 hall dining room feeding residents with no eye protection on. The COVID-19 Policy, dated 5/27/20, page 3, documents When community transmission levels are substantial or high, employees must wear a well-fitted face mask and eye protection. On 9/21/22 at 1:22 PM, The Community Transmission Rate COVID Data Tracker for Madison County, where the facility is located, is High. On 9/22/22 at 2:30 PM, V2, Director of Nurses (DON), states she would expect staff to wear their masks and eye protection at all times in the resident areas. The Updated guidance for nursing homes and other licensed long-term care facilities by the State of Illinois/The Illinois Department of Public Health, updated 3/22/22 documents the following: page 8 - When community transmission levels are substantial or high, at a minimum, health care personnel must wear a well-fitted mask at all times and eye protection while present in resident care areas. The Resident Census and Conditions of Residents (CMS Form 672), dated 9/20/22, documents there are 104 residents residing in the facility.

Based on interview and record review, the facility failed to ensure that the information on the Practitioner Order for Life Sustaining Treatment Form (POLST) matched the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. R23's POLST, dated 12/4/22, documents R23 wishes to be a do not resuscitate (DNR). R23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 2. R33's POLST, dated 5/13/22, documents R33 wishes to be a DNR. R33's POS, fails to document a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. R48's POLST, dated 4/22/22, documents R48 wishes to be a full code. R48's POS, dated 7/15/22, documents R48 is a DNR. 4. R155's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R155's POLST form dated the same date, 9/8/22, documents R155 directives is to be a Do Not Resuscitate status. On 9/22/22 at 9:25 AM, V19, Licensed Practical Nurse (LPN) stated if a resident is sent out to the hospital she would send their face sheet, a list of their medications (their Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V19 stated if she entered a room and found a resident unresponsive she would look at the indicator that comes up on the computer screen for that resident that will show if they are a DNR or Full Code, and she would follow that. On 9/22/22 at 9:40 AM, V2, Director of Nursing (DON) stated if a resident is sent to hospital they send that resident's Face Sheet and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she would expect the physician order, POLST form and Face Sheet to all match with the resident's code status the same on all three forms. V2 stated the nurses are responsible to enter the orders into the computer, but the Admissions Coordinator or the Social Service Director are responsible to get the POLST form signed and talk to the residents about their wishes. On 9/22/22 at 10:18 AM, V13, Admissions Coordinator, stated she is responsible to go through the Admissions Packet with residents upon admission, which includes their Advanced Directives. V13 stated she reads through the POLST form with the resident or their representative, and if the resident is alert and oriented , they are able to go ahead and sign it right then, and then she gives it to the nurses and they get a verbal signature from the physician, and then the form is given to medical records and the physician signs the form when they come to the facility. V13 stated she changes the Face Sheet after the resident or family first signs the POLST form if applicable, but she does not do anything with physician orders. The facility's policy, Advanced Directives adopted 2/18 documents, The facility shall support the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive. Procedure: Staff will determine, at the time of admission, whether or not any advanced directives are present, and make an effort to obtain pre-existing directives. Staff shall then ensure that they are placed in the resident's medical record. Pertinent facility staff and the physician shall be made aware of the existence of these directives. Documentation of the resident's Advanced Directives shall be present within the medical record and specified on the individual's Face Sheet. All Advanced Directives shall be uploaded into (electronic medical record) and stored in the resident's clinical record.

Based on interview, observation and record review, the facility failed to implement range of motion (ROM) programs to maintain or prevent a decrease in mobility of the joints for 4 of 4 residents (R23, R34, R48, R50) reviewed for ROM in the sample of 42. Findings include: 1. On 9/20/22 at 09:52 AM, R23 was observed with limited ROM and an inability to fully raise her arms and legs. R23's Face Sheet, undated, documents R23 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R23's Minimum Data Set (MDS), dated [DATE], documents R23 has impairment in ROM one side of the upper and lower extremities. R23's Activities of Daily Living (ADLs) skills analysis/restorative programs, dated 5/20/22, document R23 has impairment in ROM in the left upper extremity with a mild risk of contracture development. R23's Physical Therapy (PT) Discharge Summary, dated 8/8/22, documents PT recommends R23 participates in a restorative therapy program to maintain current functional gains. Restorative range of motion program for generalized strengthening and endurance by participating in restorative therapy program by patient. R23's Occupational Therapy (OT) Discharge Summary, dated 8/8/22, patient is currently able to raise arms above head and raise arms straight out from shoulders. With a restorative nursing program, patient will be able to maintain participation in daily activities by performing the following restorative nursing interventions: active ROM and allow resident to assist as possible, keep hands in position to maintain support of joint. 2. On 9/20/22 at 11:25 AM, R34 was observed with limited ROM to her upper and lower extremities with an inability to fully raise her arms and legs. R34's Face Sheet, undated, documents R34 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R34's ADL Skills Analysis/Restorative Programs, dated 7/6/22, documents R34 has mild impairment in ROM with mild risk for contracture development. 3. On 9/20/22 at 9:59 AM, R48 was observed with limited ROM in both of her upper and lower extremities with an inability to fully raise her arms and legs. R48's Face Sheet, undated, documents R48 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R48's Monthly Summary of Care, dated 8/22/22, document R48 is not receiving restorative services. 4. On 9/21/22 at 10:44 AM, R50 was observed with limited ROM to her upper and lower extremities with an inability to fully raise her arms and legs. R50's Face Sheet, undated, documents R50 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/21/22 at 1:35 PM, V2, Director of Nurses (DON), states R23, R34, R48 and R50 are not on a ROM program. On 9/22/22 at 2:30 PM, V2, DON, states she would expect a resident with limited ROM be on a ROM program. The Range of Motion (Passive and Active) policy, dated 3/2009, documents the purpose of ROM is to prevent contractures, to maintain normal range of motion, to increase joint motion to the maximum possible range, to maintain and build muscle strength, to stimulate circulation, to prevent deformities and to prevent contracture from becoming worse if they are already present.

Based on observation, interview, and record review, the facility failed to implement progressive interventions and provide supervision to prevent falls for 1 of 16 residents (R65), reviewed for falls in the sample of 42. Findings include: R65's Physician Order Sheet for September 2022 document R65 is a [AGE] year old female with a diagnosis of Unspecified dementia with behavioral disturbances, Elevated white blood cell count, unspecified abnormalities of gait and mobility; Other lack of coordination; muscle weakness; cognitive communication deficit. On 9/23/2022 at 10:58 AM, R65's room was on the dementia unit. R65 had a cast on her arm. R65's Care Plan dated 8/15/2022 documents (R65) has dementia with behaviors. R65's Care Plan with a revision date of 8/31/2022 documents, Resident at risk for falling related to recent illness/hospitalization and new environment. On 9/22/2022 at 2:41 PM, V2, Director of Nursing (DON), stated, I would expect all interventions for falls to be on the Care Plans. R65's Progress Notes dated 8/18/2022 at 12:50 PM, document, Certified Nursing Assistant (CNA) witnessed resident fall to floor extremely hard hitting face against ground and causing a CNA witnessed resident fall to floor extremely hard hitting face against ground and causing a very small skin tear to right frontal lobe. Resident assisted self from floor prior to Nurse arrival without help. Resident able to follow all commands, Range of Motion, Within normal Limits and denies any pain. Resident did hit head and has a small skin tear noted. Area was cleansed and dry dressing applied. Resident has been placing furniture in front of bathroom door stating 'I'm keeping the man out.' Hallucinations have been noted since admitted and currently has new medication orders in place. Resident eating at this time and still continues to deny pain. Current vitals 100/59, 71 pulse, 96% on RA, and 98.5 temp. Neurological checks have been put into place. POA (Power of Attorney) and MD (Medical Doctor) NP (Nurse Practitioner) made aware. R67's Care Plan does not have any interventions documented on her plan for this fall. R65's Progress Notes dated 8/18/2022 at 9:01 PM, Bruise forming where resident had unwitnessed fall. Measuring 5 centimeters (cm) x 3 cm. Light purple/red in color. R65's Evaluation Note Report for 8/1/2022 to 9/23/2022 does not document any intervention for her fall on 8/18/2022 in her Care Plan. R65's Progress Notes dated 8/19/2022 at 12:49 PM, document, Root Cause analysis related to fall on 8/18: CNA was walking with resident, resident stumbled due to shoes not fitting properly and resident fell . Intervention: Residents family contacted to bring resident some shoes that fit properly. This intervention was not documented in R65's Care Plan and there were no notes to document if the family had brought in any shoes. R65's Progress Notes dated 8/29/2022 at 4:16 PM, Resident had witnessed fall, playing game in dayroom with other residents, resident began walking backwards and tripped over her own feet and tried to catch herself and landed on her Right wrist, resident did not hit her head. Right wrist swelling noted. PRN (As needed) Acetaminophen administered, wrapped in ace wrap, Ice pack placed alternating on/off for 20 minutes. MD notified, received orders to wrap/immobilize, and get STAT (right away) x-ray. R65's Progress Note dated 8/29/2022 at 8:00 PM, x-ray technician here at this time, x-ray done. R65's Care Plan does not document any interventions for this fall. R65's Progress Note dated 8/30/2022 at 5:41 AM, Residents bruise to Right side of eye is healing well, no swelling or redness to resident Left Knee, resident had a fall on 8/29 resulting in a Right wrist injury, resident denies any pain or discomfort at this time, this writer notices that Right wrist swollen with some redness and dark blue bruising, continuing to wait on results of x-ray related to wrist injuries. R65's Problem Evaluation Notes Report dated 9/22/2022 Root cause analysis related to fall on 9/21/2022. Resident was ambulating independently from day room to resident room; stumbled and fell . Intervention: Resident encouraged to allow staff to assist with ambulation. (R65 is on the dementia unit). This was not documented on her Care Plan. The Accident/Incident Prevention Policy undated documents, When a resident has been identified as a high risk for accident/incidents, interventions will be put into place per the individual resident assessment and care plan.

Based on interview, and record review, the facility failed to provide safe transfers for 1 of 3 residents (R2) reviewed for injuries in the sample of 10. This failure resulted in R2 sustaining fractures to the left Proximal tibia and fibular to lower leg. Findings include: R2's Minimum Data Set (MDS) dated [DATE] documents that resident has severely impaired cognition. R2's MDS also documents that resident is total dependence of two plus for bed mobility, transfer, toilet use, and bathing. Resident is total dependence of one-person for locomotion on unit, locomotion off unit, dressing, eating, and personal hygiene. Resident requires a wheelchair for mobility. R2's Physician Order dated 07/09/18 documents a diagnosis of Ankylosing [CONDITION(S)] (condition in which new bone is laid down on the vertebrae forming spurs or bridges). R2's Physician Order dated 12/26/21 documents a diagnosis of left tibia stress fracture. R2's Care Plan dated 07/07/20 documents (R2) has chosen receive Hospice care from Heartland Hospice related to Cerebral Artherosclerosis. R2's Care Plan dated 07/10/18 documents Safe Resident Handling Procedures: Transfer Method: full mechanical lift large combi Level of assistance: 2 assist sling style: combi sling size XL. R2's Nursing Note dated 12/22/21 at 11:53 AM documents Nurse brought to my attention that resident had a bruise to inner left foot. After assessing area an investigation was put into place. R2's Nursing Note dated 12/26/21 at 7:00 AM documents, Res. (Resident) moaning and reaching for her L (left) knee when moved or repositioned. LLE (left lower extremity) relaxed not stiff like her norm. MD (physician) notified. R2's Nursing Note dated 12/26/21 at 12:08 PM documents x-ray of LLE ordered. Leg swollen and bruised. R2's Nursing Note dated 12/26/21 at 6:40 PM documents This writer received notification of an injury to residents L Knee a fracture that was identified. Physician, Hospice and POA (Power of Attorney) notified. Investigation initiated and began calling staff that had assisted resident in the previous 3 days. Statements received bruising had been noted to her left foot on 12-22-21. Investigation continues and staff to be interviewed that assisted resident on 12.21.21 and 12.22.21. R2's X-ray report dated 12/26/21 documents Proximal tibia and fibular (lower leg bones) fracture. On 01/04/22 at 9:00 AM, V1, Administrator, stated he did an investigation of R2. I came in on every shift and interviewed staff. Nobody knows how she (R2) broke her leg. I have a feeling it was when they were transferring her with the mechanical lift. I did in-service on using the mechanical lift, and safe tranfser of residents. On 01/05/22 at 3:51 PM, V28, Licensed Practical Nurse (LPN), stated, That morning whenever the CNA (Certified Nursing Assistant) was getting her cleaned up. She was complaining her knee hurt. I thought that maybe it was because she hadn't gotten her scheduled tylenol yet. Later on whenever we got R2 up in the chair I noticed that her leg looked swollen. We pulled up her pants leg and she had a knot on the inside of her shin. Her leg was swollen from the knee down and was discolored. It didn't look bruised just discolored. I messaged the doctor and ordered an xray. I don't know what happened on the previous shift. On 01/05/22 at 4:30 PM, V10, LPN, stated, I was just helping the nurse that evening because she was agency. She didn't know what to do, so I helped send the X-ray to the doctor and put in the order. Her leg looked pretty bad. On 01/06/22 at 7:50 AM, V1, Administrator, stated, (R2) did not go to the hospital. (Mobile X-ray Company) came here to X-ray her. She's hospice so they didn't do anything besides give her pain medication. She has had a lot broken bones because of [CONDITION(S)]. On 01/06/22 at 8:26 AM, V29, LPN, stated, I did not work with her that morning of the 26th but I did work with her before. I never noticed anything out of the ordinary with her, and her leg. She never showed any signs of distress. On 01/06/22 at 8:32 AM, V30, LPN, stated, I didn't notice anything other than the bruise on her left foot. I did range of motion on her left leg. No distress. No grimacing. I worked a 12 hour shift Christmas Eve and there was nothing going on with her leg. Facility policy Emergencies revised 04/03/18 documents It is the policy of the facility to provide emergency care to a resident in need of it.

Based on observation, interview, and record review the facility failed to implement their Abuse policy by not reporting alleged sexual abuse allegations to the Administrator, not investigating alleged sexual abuse, not reporting alleged sexual abuse to the police and the survey agency, and not removing alleged perpetrators with dementia (R1 and R5) from direct contact with each other after several allegations of sexual abuse were observed for two of three residents (R1, R5) reviewed for abuse allegations in the sample of seven. These failures resulted in R1 and R5 having continued access to each other in the facility, resulting in R1 and R5 sexually assaulting each other on three different occasions. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 11-21-20, the facility remains out of compliance at a severity level two. The facility continues to educate all staff on the Abuse Prohibition Policy and the Dementia and Behavior Management policies, and the facility implements these policies. Findings include: The facility's Abuse Prohibition and Reporting policy dated 11-28-19 documents, Purpose: To protect residents from any kind of abuse such as verbal, sexual, mental, and physical. Facility employee or agent who become aware of alleged abuse or neglect of a resident should immediately report the matter to the facility Administrator or designee. If the matter involves alleged abuse or results in bodily injury, the Administrator shall provide the Illinois Department of Public Health with an initial notice of the alleged abuse as soon as possible, but more than two hours after the matter becomes known. The Administrator shall notify the resident's representative of the alleged abuse. The administration shall immediately contact local law enforcement authorities in the following situation: Sexual abuse of a resident by a staff member, another resident, or a visitor. If the incident involves alleged abuse and substantiated evidence indicates another resident of the facility is the perpetrator of the abuse, then the Administrator shall take all steps necessary to protect all residents in the facility from abuse until the alleged perpetrator can be evaluated. If another resident is the suspected perpetrator of the abuse, then the suspected resident shall be supervised 1:1 (one on one) or kept physically separate from all other residents until further orders. R1's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set assessment dated [DATE] documents R1 is severely cognitively impaired. R5's current POS's document R5 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Minimum Data Set assessment dated [DATE] documents R5 is moderately cognitively impaired and R5 walks independently inside and outside of her room. On 11-13-20 at 11:40 AM R5 stated, I love that man. We are friends and he can play with my breasts. During this time R1 and R5 were lying in bed in their rooms. R1 and R5's rooms were next door to each other, and both R1 and R5 reside on the specialized Dementia care unit. On 11-13-20 at 11:11 AM V11 (Dementia Unit Coordinator) stated, On October 13, 2020 (R1) made sexual comments to (R5). (R1) was telling (R5) that he was going to rape (R5). I did not report this incident to (V1/Administrator). On 11-13-20 at 11:22 AM V12 (CNA/Certified Nursing Assistant) stated, (R1) has grabbed (R5's) breasts twice. Last month (R1) was working with therapy and took off running away from the therapist. (R1) then went up to (R5) and squeezed (R5's) left breast. We (staff) wrote statements about this incident and gave them to (V23/Licensed Practical Nurse). On 11-14-20 at 7:10 PM V19 (CNA) stated, A couple weeks ago (R1) and (R5) were in the dining room and (R5) was making moaning noises. (R5) was standing next to (R1), and (R1) was sitting in the chair. (R5) was rubbing (R1's) genitals on the outside of his pants and (R5) was moaning. I am not aware of any interventions we are to use to keep (R1) and (R5) separated. I did not report this incident to (V1). I am not sure if (V22) reported the incident to (V1). On 11-14-20 at 7:30 PM V20 (CNA) stated, (R5) always tries to go in (R1's) room. A couple weeks ago (R1) and (R5) was in the dining room and (R1) was telling (R5) to go in his room so they could try to make a baby. On 11-14-20 at 7:35 PM V21 (CNA) stated, Around two or three weeks ago (R5) and (R1) were in the dining room. (R5) was rubbing the outside of (R1's) pants in the genital area. (R1) was telling (R5) to rub faster. (V22/Registered Nurse/RN) was the nurse that witnessed this. I thought (V22) would notify (V1). I did not report this to (V1/Administrator). On 11-13-20 at 1:00 PM V1 (Administrator) stated, It was not reported to me that (R1) told (R5) that he was going to rape (R1). I have not done an investigation. I was never informed that (R1) had grabbed (R5's) breast. If I would have known I would have investigated this as potential abuse. On 11-15-20 at 8:40 AM V11 stated, We (facility staff) have never met to discuss (R1) and (R5's) sexual encounters or developed care plan interventions to keep (R1) and (R5) safe from each other's sexual advances. We (facility staff) cannot do anything about (R1) and (R5's) sexual advances towards each other if we are not made aware of them. We have not done anything differently or developed any new interventions to keep (R1) and (R5) from making sexual advances since you (this surveyor) informed us of the allegations on Friday (11-13-20). On 11-15-20 at 9:00 AM V1 stated that he was not made aware of R5 rubbing R1's genitals on the outside of R1's pants, so an investigation has not been done. On 11-15-20 at 2:35 PM, V22 (RN) stated, I cannot recall the night that (R5) was rubbing (R1's) genitals above his pants. (V1) asked me about (R5) rubbing (R1's) penis above his pants last night and I told him I could not recall. On 11-15-20 at 10:40 AM V24 (R5's Family Member) stated, (R5) would think that it was very offensive to have her breast grabbed or to be told she was going to be raped. (R5) would have called the police and family immediately. (R5) would be crying and would fear the person that did it, especially if they were living in the same area. (R5) would be devastated to know that sexual advances are being made between her and (R1). (R5) does not have her right mind and is demented. The facility should have kept (R1) and (R5) separated at all times. On 11-15-20 at 10:55 AM V25 (R1's Family Member) stated, No sexual advances would be being made if (R1) was in his right mind. I have been told that (R5) tries to kiss (R1) and tries to go in (R1's) room all of the time. When we (R1's Family) would visit before March 2020, (R5) would come up and try to kiss (R1) in front of us. The facility should keep (R1) and (R5) separated. The facility's Abuse Investigations dated 10-1-20 to 11-12-20 do not include any abuse investigations or notifications to the state agency and police regarding R1 and R5's sexual abuse allegations. R1 and R5's medical records and the interdisciplinary notes do not include any documentation about the three different occasions of sexual abuse between R1 and R5. R1's Behavioral Plan of Care dated 8-27-20 documents R1 has been making inappropriate sexual comments and sexual advances towards others. R1's current Plan of Care documents the following approaches: Before staff starts care on R1, staff will talk to R1 about fishing and how he caught big fish back in the day. Explain to R1 that R1's comments are inappropriate and other people do not like to be talked to in this manner. Re-direct R1 from behaviors with conversation about his wife and daughter. Administer [MEDICATION(S)]. Administer [MEDICATION(S)] at bedtime. Administer [MEDICATION(S)] once daily. R1's Behavioral Care Plan dated 8-27-20 does not include any documentation or interventions to address R1 making inappropriate sexual comments, or sexual advances towards another resident (R5). R5's current Plan of Care dated 11-29-19 documents that R5 has instances of verbal and physical behaviors towards others and makes sexual comments and unwanted sexual advances towards others. This same care plan has had no new behavioral interventions or updates since 9-1-20 and does not address R5's sexual advances towards another resident (R1). The Immediate Jeopardy was identified on 11-18-20 at 9:15 A.M. to have begun on October 13, 2020 when R1 made sexual comments to R5, R1 told R5 that he was going to rape R5, and the facility staff did not report this allegation to V1. On 11-18-20 at 9:15 AM V1 (Administrator) and V8 (Minimum Data Set Coordinator) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 11/13/2020, 11/14/2020, 11/15/2020, and 11/19/2020 all staff present were in-serviced by V1 (Administrator) on the Abuse Prohibition Policy with specific emphasis on reporting any abuse allegations to V1. Staff not present will receive in-service prior to their next scheduled shift. V1 was trained by V34 (Director of Clinical Services) on 11/19/2020. 2. All alleged sexual abuse allegations between R1 and R5 have been investigated and have been reported to IDPH (Illinois Department of Public Health), the families, the physician, and the police as of 11/18/2020. 3. The plans of care for R1 and R5 were revised to address the sexual behavior with interventions put into place on 11/18/2020. 4. On 11/15/2020 R1 was moved to a room on another unit and continued to be provided with one on one by staff. R5 remains in her room on Garden Court (Dementia Unit) and staff are following recommendations by the psychiatrist. R5 was provided a one on one while in the common area and was being separated from R1. 5. On 11/18/2020 all staff have been in-serviced on Dementia and Behavior Management, including sexual behaviors, before working their next shift. Several staff members are out due to COVID-19 (Coronavirus Disease) and will be contacted via telephone to in-service. If they (facility) staff are to ill, they will be in-serviced before they return to work. 6. Facility did revise/or develop a Dementia Program and Behavior Management Policy to ensure it met the needs of the residents. The changes to the policy included specific language to address sexual contact between residents with specific approaches for staff to address this behavior immediately and report it to V1. The Dementia policy was developed on 11/16/2020 and V35 (Social Service Director) has provided the in-services to all staff present on 11/18/2020 and 11/19/2020. All other staff will be trained prior to their next scheduled shift utilizing the power point presentation developed for the dementia training manual. 7. An audit was done on 11/18/2020 by V1 to ensure that no other allegations of abuse, including sexual abuse, have not been reported to V1 to investigate. On 11-21-20 from 9:40 AM to 10:25 AM R1 was in his room alone. No staff were directly supervising R1 during this time. On 11-21-20 at 9:50 AM, V36 (CNA) was working on R1's unit. V36 stated, (V1) has not in-serviced me on the abuse policy, and I have not been in-serviced on behavior policies. I am not aware of (R1) requiring 1:1 direct care supervision. On 11-21-20 at 10:00 AM, V38 (CNA) was working on R1's unit. V38 stated, (R1) does not have 1:1 supervision. On 11-21-20 at 10:05 AM, V37 (Housekeeper) stated, I have not been in-serviced on abuse or behavior policies within the last month. On 11-21-20 at 10:30 AM, V1 (Administrator) stated, Corporate had me remove (R1's) 1:1 supervision of staff even though it was part of the abatement plan. V1 verified that V36 and V38 had not been in-serviced on the abuse and behavior policies. Due to all staff not being in-serviced on abuse and behavior policies and R1 not having direct 1:1 supervision, the facility's abatement plan was not completely executed by 11-20-2020 as documented by the facility. V1 (Administrator) stated per interview conducted on 11/23/2020 that all staff inservicing was completed on the evening of 11/21/2020 after surveyor had left and that R1 was immediately placed on continued direct 1 : 1 staff supervision. Therefore the immediacy was removed on 11/21/2020. Based on observation, interview, and record reviews conducted on 11-23-20 the facility completed all measures on the abatement plan, including providing R1 with direct 1:1 staff supervision and in-servicing all of the staff on abuse and behavior policies. Therefore the abatement plan could be approved on 11-23-20. Completion Date: 11/21/2020

Based on observation, record review, and interview the facility failed to provide staff supervision and behavioral interventions to prevent injury and sexual abuse for three of five residents (R1, R3, and R5) reviewed for accidents and behaviors in the sample of seven. These failures resulted in R1 and R5 sexually assaulting each other on three occasions, and resulted in R1 swinging his arms, hitting R3 in the left eye, causing R3 a black eye, head hematoma, and pain. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 11-21-20, the facility remains out of compliance at a severity level two. The facility continues to educate all staff on the Abuse Prohibition Policy and the Dementia and Behavior Management policies, and the facility implements these policies. Findings include: The facility's Abuse Prohibition and Reporting policy dated 11-28-19 documents, If the incident involves alleged abuse and substantiated evidence indicates another resident of the facility is the perpetrator of the abuse, then the Administrator shall take all steps necessary to protect all residents in the facility from abuse until the alleged perpetrator can be evaluated. If another resident is the suspected perpetrator of the abuse, then the suspected resident shall be supervised 1:1 (one on one) or kept physically separate from all other residents until further orders. 1. R1's current physician's orders [REDACTED]. R1's Minimum Data Set assessment dated [DATE] documents R1 is severely cognitively impaired. R5's current POS's document R5 has [DIAGNOSES REDACTED]. R5's Minimum Data Set assessment dated [DATE] documents R5 is moderately cognitively impaired and R5 walks independently inside and outside of her room. On 11-13-20 at 11:40 AM R5 stated, I love that man. We are friends and he can play with my breasts. During this time R1 and R5 were lying in bed in their rooms. R1 and R5's rooms were next door to each other, and both R1 and R5 reside on the specialized Dementia care unit. R5 did not have staff directly supervising him and did not have any staff sitting outside of his room supervising him. On 11-13-20 at 11:11 AM V11 (Dementia Unit Coordinator) stated, On October 13, 2020 (R1) made sexual comments to (R5). (R1) was telling (R5) that he was going to rape (R5). (R1) was also telling staff that he was going to rape them. We (the facility) sent (R1) to the hospital emergency room . The hospital said they could not do anything for (R1) because he has Dementia and we (the facility) need to deal with (R1's) behaviors. When (R1) returned to the facility we kept him on 1:1 (one on one) staff supervision. To keep (R1) from making sexual advances, staff are supposed to sit outside of (R1's) room and watch (R1) at all times. On 11-13-20 at 11:22 AM V12 (CNA/Certified Nursing Assistant) stated, (R1) has grabbed (R5's) breasts twice. Last month (R1) was working with therapy and took off running away from the therapist. (R1) then went up to (R5) and squeezed (R5's) left breast. (R1) has not been directly supervised today. We (facility staff) have been dealing with other residents and their behaviors. On 11-13-20 at 6:50 PM V17 (Licensed Practical Nurse) stated, We (the facility) only have two CNA's tonight. We do not have enough staff to do a 1:1 with (R1) tonight. On 11-14-20 at 7:10 PM V19 (CNA) stated, A couple weeks ago (R1) and (R5) were in the dining room and (R5) was making moaning noises. (R5) was standing next to (R1), and (R1) was sitting in the chair. (R5) was rubbing (R1's) genitals on the outside of his pants and (R5) was moaning. I am not aware of any interventions we are to use to keep (R1) and (R5) separated. I know (R1) is always supposed to have staff directly supervising him. We (staff) cannot directly supervise (R1) when we only have two certified nursing assistants on the unit at times. We just try to watch for (R1) to leave his room. On 11-14-20 at 7:30 PM V20 (CNA) stated, (R5) always tries to go in (R1's) room. A couple weeks ago (R1) and (R5) were in the dining room and (R1) was telling (R5) to go in his room so they could try to make a baby. On 11-14-20 at 7:35 PM V21 (CNA) stated, Around two or three weeks ago (R5) and (R1) were in the dining room. (R5) was rubbing the outside of (R1's) pants in the genital area. (R1) was telling (R5) to rub faster. (V22/Registered Nurse/RN) was the nurse that witnessed this. We (staff) do not always directly supervise (R1). (R1) will not let us in his room because he gets aggressive. We are usually working with other residents and try to keep an eye out for (R1) leaving his room. On 11-16-20 at 1:00 PM V1 (Administrator) stated, (R1) and (R5) should have been put on 1:1 staff direct supervision after the first allegation of sexual abuse. (R1) is supposed to be supervised at all times from the outside of his room due to (R1's) falls. We put a chair on the outside of (R1's) room for the staff to sit in and watch (R1). On 11-13-20 when you (this surveyor) toured the unit, staff were not directly supervising (R1) because another resident was having behaviors. On 11-15-20 at 8:40 AM V11 stated, We (facility staff) have never met to discuss (R1) and (R5's) sexual encounters or developed care plan interventions to keep (R1) and (R5) safe from each other's sexual advances. We have not done anything differently or developed any new interventions to keep (R1) and (R5) from making sexual advances since you (this surveyor) informed us of the allegations on Friday (11-13-20). On 11-15-20 at 10:40 AM V24 (R5's Family Member) stated, (R5) would think that it was very offensive to have her breast grabbed or to be told she was going to be raped. (R5) would have called the police and family immediately. (R5) would be crying and would fear the person that did it, especially if they were living in the same area. (R5) would be devastated to know that sexual advances are being made between her and (R1). (R5) does not have her right mind and is demented. The facility should have kept (R1) and (R5) separated at all times. On 11-15-20 at 10:55 AM V25 (R1's Family Member) stated, No sexual advances would be being made if (R1) was in his right mind. I have been told that (R5) tries to kiss (R1) and tries to go in (R1's) room all of the time. When we (R1's Family) would visit before March 2020, (R5) would come up and try to kiss (R1) in front of us. The facility should keep (R1) and (R5) separated. R1's current Sexual Behaviors Plan of Care dated 8-27-20 does not include any interventions to supervise R1, or to keep R1 from making inappropriate sexual comments/advances towards R5. R5's Plan of Care dated 11-27-19 documents that R5 has instances of verbal and physical behaviors towards others and makes sexual comments and unwanted sexual advances towards others. This same care plan has had no new behavioral interventions or updates since 9-1-20 and does not address R5's sexual advances towards another resident (R1). 2. R3's Minimum Data Set (MDS) assessment dated [DATE] documents R3 is severely cognitively impaired. R3's current POS (physician's orders [REDACTED]. R3's Progress Notes dated 10-20-20 at 6:15 AM and signed by V22 (Registered Nurse) document, This nurse and day shift nurse (V23/Licensed Practical Nurse) went and looked at (R3's) left eye. Left eye had slight swelling and was black with a lump to the left side of (R3's) head. (R3) stated that it hurts. R3's Progress noted dated 11-20-20 at 11:30 PM and signed by V1 (Administrator) document, I (V1) assisted (R3) to meet with (V27/R3's Family Member) to interview (R3) regarding (R3's) bruise to the left eye. (R3) explained that a man had hit her yesterday. (R3) stated that a man was acting crazy. R3's Final Incident Description dated 10-23-20 and signed by V7 (Director of Nursing) documents, After further investigation it has been found that (R1) did in fact hit (R3) during (R1's) episode of agitation towards staff. (R3) was standing in very close proximity. R1's current Plan of Care dated 8-27-20 does not include any documentation of R1 having physical behaviors, or any interventions to address R1's physical behaviors. On 11-13-20 at 11:11 AM V11 (Dementia Coordinator) stated, On 10-19-20 (R1) came out of his room wanting to be tucked into his bed better. (R1) was swinging his arms around and yelling. (V26/Certified Nursing Assistant/CNA) was trying to talk (R1) down. (R3) was walking with her walker and was bent over. (R3) walked right up to (R1) while he was swinging his arms, and (R1) hit (R3) in the right eye. (R1) did not realize that he hit (R3). (R3) did not have any pain or bruising until later that night. No staff attempted to re-direct (R3) away from (R1) to prevent her from being hit. There was not enough staff there to re-direct (R3) and deal with (R1's) behaviors. (R1) is always getting upset. (R1) will yell and grab at staff when he does not get his way. On 11-16-20 at 8:10 AM V26 (CNA) stated, Around breakfast time on 10-19-20, (R1) came out of his room and was swinging his arms. I was trying to re-direct (R1). (R3) was walking with her walker and walked into (R1's) path while (R1) was swinging his arms. (R1) hit (R3) in the left eye while swinging at staff. (R3) complained of her left eye hurting later that day and her eye was turning color. I am not sure why staff did not try to re-direct (R3) away from the situation. The Immediate Jeopardy was identified on 11-18-20 at 9:15 A.M. to have begun on October 13, 2020 when R1 made sexual comments to R5, R1 told R5 that he was going to rape R5, and the facility staff did not provide supervision of R1 and R5 to prevent the sexual comments. On 11-18-20 at 9:15 AM V1 (Administrator) and V8 (Minimum Data Set Coordinator) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 11/13/2020, 11/14/2020, 11/15/2020 and 11/19/2020 all staff present were in-serviced by the V1 (Administrator) on the Abuse Prohibition Policy with specific emphasis on reporting any abuse allegations V1. All staff not available will be in-serviced prior to them working their next shift. V1 did receive training on the abuse prevention policy and reporting guidelines from V34 (Director of Clinical Services) on 11/19/2020. 2. All alleged sexual abuse allegations between R1 and R5 have been investigated and have been reported to IDPH (Illinois Department of Public Health, the families, the physician, and the police as of 11/18/2020. 3. On 11/15/2020 R1 was moved to a room on a different unit and continued to be provided with one on one care by the staff. R5 remains in her room on Garden Court (Dementia Unit) and following recommendations by the psychiatrist. R5 was provided a one on one while in the common area and was separated from R1. R3 remained on Garden Court, separated from R1 as well. 4. On 11/18/2020 all staff was in-serviced on Dementia and Behavior Management, including sexual behaviors, using the power point slide materials. All staff were in-services before the start of their next shifts. Several staff members were out due to COVID-19 (Coronavirus Disease) and will be contacted via telephone to in-service. If this staff is to ill, they will be in-serviced before they return to work. 5. The facility revised and developed a Dementia program and Behavior Management Policy to ensure it met the needs of the residents. The policy for Dementia program and Behavior Management was developed on 11/18/2020 and it addressed aggressive behavior, behavior emergencies, and did specifically address steps for staff to take to respond to a behavior emergency. V35 (Social Service director) did in-service all staff prior to their next shift and started these training's on 11/18/2020 and 11/19/2020. For those staff out with COVID, they will receive this training before returning to work. 6 An audit was done to ensure all allegations of abuse, including sexual abuse, have been reported to V1 to investigate. On 11-21-20 from 9:40 AM to 10:25 AM R1 was in his room alone. No staff were directly supervising R1 during this time. On 11-21-20 at 9:50 AM, V36 (CNA) was working on R1's unit. V36 stated, (V1) has not in-serviced me on the abuse policy, and I have not been in-serviced on behavior policies. I am not aware of (R1) requiring 1:1 direct care supervision. On 11-21-20 at 10:00 AM, V38 (CNA) was working on R1's unit. V38 stated, (R1) does not have 1:1 supervision. On 11-21-20 at 10:05 AM, V37 (Housekeeper) stated, I have not been in-serviced on abuse or behavior policies within the last month. On 11-21-20 at 10:30 AM, V1 (Administrator) stated, Corporate had me remove (R1's) 1:1 supervision of staff even though it was part of the abatement plan. V1 verified that V36 and V38 had not been in-serviced on the abuse and behavior policies. Due to all staff not being in-serviced on abuse and behavior policies and R1 not having direct 1:1 supervision, the facility's abatement plan was not completely executed by 11-20-2020 as documented by the facility. V1 (Administrator) stated per interview conducted on 11/23/2020 that all staff inservicing was completed on the evening of 11/21/2020 after surveyor had left and that R1 was immediately placed on continued direct 1 : 1 staff supervision. Therefore the immediacy was removed on 11/21/2020. Based on observation, interview, and record reviews conducted on 11-23-20 the facility completed all measures on the abatement plan, including providing R1 with direct 1:1 staff supervision and in-servicing all of the staff on abuse and behavior policies. Therefore the abatement plan could be approved on 11-23-2020. Completion Date: 11/21/2020

Based on interview and record review, the facility failed to ensure a physician ordered medication (blood thinner) was administered for one of three residents (R4) reviewed for medication errors in the sample of seven. This failure resulted in R4 exhibiting chest pain and anxiety resulting in R4 requiring hospitalization and treatment of [REDACTED]. Findings include: The Facility's Pharmaceutical policy dated 10/18/19, states All orders received in the facility either by telephone or direct order shall be immediately transcribed onto Medication Administration Record [REDACTED]. R4's Hospital Discharge records dated 8/3/20, document R4 was ordered Eliquis (blood thinner) 5 milligrams by mouth every 12 hours for a [DIAGNOSES REDACTED]. R4's Physician order [REDACTED]. R4's Nurses Notes dated 8/16/20 at 6:39 p.m., document R4 complained of pain to her chest that she rated at 9 on a pain scale of 1-10. This same Nurses Note documents R4 was pale, visibly anxious, grabbing her chest and that R4 was sent to the local hospital for evaluation. R4's Hospital Records dated 8/16/20, document R4 was admitted to the hospital with [REDACTED]. R4's hospital records indicate she was in the hospital from 8/16/20 to 8/19/20, due to not receiving the Eliquis and required anticoagulant therapy (blood thinner) for the blood clots in both of her lungs. R4's Hospital History and Physical, documented by V33 (R3's Hospital Physician), dated 8/17/20 at 12:13 a.m., states (R4) is supposed to be on Eliquis although it appears she has not been on Eliquis at (the facility). (R4) was evaluated in the (emergency room ) tonight and found to have bilateral [MEDICAL CONDITION] emboli. V33 also documented under the Assessment and Plan to Restart Eliquis as (R4) doesn't appear to be on any blood thinners. On 11/16/20 at 9:51 a.m., V1 (Administrator) stated R4 did not receive her Eliquis as ordered by the physician from 8/3/20 through 8/16/20 and required hospitalization for treatment of [REDACTED]. On 11/18/20 at 9:30 a.m., V1 stated, Yes, I totally agree that we failed (R4) and she did not get her Eliquis and ended up with blood clots.

Based on observation, record review, and interview the facility failed to protect two residents with Dementia from sexual abuse for two of three residents (R1, R5) reviewed for abuse in the sample of seven. This failure resulted in R1 and R5 sexually abusing each other on three different occasions. Findings include: The facility's Abuse Prohibition Policy dated 11-28-19 documents, Purpose: To protect residents from any kind of abuse such as verbal, sexual, mental, physical, involuntary seclusion, neglect, misappropriation of property, exploitation, and any physical/chemical restraint. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual coercion shall include any intentional or knowing touching or fondling of a non-consenting resident's sex organs, anus or breast either directly or through clothing for the purpose of sexual gratification or arousal of the accused. R1's current physician's orders [REDACTED]. R1's Minimum Data Set assessment dated [DATE] documents R1 is severely cognitively impaired. R5's current POS's document R5 has [DIAGNOSES REDACTED]. R5's Minimum Data Set assessment dated [DATE] documents R5 is moderately cognitively impaired and R5 walks independently inside and outside of her room. On 11-13-20 at 11:40 AM R5 stated, I love that man. We are friends and he can play with my breasts. During this time R1 and R5 were lying in bed in their rooms. R1 and R5's rooms were next door to each other, and both R1 and R5 reside on the specialized Dementia care unit. On 11-13-20 at 11:11 AM V11 (Dementia Unit Coordinator) stated, On October 13, 2020 (R1) was telling (R5) that he was going to rape (R5). On 11-13-20 at 11:22 AM V12 (CNA/Certified Nursing Assistant) stated, (R1) has grabbed (R5's) breasts twice. (R1) then went up to (R5) and squeezed (R5's) left breast. On 11-14-20 at 7:10 PM V19 (CNA) stated, A couple weeks ago (R1) and (R5) were in the dining room and (R5) was making moaning noises. (R5) was standing next to (R1), and (R1) was sitting in the chair. (R5) was rubbing (R1's) genitals on the outside of his pants and (R5) was moaning. On 11-14-20 at 7:35 PM V21 (CNA) stated, Around two or three weeks ago (R5) and (R1) were in the dining room. (R5) was rubbing the outside of (R1's) pants in the genital area. (R1) was telling (R5) to rub faster. On 11-15-20 at 8:40 AM V11 stated, We (facility staff) have never met to discuss (R1) and (R5's) sexual encounters or developed care plan interventions to keep (R1) and (R5) safe from each other's sexual advances. On 11-15-20 at 10:40 AM V24 (R5's Family Member) stated, (R5) would think that it was very offensive to have her breast grabbed or to be told she was going to be raped. (R5) would have called the police and family immediately. (R5) would be crying and would fear the person that did it, especially if they were living in the same area. (R5) would be devastated to know that sexual advances are being made between her and (R1). On 11-15-20 at 10:55 AM V25 (R1's Family Member) stated, No sexual advances would be being made if (R1) was in his right mind. R1's Behavioral Care Plan dated 8-27-20 does not include any documentation or interventions to address R1 making inappropriate sexual comments, or sexual advances towards another resident (R5). R5's current Plan of Care dated 11-29-19 does not include any documentation or interventions to address R5 making sexual advances towards another resident R1.

Based on observation, record review and interview, the facility failed to provide supervision, identify and implement resident specific fall interventions, and provide safe transfers for fall prevention for 2 of 3 residents (R2, R3) reviewed for falls in the sample of 6. This failure resulted in R2's fall sustaining subarachnoid hemorrhage (brain bleed), left orbital (around eye) fracture, and zygomatic (cheek bone) fracture requiring hospitalization . Findings include: 1. The Facility fall log, dated 1/18/20-8/18/20, documents that R2 has had 7 falls since 3/30/20. R2's Quarterly Fall Risk Assessment, dated 5/18/20, documents R2 as high risk for falls with a score of 25 (a score of greater than 16 equals high risk for falls). R2's Minimum Data Set (MDS), dated [DATE], documents R2 has severely impaired cognition, requires supervision and set up only for walking in room and toileting, and requires supervision and one person physical assist for transfers. R2's Annual Fall Risk Assessment, dated 8/17/20, documents R2 as high risk for falls with a score of 22. R2's care plan, dated 8/16/19, documents that R2 is at a risk for falls related to recent illness/ hospitalization and new environment, [DIAGNOSES REDACTED]with impaired safety awareness, unspecific visual loss, [MEDICAL CONDITION] and subarachnoid hemorrhage. Under Resident Care Information, approaches with start date 2/3/20 include: alternate call light, mobility: ambulates without devices, Safe Resident Handling Procedure- Transfer Method: Stand pivot transfer with gait belt with one assist. Under Risk for Falls, approaches include encourage resident to call for assist before getting out of bed or transferring and encourage resident to stand slowly (dated 8/16/19), encourage resident to use side rails/enablers as needed (dated 8/16/19). Fall Investigation Report documents R2's fall 5/1/20 at 1:15 PM in the hallway. Reason- right leg gave out, complaint of pain back of head. Report documents no injury. Approach of distant supervision, dated 5/1/20, was added to R2's Care Plan for risk for falls. There was no direction on the specifics of distant supervision. Fall Investigation Report documents that R2 fell on [DATE] at 12:34 PM walking to his bed. Report documents that R2 stated felt shaky. Stated bumped left side of face and left side on table. Physician review on 6/1/20 documents Plan: Fall meds reviewed, nothing is new causing resident to fall. Resident has history of [MEDICAL CONDITIONS](stroke), maybe TIA (mini [MEDICAL CONDITION]) and weakness caused from last [MEDICAL CONDITION]. IDDM (insulin dependent diabetes mellitus) - recommend increasing 70/30 has helped some, will follow blood sugars and consider adding [MEDICATION NAME]. Possible [MEDICAL CONDITION] ([MEDICATION NAME] BID ([MEDICAL CONDITION] medication twice daily)) Decrease [MEDICATION NAME] 25 mg (milligrams) BID. R2's Care Plan for risk for falls had no additional approaches added for the 6/1/20 fall. Fall Investigation Report documents on 6/26/20 at 6:42 PM R2 walking to the bathroom, stated reason for fall as being dizzy. Root cause: R2 states he got dizzy and fell . Report documents that R2 has hypertension so orthostatic BP (blood pressure) for 72 hours every shift related to fall. R2's Care Plan for risk for falls had no additional approaches added for the 6/26/20 fall. Fall Investigation Report documents unwitnessed fall on 7/25/20 at 11:22 PM, R2 fell coming from the bathroom. R2 stated had a dream and maybe got up too quick. Root cause analysis documents returning from restroom without assistance, states had a dream made him get up quick. Receiving therapy services at this time. Teaching per nurse on importance of use of call light for assistance related to unwitnessed fall. R2's Care Plan for risk for falls had no additional approaches added for the 7/25/20 fall. Fall Investigation Report, dated 8/6/20, documents that R2 fell in the bathroom at 12:58 PM. The report documents the reason as blacked out. The form documents an abrasion and R2 complaining of a headache. Root cause analysis dated 8/7/20 at 10:00 AM documents walking to the bathroom and blacked out per R2. Documents that R2 has [MEDICAL CONDITION], unspecified visual loss and [MEDICAL CONDITION], poor safety awareness, advise R2 to ask for help with ambulation, and closely monitor related to fall on 8/6/20. Was later sent out for evaluation due to neurological deficits and transferred to another hospital with a subarachnoid hemorrhage, fractured left eye orbit and fractured zygomatic process, and admitted to the hospital. R2's CT (computed axial tomography) Scan without contrast, dated 8/8/20 documents a small acute subarachnoid hemorrhage, Left orbital inferior and lateral wall fracture, Left zygomatic arch fracture and Left maxillary sinus fracture R2's notes document that R2 returned from hospital on [DATE], reviewed fall care plan, low bed, mats at bedside when in bed, alternate call light program initiated. Medical doctor (MD) added Kepra to med regimen per MD to assist with [MEDICAL CONDITION] disorder at hospital. Approaches of low bed and alternate call light were added to R2's Care Plan for risk for falls on 8/13/20. The alternate call light had already been an approach since 2/3/20 under R2's Resident Care Information Care Plan. Fall Investigation Report documents that R2 had an unwitnessed fall in his bathroom on 8/15/20 at 2:21 PM. The reason identified was attempting to self ambulate to bathroom. Root cause analysis documents got weak and fell . Intervention identified to re-educate per nurse related to use of call light. Will request u/a (urinalysis) from MD due to urinary frequency, staff inservice/education to give R2 verbal reminders not to ambulate without assistance. Evaluation Notes, dated 8/17/20, on R2's fall risk Care Plan documents, Inservice/education to give R2 verbal reminders not to ambulate/transfer without assistance R/T (related to) unwitnessed fall attempting to ambulate self to bathroom without assistance on 8/15/2020. No additional approaches were added to R2's fall risk care plan. On 8/13/20 at 10:15 AM, V3, Certified Nursing Assistant (CNA) stated that she had taken care of R2 prior to hospital admission, V3 stated that R2 used be independent before he fell . V3 stated stated that before his fall when went to hospital he would ambulate to the bathroom, and walk independently. V3 stated that R2 is now in a wheelchair. On 8/13/20 at 9:08 AM, V7 and V8, CNAs, transferred R2 from the wheelchair to bed. V7 place a gait belt around R2 under his armpits, across top of R2's chest with the buckle on the right side of R2's chest. When assisting R2 to stand, V7 grasped the gait belt by the buckle. On 8/20/20 at 2:43 PM, V14, Physician, stated that reminding a resident with memory impairment to use their call light or ask for help prior to getting up is not going to work. V14 stated he would expect the facility to follow their accident/ incident policy in regards to location of resident rooms for high fall risk. 2. On 8/18/20 at 9:20 AM, R3 was up in a reclining geriatric chair in reclined position with feet elevated. R3's call light was not within reach and was hanging on the bed. No floor mats were present beside R3's chair. R3 had yellow fading bruising to her right frontal skull extending down temporal side of her face. R3 stated when she falls it is because she wants to get up. R3's Nurses notes, dated 8/12/2020 at 10:45 AM, documents that R3 was found on the floor and slid out of reclining geriatric chair that was in reclined position, root cause analysis documents that mats are to be placed beside reclining geriatric chair when R3 is in her chair. R3's Care Plan with intervention dated 8/13/20 documents mats are to be placed by R3's chair when R3 is up in her chair. R3's most current fall risk assessment dated [DATE] documents R3 is at high risk for falls with a score of 20 (score greater than 13 is high risk for falls). R3's MDS, dated [DATE], documents that R3 is cognitively impaired. R3's MDS also documents that R3 is totally dependent and requires 2 plus staff assistance for bed mobility and transfers. R3's undated Face sheet documents R3 has Dementia. On 8/18/20 at 9:30 AM, V11, Licensed Practical Nurse (LPN), stated that she observed R3 on the floor on 8/12/20. V11 stated that R3 scoots herself down, and that R3 can move. V11 stated that R3 was reclined back in a reclining geriatric chair when she fell . 08/24/2020 3:15 PM, V1, Administrator, stated that staff are trained to use gait belts and the gait belt is to be placed around the resident's waist. V1 stated that he was aware that R3 did not have mats beside her wheelchair as identified as an intervention to be in place. The Facility's Accident and Incidents policy and procedure, dated 8/2014, documents under Accident/ Incident Prevention, When a resident has been identified as a high risk for accidents /incidents, interventions will be put into place per individual assessment and care plan. The policy documents the interventions may include, but not limited to the following: monitoring of residents when mobile, assist with transfers when unsteady, ensure call light is within reach and working, monitor during high risk times according to resident's history, monitor gait balance and fatigue with ambulation, place high risk residents in rooms near the nurse's station as appropriate. Under accident investigation, the policy documents, When accidents/incidents are unwitnessed the area around the resident should be analyzed for probable cause. If a resident is falling more often in a particular area, at a particular time or during a particular activity, this should be identified in the investigation and interventions put into place to assist in reoccurrences. The Facility's Gait Belts policy and procedure, revised 12/2002, documents proper body mechanics will be used when transferring a resident, and staff will be orientated on proper use of gait belts and proper body mechanics.

Based on observation, interview and record review, the facility failed assess for the root cause of falls and failed to implement progressive interventions to prevent future falls and skin tears for 7 of 7 residents (R3, R4, R5, R14, R21, R22, R23) reviewed for falls and skin tears in the sample of 27. This failure resulted in R5 falling and sustaining fractures of the face, neck and upper back bone. Findings include: 1. R5's Minimum Data Set ((MDS) dated [DATE] documents R5 has severe cognitive impairment for daily decision making and never/rarely makes decisions and requires more than 50 to 75 percent help from two staff for transfers, toilet use. The MDS documents R5 is not steady, only able to stabilize with staff help when moving from seated to standing, moving on and off toilet, and transfer from bed to chair or wheelchair and vice versa. R5's Care Plan dated 8/27/19 documents, At risk for falling related to recent illness/hospitalization and new environment, Hard of hearing, bilateral hearing aids/right ear deaf, Impaired memory, History of falling. R5's [NAME]s Hopkins Fall Risk Assessment Tool dated 3/5/19 documents R5 is a high fall risk. R5's electronic record from 4/19/2019 until 9/30/2019 documents 20 falls as follows: R5's Event Report dated 4/19/19 documented at 3:00 PM, R5 had a witnessed fall in the day room as she stood from wheelchair and attempted to walk. The Report documented that directly after the fall R5 held the back of her head. The Report documented she had bruising to the back of her head. The Report documented the following immediate interventions put into place after fall were: bed alarm, chair/wheelchair alarm, increased toileting and low bed. R5's Problem Evaluation Notes Report documents the intervention/Approach to address R5's fall on 4/19/19 as Staff inservice to assist/encourage to go to activity department to participate in group activity between noon and evening meals. R5's Event Report dated 4/25/19 documented at 3:55 PM, R5 had a witnessed fall in the day room when she attempted to stand from her wheelchair, stumbled over her feet, fell backwards and hit her head on the floor. The Report did not document if her chair/wheelchair alarm sounded to alert staff of her movement. The Report documented she sustained a bump on the back of her head. The Report documented the following immediate interventions put into place after the fall were: chair/wheelchair alarm, ice, rest, increased toileting and low bed. R5's Problem Evaluation Notes Report documented the Interventions/approaches to address R5's fall on 4/25/19 were to conduct vital signs for 72 hours after her fall. There were no interventions to address R5's need for increased supervision. R5's Event Report dated 4/29/19 at 2:28 PM documented R5 had an unwitnessed fall in her room. The Report does not document what R5 was doing prior to the fall. The Report documented she was found on the floor but had no injuries. The Report did not document any immediate interventions put into place after this fall. R5's Problem Evaluation Notes Report documented the interventions/approaches to address R5's fall on 4/29/19 were to have a clothes tab audible safety device and for physical therapy to screen. R5's Event Report dated 5/6/19 documented at 6:33 AM R5 had a witnessed fall in her bathroom. The report documented she had a bump but did document the location of this bump. The Report did not document if R5 was in her bed or wheelchair prior to the fall. The Report documented the immediate interventions put into place after this fall as: bed alarm, chair/wheelchair alarm, ice, rest and alternate call. R5's Problem Evaluation Notes dated 5/6/19 documents the interventions/approaches to address R5's fall on 5/6/19 as Audible safety device to bed related to fall 5/6/19. R5's Event Report dated 5/20/19 documents at 6:09 AM, R5 had an unwitnessed fall in her room. There was no documented description of the fall including if R5 was in bed or in her wheelchair prior to this fall. There was no documentation if R5's safety alarms were activated and sounding prior to this fall. There were no immediate interventions to address this fall documented on this report. There was no documentation R5 sustained injuries from this fall. R5's Problem Evaluation Notes dated 5/21/19 documents R5 was sent to hospital for x-ray regarding her fall on 5/20/19. The Note documented the x-ray was negative. The Note documented the interventions/approaches to address R5's fall on 5/20/19 were Audible safety device bathroom door related to fall on 5/20/19. Occupational Therapy Screen wheelchair modification. R5's Event Report dated 6/3/19 documents at 4:41 PM, R5 had a witnessed fall in the day room. The report documented R5 was sitting in the day room, staff saw her stand but could not get to her in time. R5's Problem Evaluation Notes dated 6/3/19 documents interventions/approaches to address R5's fall on 6/3/19 documented Staff Inservice to engage/encourage (R5) to participate in activity that she enjoys, painting/drawing/coloring when she is sitting at activity table in dayroom related to fall on 6/3/19. R5's Event Report dated 6/4/19, documents at 4:21 PM R5 had a witnessed fall in the dining room when she stood from her wheelchair and hit her head. She sustained a bump to the back of her head. R5's Problem Evaluation Notes dated 6/5/19 documents interventions/approaches to address R5's fall on 6/4/19 as Busy board related to fall out of wheelchair on 6/4/19. R5's Event Report dated 6/11/19 documents at 1:06 PM, R5 had a witnessed fall in the day room. The report documented she was sitting in her wheelchair prior to her fall. The Report did not document if R5 was being engaged in activities or had the busy board. The Report did not document if R5 fell while standing from her wheelchair or turned her wheelchair over. The report did not document her wheelchair alarm sounded. The report did not document if R5 sustained injuries from this fall. The Report documented the immediate measures implemented to address this fall was chair alarm. R5's Nurse's Note dated 6/11/2019 at 1:09 PM documents, Resident had a witnessed fall @ (at) PM. Attempted to stand in day room without assistance. The Note documented Resident has an abrasion noted to right ear. Bruise also noted to right wrist. R5's Problem Evaluation Notes dated 6/11/19 documents intervention/approach to address this fall as Staff in serviced to ensure that (R5) is in her proper wheelchair with anti-rollback bars related to the fall on 6/11/19. R5's Event Report dated 6/15/19 documents at 7:02 AM. R5 had an unwitnessed fall in her room. This Report had no description as to where R5 was found and if she had fallen from her bed or wheelchair. The Report did not document if any safety alarms were sounding. R5's Problem Evaluation Notes dated 6/17/19 documents intervention/approach to address the fall as Staff in serviced to encourage/assist (R5) up out of bed first in AM for AM meal related to fall on 6/15/19. R5's Event Report dated 6/19/19 documented at 11:20 AM, R5 had an unwitnessed fall in her room. The Report documented a Certified Nurse's Aide (CNA) heard R5's alarm sounding and found her on the floor at the foot of her bed. R5's Problem Evaluation Notes dated 6/19/19 documents interventions to address R5's fall as Bilateral body pillows when in bed related to fall on 6/19/19. R5's Event Report dated 6/20/19 documents at 3:40 AM, R5 had an unwitnessed fall in her room. The Report documented that R5 has been continually trying to get up herself. The Report did not document if R5's alarms were sounding when R5 was found. The Report document she had pain in her left lower extremity. The Report documented immediate measures taken as: bed alarm, increased toileting. R5's Problem Evaluation Notes dated 6/20/19 documents interventions to address R5's fall as Staff Inservice to ensure that (R5's) audible safety device is on and operable at all times. Care Plan reviewed. No new changes. Transferred to (Hospital) ER for evaluation of fall. There were no interventions or reassessment to address R5's need for increased supervision. R5's Event Report dated 7/2/19 documents, at 1:02 AM. R5 had an unwitnessed fall in her room. The Report documented R5 was in bed prior to the fall and a CNA found her on the floor next to her bed. The Report did not document if R5's safety alarms were sounding. The report documented the immediate measures taken after the fall were the bed alarm and low bed. R5's Problem Evaluation Notes dated 7/2/19 documents interventions to address R5's falls as Bilateral floor mats while in bed related to fall on 7/2/19. There were no interventions to address R5 getting out of bed unsupervised or need for increased supervision. R5's Event Report dated 7/7/19 documents at 8:32 AM, R5 had an unwitnessed fall in her bed room but did not document where she fell in her room. The Report documented she was grabbing the knot on the back of her head, crying, after the fall. The report documented she sustained a bump and bruise to the back of her head. The report did not document if the R5 was in bed or in her wheelchair at the time of the fall. The report did not document if R5's safety alarms were sounding. R5's Problem Evaluation Notes dated 7/7/19 documents the interventions to address R5's fall as Staff in serviced to ensure that bathroom door audible safety device is on and operable at all times related to fall on 7/7/19. R5's Event Report dated 7/17/19 documents at 2:31 AM. R5 had an unwitnessed fall in her room and had a right forehead bruise with a bump. The Report did not document where R5 was found and if her safety alarms were sounding. R5's Problem Evaluation Notes dated 7/17/19 documents interventions to address R5's fall as PT (Physical therapy) to observe related to fall on 7/17/19. Staff in service to offer snack, conversation, activity when (R5) is awake during night hours/unable to sleep, assist to staff area. R5's Event Report dated 7/23/19 documents at 6:13 AM R5 had a witnessed fall from her wheelchair at the nurse's desk. The Report documented that she was attempting to get up out of wheelchair. The Immediate measures taken to address this fall was Resident kept by staff at all times. R5's Problem Evaluation Notes dated 7/23/19 documents interventions to address R5's falls as Referral to Therapy to evaluate related to fall on 7/23/19. This was the same as the interventions on 7/17/19. R5's Event Report dated 7/28/19 documents at 12:07 PM R5 had a witnessed fall in another resident's room. The Report did not document if R5 was in her wheelchair or ambulating. The Report did not document what the resident was doing in the other resident's room or the circumstances surrounding the fall. R5's Problem Evaluation Notes dated 7/29/19 documents the interventions as Staff in service to ensure (R5)'s hearing aids are in place and operable at all times related to fall on 7/28/19. R5's Event Report dated 8/16/19 documents at 4:20 AM, R5 had an unwitnessed fall in her bathroom. The report documented R5 was in bed prior to the fall. The report documented she had right should pain and right arm pain. The report documented she was found on the floor near the TV. The Report documented she was sent to the emergency room for evaluation. R5's Problem Evaluation Notes dated 8/16/19 documents interventions to address R5's fall on 8/16/18 as Staff education to inquire/ask (R5) if she prefers tv on/off at night. R5's Event Report dated 8/18/19 documents at 6:02 AM. R5 had an unwitnessed fall in her room. The report documented Writer and CNA heard pressure alarm sounding. resident was observed behind closed bedroom door, sitting on the floor with her back parallel to the wall. R5's Problem Evaluation Notes dated 8/18/19 documents the interventions for R5's falls as Staff education to ensure that bedroom door is open at all times related to fall on 8/18/19. There were no interventions to address increased supervision for R5. R5's Event report dated 9/18/19 documents at 3:03 PM R5 had an unwitnessed fall at the nurse's station when she attempted to stand on her own. The Report did not document if R5's safety alarms sounded. R5's Problem Evaluation Notes dated 9/18/19 interventions for R5's falls as Staff in service /education to assist (R5) to dining room, transfer to dining room chair from wheelchair when awake before PM meal, offer meaningful conversation, enjoys folding clothes, offer snacks related to fall on 9/18/19. R5's Event Report dated 9/22/19 documents at 10:16 AM. R5 had a witnessed fall in the dining room while attending church service. The report documented she had injuries to her facial area. R5's Problem Evaluation Notes dated 9/22/19 documents interventions for R5's falls as EMS (emergency medical service) 911. Sent to (hospital) for eval of fall 9/22/19. readmitted status [REDACTED]. Bruising to both eyes, face swollen. Distant observation staff in service/education to ensure (R5) is always in sight related to fall on 9/22/19. R5's Hospital Trauma Admission History and Physical (H and P) dated 9/22/19 documents,[AGE] year old status [REDACTED]. Patient is demented at baseline. admitted for management of facial fractures and delineation of cervical spine surgery. R5's History and Physical documents, Plan/Assessment: Nasal bone fracture, Right zygomatic arch fracture - non-operable, head of bed above 30 degrees; C5/T5-7 spinous process fracture - spinal precautions. On 10/29/19 at 2:59 PM, V8, Certified Nursing Aide (CNA), wheeled R5 in her wheelchair to the bathroom. V8 carried washcloths and adult incontinent brief on her left hand while pushing R5 in her wheelchair inside the bathroom. As they entered the bathroom, V8 reached to her left to put the supplies on top of the sink, R5 suddenly stood up and walked the last couple of steps towards the toilet without V8 locking the wheelchair breaks and without using a gait belt on R5. V8 was able to hold/grab R5's arms and guided R5 to sit in the toilet. On 10/29/19 at 3:15 PM, V8 stated she should have used the gait belt on R5 but R5 was very quick and just stood up before she could lock the brakes and use a gait belt on R5. On 11/13/19 at 1:35 PM, V29, Occupational Therapist, stated she saw R5 for a few post fall evaluations. V29 stated she tried to work on balance because it would seem like R5 just wanted to get up and walk for no reason and did not know if R5 understood what therapy wanted her to do, or maybe she could not hear so she could not follow instructions and verbal cueing. V29 stated R5 was hard of hearing even with a hearing aid on. V29 stated they could never get R5 to do the balance or any other exercises because she would go another way if she is instructed to go this way, or she would do something else. On 11/13/19 at 1:40 PM, V28, Physical Therapist, stated she tried to do different things/approaches, but they were not making any progress so R5 was discharged from PT. V28 stated R5 was a very high fall risk because she was very impulsive. It was very hard to figure out what was going on with her. V28 stated R5 always needed assist with transfers and walking. V28 stated therapy exhausted all efforts to help R5. V28 stated because of her impulsivity, R5 need much supervision and activities to keep her safe and busy to reduce her risk of falling. 2. R4's MDS dated [DATE] documents R4 is oriented to place and person and needs staff contact assistance to stabilize herself during transfers from seated to standing, moving on and off toilet and surface to surface transfers. R4's Physical Therapy (PT) Evaluation Notes dated 6/26/19 documents, Medical Diagnosis: [REDACTED]. Patient suffered a [MEDICAL CONDITION] (stroke) on 6/5/19. Was in acute care hospital for 20 days. Now presented to therapy with right sided weakness impacting ability to perform transfers and ambulation. The PT Notes further document R4 needs partial moderate assist (needs 50 percent help of the task to lift the weight of the body in standing position, or to move a limb or wheelchair, for example) with transfers to chair/bed, sit to stand, to toilet and ambulation. R4's Face Sheet, undated, documents R was admitted on [DATE] and was discharged to the hospital on [DATE]. R4's Event Reports on Falls are as follows: R4's Event Report dated 6/27/19 documents at 1:59 PM R4 slid down to floor from toilet with help of staff in R4's bathroom. The Report documented R4 was attempting to wipe herself and leaned over too far and lost balance. R4's Problem Evaluation Note, dated 6/27/19 documented interventions for R4's fall as Staff in service on the importance of close monitoring while toileting residents [MEDICAL CONDITION] weakness r/t (related to) fall on 6/27/19. R4's Event Report dated 6/28/19 documents at 1:09 PM R4 fell from her wheelchair in the television room. The report documented Poor balance control while in wc (wheelchair). R4's Problem Evaluation Note Report, dated 6/28/19 documented the following interventions Staff in serviced to encourage/assist (r4) to activity department after emails, ensure that (R4) is within eyesight of staff when up out of bed. R4's Event Report dated 6/29/19 documents at 5:00 PM R4 had an unwitnessed fall in her room. The Report documented R4 stated she was sitting on the side of her, bed attempting to get up from her bed and slid out. The Report documented she was found on her right side of her bed, on her back. R4's Problem Evaluation Note, dated 7/1/19 documented the intervention was family education regarding staff assistance r/t fall on 6/29/19. R4's Event Report dated 6/30/19 documents at 1:30 PM, R4 had a witnessed fall in the bathroom. The Report documented that R4 was attempting to transfer off the toilet with the help of a staff member. R4 fell to floor and sustained a laceration to the back of her head measure 1 centimeter (cm) by 2 cm. The Report Note section documented Nurse called to resident room by CN[NAME] Upon arrival resident was observed on the bathroom floor with small amount of blood near her head. CNA stated that she was assisting the resident off of the toilet when the resident began to lean to her right and lost her balance and she was unable to stop her from falling. R4's Problem Evaluation Note, dated 7/1/19 documented the interventions to address R4's falls as Raised toilet seat r/t fall on 6/29/19. R4's Event Report dated 7/14/19 documents at 3:37 PM, R4 had a witnessed fall in main lobby. The Report documented Nurse stated that she heard the residents chair alarm and looked up to see resident standing up from her chair and was beginning to lean to her side. Nurse stated she attempted to make it to the patient to avoid the fall, but was too far away. The Report documented she sustained a laceration to the right side of her head. The Report documented R4 briefly lost consciousness, 911 was called and she was sent to the hospital. R4's Nurses Notes dated 7/14/19 at 3:38 PM, documents, 911 called at this time related to fall. Nurses Notes dated 7/14/19 at 6:09 PM, documents, Call placed to (hospital) for patient update. CT (Computed [NAME]ography) showed subarachnoid hemorrhage (bleeding between the space between the brain and the tissue covering the brain) present, no fractures, family opting for hospice. R4's Hospital CT Scan Result dated 7/14/19 documents Bilateral acute subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). On 11/12/19 at 2:00 PM, V3, Care Plan Coordinator, stated there was no Fall Risk Assessment done on R4. On 11/12/19 at 11:15 AM, V27, Occupational Therapist (OT), stated R4 needed hands on assist of continuous guiding and guarding during transfers when R4 was discharged to the hospital on [DATE]. On 11/13/19 at 10:27 AM, V20, Physician/Medical Director, stated he was aware R4 had a previous subarachnoid bleeding and was hospitalized in a different hospital for a long time before coming to the facility. V20 stated without comparing the imaging results between the two subarachnoid hemorrhages, he can't give an absolute answer. V20 stated, typically, radiology would do a comparison but these were two different hospitals and maybe nobody thought of requesting the earlier imaging report for comparison so there is no way of quantifying the results. V20 stated an important question to consider is did (R4) bleed and fall or did she fall and bleed. V20 stated as long as the facility provided maximum fall precaution approaches and followed their policies, the facility could not have not done anything more short of restraining the resident. 3. R3's Care Plan updated 10/29/19 documents, At Increased risk for pressure ulcers related to decreased mobility, generalized muscle weakness following recent illness and hospitalization . Skin tear to left lateral calf, Unstageable ulcer to left heel, Skin tears to left and right forearm. Approaches: Treatment to skin tear to left forearm, right forearm, left lateral calf per MD order until healed, monitor for s/s of infection every shift notify MD. Geri sleeves on at all times except for hygiene. R3's Physician order [REDACTED]. On 10/28/19 during lunch meal service observation at the 200 Hall Dining room from 12:26 PM until 12:47 PM, R3 sat in her wheelchair. R3 was wearing a Geri sleeve on her right forearm and none on the left arm. R3's Clinical Record documents the following skin tears between 8/2019 thru 10/2019 as follows: a. Event date: 8/9/19 at 9:39 PM documents, Skin ear to right lower arm. 1.5 centimeters (cm) x 1.5 cm. Staff was getting R4 ready for bed and became combative and started trying to hit staff and right lower arm hit bedrail. b. Event date: 10/7/19 at 2:45 AM documents, Skin tear to left lateral calf 4 cm x 2 cm. Resident got skin tear while toileting, resident had tried to kick staff when her leg scraped against staff name badge causing skin tear 4 cm x 2 cm. Nurses Note dated 10/17/19 documents, New orders to start [MEDICATION NAME] 100 mg twice a day for 7 days related to [MEDICAL CONDITION] to left lower leg and [MEDICATION NAME] and nonadherent dressing to left lateral calf. c. Event date: 10/25/19 at 6:17 AM documents,skin tear to right forearm. 8 cm skin tear to right anterior forearm. Nurses Notes dated 10/25/19 at 6:10 AM documents,8 cm skin tear found on anterior right forearm. Area cleaned and skin approximated. Steri strips applied, bleeding controlled, and dry dressing applied. d. Nurse's Notes dated 10/29/19 at 10:07 AM, documents, Resident was combative during dressing has new skin tear to left forearm 9 cm. On 10/28/19 at 1:25 PM, V9, Certified Nursing Aide (CNA), stated R3 should be wearing geri sleeves on at all times. V9 stated R3's skin is so fragile she has had skin tears on her arms and leg and she struggles during care. On 10/28/19 at 2:19 PM, V14, CNA, stated R3 has an order for [REDACTED]. 4. R23's Care Plan, review date 10/03/2019, documents (R23) is at risk for falls related to weakness and history of falls. Resident is receiving medications that are associated with increased fall potential. Resident has balance deficits and impaired safety awareness. Floor mats bilateral bedside when in bed. On 10/31/2019 at 1:54 PM, R23 was bed and no floor mats were at R23's bedside. 5. R21's Care Plan, dated 9/5/2019, documents (R21) is at risk for falling related to recent illness/hospitalization , impaired injury, and new environment. Bilateral floor mats when in bed. On 10/31/2019 at 1:55 PM R21 was in bed and no floor mats were on the floor. On 11/12/2019 at 2:40 PM to 3:20 PM R21 was in the bed and no floor mats were observed on the floor. The mats were laying against wardrobe. 6. R22's Care Plan, review date 9/20/2019, documents (R22) is at risk for falling related to weakness. Resident is receiving medications that are associated with increase fall potential. Vitamin D deficiency, resident has balance deficits and impaired safety awareness related to dementia. Mats at bilateral BS (bedside) while in bed. On 10/31/2019 at 1:57 PM, R22 wasin bed and no floor mats were at bedside. On 11/12/2019 at 2:40 PM to 3:20 PM R22 was in the bed and no mats at bedside. R22's floor mats were against wardrobe. 7. R14's Care Plan, dated 11/2/2019, documents (R14) at risk for falling related to recent hospitalization and new environment, history of multiple falls, right foot drop, [MEDICAL CONDITION], fall with rib fracture. Floor mats bilateral bedside when in bed. On 11/12/2019 at 9:40 AM V23, Garden Court Coordinator and V24, CNA, assisted R14 into the bed. V24 then lowered the bed into the low position and raised the head of the bed. V24 placed the call light in R14's hand. V23 and V24 left the resident's room without placing floor mats at bedside. Floor mats observed against R14's wardrobe. On 11/12/2019 at 9:45 AM to 10:50 AM, R14 was observed at 15-minute intervals in bed. No bilateral mats were at R14's bedside. On 11/13/2019 at 10:33 AM, V22, Licensed Practical Nurse (LPN), stated, The CNAs put mats in place when they put the resident to bed, if that's what the care plan says. We do whatever the care plan says. On 11/13/2019 at 10:45 AM, V37, CNA, stated, The CNA puts the mat down after we lay the resident down . On 11/13/2019 at 11:56 AM, V24, CNA, stated, The mats are in place anytime the resident is in bed and the CNA puts them in place. On 11/14/2019 at 9:58 AM, V23, Garden Court Coordinator, stated, If a residents care plan has floor mats, the mats are put in place after the bed is lowered to the lowest position and the CNAs are to check to make sure they are down prior to leaving the room. 4. R23's Care Plan, review date 10/03/2019, documents (R23) is at risk for falls related to weakness and history of falls. Resident is receiving medications that are associated with increased fall potential. Resident has balance deficits and impaired safety awareness. Floor mats bilateral bedside when in bed. On 10/31/2019 at 1:54 PM, R23 was bed and no floor mats were at R23's bedside. 5. R21's Care Plan, dated 9/5/2019, documents (R21) is at risk for falling related to recent illness/hospitalization , impaired injury, and new environment. Bilateral floor mats when in bed. On 10/31/2019 at 1:55 PM R21 was in bed and no floor mats were on the floor. On 11/12/2019 at 2:40 PM to 3:20 PM R21 was in the bed and no floor mats were observed on the floor. The mats were laying against wardrobe. 6. R22's Care Plan, review date 9/20/2019, documents (R22) is at risk for falling related to weakness. Resident is receiving medications that are associated with increase fall potential. Vitamin D deficiency, resident has balance deficits and impaired safety awareness related to dementia. Mats at bilateral BS (bedside) while in bed. On 10/31/2019 at 1:57 PM, R22 wasin bed and no floor mats were at bedside. On 11/12/2019 at 2:40 PM to 3:20 PM R22 was in the bed and no mats at bedside. R22's floor mats were against wardrobe. 7. R14's Care Plan, dated 11/2/2019, documents (R14) at risk for falling related to recent hospitalization and new environment, history of multiple falls, right foot drop, [MEDICAL CONDITION], fall with rib fracture. Floor mats bilateral bedside when in bed. On 11/12/2019 at 9:40 AM V23, Garden Court Coordinator and V24, CNA, assisted R14 into the bed. V24 then lowered the bed into the low position and raised the head of the bed. V24 placed the call light in R14's hand. V23 and V24 left the resident's room without placing floor mats at bedside. Floor mats observed against R14's wardrobe. On 11/12/2019 at 9:45 AM to 10:50 AM, R14 was observed at 15-minute intervals in bed. No bilateral mats were at R14's bedside. On 11/13/2019 at 10:33 AM, V22, Licensed Practical Nurse (LPN), stated, The CNAs put mats in place when they put the resident to bed, if that's what the care plan says. We do whatever the care plan says. On 11/13/2019 at 10:45 AM, V37, CNA, stated, The CNA puts the mat down after we lay the resident down . On 11/13/2019 at 11:56 AM, V24, CNA, stated, The mats are in place anytime the resident is in bed and the CNA puts them in place. On 11/14/2019 at 9:58 AM, V23, Garden Court Coordinator, stated, If a residents care plan has floor mats, the mats are put in place after the bed is lowered to the lowest position and the CNAs are to check to make sure they are down prior to leaving the room. 4. R23's Care Plan, review date 10/03/2019, documents (R23) is at risk for falls related to weakness and history of falls. Resident is receiving medications that are associated with increased fall potential. Resident has balance deficits and impaired safety awareness. Floor mats bilateral bedside when in bed. On 10/31/2019 at 1:54 PM, R23 was bed and no floor mats were at R23's bedside. 5. R21's Care Plan, dated 9/5/2019, documents (R21) is at risk for falling related to recent illness/hospitalization , impaired injury, and new environment. Bilateral floor mats when in bed. On 10/31/2019 at 1:55 PM R21 was in bed and no floor mats were on the floor. On 11/12/2019 at 2:40 PM to 3:20 PM R21 was in the bed and no floor mats were observed on the floor. The mats were laying against wardrobe. 6. R22's Care Plan, review date 9/20/2019, documents (R22) is at risk for falling related to weakness. Resident is receiving medications that are associated with increase fall potential. Vitamin D deficiency, resident has balance deficits and impaired safety awareness related to dementia. Mats at bilateral BS (bedside) while in bed. On 10/31/2019 at 1:57 PM, R22 wasin bed and no floor mats were at bedside. On 11/12/2019 at 2:40 PM to 3:20 PM R22 was in the bed and no mats at bedside. R22's floor mats were against wardrobe. 7. R14's Care Plan, dated 11/2/2019, documents (R14) at risk for falling related to recent hospitalization and new environment, history of multiple falls, right foot drop, [MEDICAL CONDITION], fall with rib fracture. Floor mats bilateral bedside when in bed. On 11/12/2019 at 9:40 AM V23, Garden Court Coordinator and V24, CNA, assisted R14 into the bed. V24 then lowered the bed into the low position and raised the head of the bed. V24 placed the call light in R14's hand. V23 and V24 left the resident's room without placing floor mats at bedside. Floor mats observed against R14's wardrobe. On 11/12/2019 at 9:45 AM to 10:50 AM, R14 was observed at 15-minute intervals in bed. No bilateral mats were at R14's bedside. On 11/13/2019 at 10:33 AM, V22, Licensed Practical Nurse (LPN), stated, The CNAs put mats in place when they put the resident to bed, if that's what the care plan says. We do whatever the care plan says. On 11/13/2019 at 10:45 AM, V37, CNA, stated, The CNA puts the mat down after we lay the resident down . On 11/13/2019 at 11:56 AM, V24, CNA, stated, The mats are in place anytime the resident is in bed and the CNA puts them in place. On 11/14/2019 at 9:58 AM, V23, Garden Court Coordinator, stated, If a residents care plan has floor mats, the mats are put in place after the bed is lowered to the lowest position and the CNAs are to check to make sure they are down prior to leaving the room. <

Based on observation, interview and record review, the facility failed to implement effective interventions and provide supervision to prevent falls for 1 of 4 (R404) residents reviewed for accidents in the sample of 42. This failure resulted in R404 sustaining a non-displaced fracture of her right hip. Findings include: The Minimum Data Set (MDS), dated [DATE], documented R404 has a Brief Interview of Mental Status (BIMS) score of 05, indicating severe cognitive impairment. The MDS further documents R404 is severely impaired, requires limited assistance with transfers, personal hygiene, toilet use, and utilizes wheelchair for mobility device. R404's Care Plan, dated 12/27/17, documents R404 was admitted to the facility with an unspecified displaced fracture 2nd cervical vertebra with a neck brace in place. The Care Plan documents R404 was at risk for falling related to recent fall at previous Long Term Care Facility, history of falls, and [DIAGNOSES REDACTED]. The Care Plan documents interventions to address falls alternate call light, activities of interest and instruct resident to call for assist before getting out of bed or transferring. R404's Investigation Report documented R404 fell on [DATE]. R404's Event Report for un-witnessed fall in bathroom dated 03/19/18 at 3:00 PM, documented in part, Why does resident think they fell ?: trying to get off toilet without assist. The Report documented other contributing factors to falls as noncompliant with transfers. Transfers without assist after frequent reminders. R404's Care Plan was revised on 3/19/18 with approach Bathroom Door Alarm. Event Report for fall dated 04/03/18 at 11:55 AM, documented R404 self-reported that she fell during the night while trying to take herself to the bathroom. The Event Report documented Stated her feet became entangled with each other, causing her to trip and fall onto floor landing on buttock. Denies hitting head. Bruising noted to mid-spine and coccyx area of buttock. Both areas of bruising are dark purple in color. The Note section under the Event report, dated 4/6/2018 documented Chatted with (R404) and daughter in TV Lounge, (R404) is pleasant and alert, stated that she is just fine and verbalized understand that she needs assistance in her bathroom and understands the bathroom door alarm is a reminder. R404's Care Plan for fall 04/03/18, documented an approach for R404 to be prompted with toileting program 8:00 PM-8:00 AM, every 2 hours when awake. R404's Fall Risk Report dated 04/11/18, documented history of one or more falls within the previous 6 months. The Fall Report documented Requires assistance or supervision for mobility, transfer, or ambulation, unsteady gait, reflecting a score of 24, identified as High Fall Risk. Event Report for fall dated 4/15/18 at 8:30 PM, documented What was resident doing just prior to fall?- walking in room unassisted. Progress Note: Resident noted laying against wall by door. R404's Investigation Report, dated 04/15/18, documented she fell on [DATE]. On 04/15/18 at 8:30 PM, R404 sustained a fall from her chair. This resulted in a non-displaced fracture to right greater trochanter (hip). On 7/26/18 at 12:15 PM, V2, Director of Nursing (DON) stated, she would expect staff to continue with frequent resident checks to all residents. V2 also stated the evening of 7/25/18, she had to remind staff residing at the nursing station, to walk up and down the hall and visually check on each and every resident while in their rooms. On 7/26/18 at 11:10 AM, V27, Certified Nurse Aide (CNA) stated that R404 needs reminders to not to get up out of bed or wheelchair without calling for assistance. On 7/26/18 at 3:16 PM, V28, R404's Family Nurse Practitioner, stated she would expect facility staff to perform hourly rounding and to increase the supervision for R404. V28 also stated she had personally educated R404 regarding calling for assistance from staff back in (MONTH) and (MONTH) of (YEAR). On 7/26/18 at 10:12 AM, R404's room [ROOM NUMBER], located at the end of the hall, bathroom door alarm was manually activated and was not audible from midway hall location and/or nurse station. The facility's policy and procedure, dated 8/2014 and entitled, Accidents/Incidents Prevention, documented in part: Monitoring of the resident when mobile, Assist with the transfers when the resident is unsteady, maintain close supervision of confused residents, monitor during high risk times according to the individuals history, (after pain medication, during night hours, after meals etc.) Place high risk residents in rooms near the nurse's station as appropriate.

Based on interview and record review, the facility failed to identify, assess and monitor signs/symptoms of wound infection for 1of 6 residents (R22) reviewed for wounds in the sample of 24. This failure resulted in R22 being admitted to the hospital and being treated for [REDACTED]. Findings include: R22's Admission sheet documents that R22 was admitted to the facility on [DATE], following hospitalization for a pacemaker implant. Admitting orders from Z2, Cardiologist, documents Watch for signs and symptoms of infection; drainage, fever/chills, swelling from the AICD (pacemaker) site. Keep AICD site dry for 2 more days, may shower on 5/9/15. Keep incision clean and dry. Call the physician promptly if case of incision problems; increased or persistent redness around incision: foul smelling or unusual discharge from incision, excessive or abnormal bleeding. R22's Progress Notes, dated 5/6/5 at 8:48 M, document that R22's strips were in place at left chest with no signs or symptoms of infection. R22's Progress notes, dated 6/27/15, at 9:55 PM documents that Resident( R22) noted moisture to left upper c chest. Assessment by the nurse documents two scabs noted to left chest .3 centimeters (cm) x 0.1 (cm) and 0.4 cm x 3cm no longer intact from pacemaker site. Site pink, small amount of serosanguious fluid noted Area cleansed and dressing applied. A telephone order from Z3, R22's Physician, dated 6/28/15 documents order to cleanse left chest pacemaker site, apply triple antibiotic ointment and dry dressing every evening until healed. There is no documentation that Z2 was notified as directed in admitting orders. R22's Progress note dated 6/29/15 at 10:22 AM documents Left chest pacemaker site noted with open wound, no drainage, redness surrounding. No odor noted. A telephone order from Z3 was received on 6/29/15 and documents that R22's treatment was changed to [MEDICATION NAME] ointment, cleanse chest site with wound cleanser, apply [MEDICATION NAME] ointment and dry dressing. Change every night and as needed. There was no documentation that Z2 was notified of pacemaker site changes. R22's Progress Note documents on 7/6/15 at 1:54 PM, R22 was transferred to Z2's office for checkup. At 2:57 PM, progress notes document Resident was sent for direct admit to hospital from office r/t (related to) infection to pacemaker site for treatment with IV (intravenous) ABT (antibiotics) and further assessment. On 7/24/15 at 1:00 PM, E2 Director of Nursing( DON), stated that Z2 should have been notified of the changes in surgical site for care and treatment as directed in admitting orders. E2 also stated primary physician should be aware. On 7/24/15 at 1:15 PM, Z1, Z2's Registered Nurse, was interviewed by telephone. Z1 stated they are to be notified of any changes in the surgical site of the pacemaker. Z1 stated that antibiotic ointment is not to be used on the incision site. Z1 stated that when R22 was seen by Z2 on 7/6/15 that she was sent to the hospital because there was a concern the site was infected, which could lead to the device having to be removed. On 7/24/15 at 2:30 p.m., E17, Registered Nurse (RN) stated that she was not aware that she was to notify Z2 of any changes in the pacemaker site. When requested, the facility had no policy regarding wounds/surgical incisions.

Based on interview and record review the facility failed to assess pertinent changes in the condition of three residents (R1, R2, and R3) reviewed for nursing assessments in a sample of 4. This resulted in R1 being admitted to the Intensive Care Unit with a [DIAGNOSES REDACTED]. It also resulted in R3's [DIAGNOSES REDACTED]. Findings Include: 1. R1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R1 resided in the facility until 3/6/14 when R1 was transferred to an outside facility where he was treated for [REDACTED]. R1's Nurses' Notes dated 3/6/14 document in part, at 8:50 AM "R1 noted this am with acute change in mental status, increased confusion noted, restlessness and fidgety, expressive aphagia of new onset, mumbled words when spoken....unable to follow simple commands." At 8:55 AM, Z1, Medical Doctor notified of change in condition. At 11:30 AM, " No reply from Z1 r/t (related to) notification of change in condition, resident transferred to Anderson ER for eval (evaluation) and tx (treatment) per nursing judgment." At 11:45 AM Emergency Medical Service, EMS called to transport R1 to emergency room . At 12:45 PM, EMS arrived at the facility to transport R1 to the emergency room for evaluation. No other documentation on the assessment or status of R1's change in condition found in R1's clinical record from the time of 8:55 AM when the change was first documented until 12:45 PM when EMS arrived at the facility to transport R1. An "Event Detail" dated 3/6/14 documents R1 having "cognition/neurological events-acute change in mental status" and "increased confusion/new onset of aphagia" On 4/14/14 at 1:38 PM, E3, Licensed Practical Nurse, LPN, stated she cared for R1 the day he was sent out to the hospital. E3 stated E4, Certified Nurse Aid, CNA, notified E3 at approximately 6:30 AM of a change in R1's condition and that R1 was more confused and had trouble getting out what he needed to say. E3 stated as the morning progressed she noticed R1 declining as he (R1) was agitated, unable to swallow morning pills and had difficulty holding spoon at breakfast. E3 stated she discussed R1's changes with E5, Speech therapist and stated she did not feel comfortable with R1's condition change so she contacted Z1, Medical Doctor at 8:45 or 9:00 AM. E3 stated she was unable to get ahold of Z1 at that time and left a message at Z1's office and faxed over a change of condition sheet to Z1's office. E3 stated the faxed change of condition sheet was not in the digital record and was unsure where it was since it was usually in residents' chart. E3 stated she made a nursing judgement to send R1 to the hospital between 10:30 and 11:30 AM when E3 stated she had not received a call back from Z1. E3 stated that R1 was progressively declining and had [MEDICAL CONDITION] which was new to resident, and speech was garbled. E3 stated in her professional opinion she thought that R1 had a stroke. E3 further stated she was aware of R1's history of having brain bleeds. E3 stated that the ambulance took one hour to get to facility and that lights and sirens were not used. E3 stated she does not recall if she requested for lights and sirens to be used when she called for an ambulance for R1. E3 states that lights and sirens are requested by nursing staff and based on nursing judgments and the critical state of the resident. E3 further stated it would take 15-25 minutes for an ambulance if lights and sirens are used. E3 also stated its "a lot faster if 911 is called." When asked how E3 determines how 911 is used E3 stated the assessment and critical state of the resident indicates if 911 is utilized. E3 further stated she is unsure of the facility's policies and would have to discuss with the Director of Nursing. On 4/14/14 at 1:35 PM, E4, Certified Nurse Aid, stated that she cared for R1 the day he was sent to the hospital. E4 stated when she came on shift around 6:00 AM, R1 was staring into space and E4 could not get a verbal response from R1. E4 stated she informed E3 of R1's change in condition and stated that this was not normal for R1. E4 stated that R1 previously could answer questions and speak normally without difficulty. On 4/15/14 at 1:58 PM, E6, Registered Nurse, RN, stated she cared for R1 on the evening of 3/5/14 and R1 took medications and ate dinner without problems, and also drank from a cup that E6 handed him without difficulty. E6 stated that R1 was alert and oriented to person, place and time and had no confusion the previous days. On 4/14/14 at 2:35 PM, E2, Director of Nursing, DON, stated that E3 had told her of R1's change in condition between 8:40-9:00 AM. E2 stated R1 was progressively declining and symptoms were one sided weakness, and slurred speech and that Z1 was called around 9:45 AM. E2 stated that in her professional opinion, R1 was having stroke like symptoms and stated she was aware that R1 had TIA's in the past. E2 further stated that the facility sends residents out according to nursing judgement if the physician cannot be reached. E2 stated that EMS makes the decision to use lights and sirens based on the symptoms of the resident and 911 is used when a resident is unresponsive and a full code. On 4/15/14 at 9:00 AM E1, Administrator stated that Z1 returned E3's call regarding R1's change in condition after R1 had been sent out of the facility to the emergency department, which was around 12:30 PM. At 10:10 AM the same day, E1 stated R1's symptom was slurred speech the morning of 3/6/14. E1 also stated it was "brutally apparent R1 was having difficulty getting words out" On 4/15/14 at 9:55 AM, E5, Speech therapist, stated that R1 was having trouble swallowing and difficulty with speech on the morning of 3/6/14. E5 further stated that she was "worried about the severe change so I watched R1 eat breakfast." On 4/15/14 at 9:55 AM, E 7, Rehab Manager, stated that nursing staff asked for R1's physical therapy to be held the morning of 3/6/14 due to R1's change in condition. E7 further stated that R1 had ambulated 430 feet the previous day. On 4/15/14 at 10:50 AM, in an interview with Z1, Medical Doctor, stated that R1 had a history of [REDACTED]. Z1 also stated that she was unsure of the time or how she was notified of R1's change in condition. Z1 stated she would expect the facility to send any resident to the emergency room for any acute change in condition. The "Cognitive Linguistic Quick Test" dated 3/4/14 performed by E5 documents R1's cognitive domains as follows : Attention: Mild Memory: WNL (Within Normal Limits) Executive functions: Mild Language: WNL Visuospatial Skills: Mild Composite Severity Rating: Mild Clock Drawing Severity Rating: Mild E5's qualitative Observations on 3/4/14 state "the patient demonstrated mild deficits in attention executive functions, and visuospatial skills, and WNL language and memory on 3/4/14. On 3/6/14, R1 was re-assessed using the same "Cognitive Linguistic Quick Test" performed by E5 and documents R1's cognitive domains as follows: Attention: Severe Memory: Severe Executive functions: Severe Language: Severe Visuospatial Skills: Severe Composite Severity Rating: Severe Clock Drawing Severity Rating: Severe E5's qualitative observations on 3/6/14 document, "re-eval on 3/6/14: pt demonstrated severe deficits in all domains." Physical therapy daily treatment note documents on 3/5/14 that R1 "ambulated 430 feet x1 with use of a front wheeled walker" and R1 able to use sit to stand from wheelchair to front wheeled walker requiring no verbal cueing for hand placement. Documentation on 3/6/14 states no skilled physical therapy due to change in medical status per nursing. Occupational Therapy dated 3/6/14, documents R1 "demonstrated increased confusion and [MEDICAL CONDITION] this date. Consulted with nursing and ST (speech therapy) regarding change in medical status. " Speech Therapy daily treatment note dated 3/5/14 documents that R1 had "good awareness of current events." Daily Treatment notes dated 3/6/14 documents in part, R1 "seen in therapy room: repeat cognitive-linguistic Quick test due to nursing reporting significant in expressive and receptive language skills. Severe across all domains which is a significant decline from mild overall deficits 2 days ago on same assessment. Nursing notified of results of assessment. Confrontation Naming: 40% with perservations and poor intelligibility of speech. Pt unable to name any animals or 'm' words. 3 oz water swallow: cough after swallow noted, decreased laryngeal elevation." EMS Patient Care Report dated 3/6/14 documents the Facility called for ambulance at 11:45 AM for R1 to be transported to the emergency room for "unable to speak clearly; acute onset stroke/[MEDICAL CONDITION]/TIA since 6 hours." EMS arrived on scene at 12:35 PM. EMS report documents in part, "primary impression: neurological-Cerebral TIA. Staff stated patient usually can speak without difficulty however today he is having trouble forming his words. Nurse stated it started possibly sometimes last night or this morning. Does have difficulty in speaking the words, and unable to speak clearly." emergency room History and Physical dated 3/6/14 documents R1 was seen for slurred speech, headache, and right sided facial droop where he (R1) was evaluated and found to have [MEDICAL CONDITION], subdural hematoma and transferred to the Intensive Care Unit at another hospital. R1's Hospital CT Scan dated 3/6/14 documents "thin right sided subacute subdural hematoma. Left-sided subdural hematoma now also evident, probably acute on subacute, suspect a small amount of acute hemorrhage within it and this was not present on exam from a week ago. On 4/17/14 at 10:48 AM, during an telephone interview with Z2, emergency room Physician, stated when R1 arrived at the emergency department R2 had visible right sided facial drooping and slurred speech. Z2 stated the history was unclear of onset of when symptoms initially started but was reported for at least the last 6 hours. Z2 further stated she would expect medical professionals and facility to directly send to an emergency room for evaluation for any stroke like symptoms of facial drooping and slurred speech. Z2 further stated "given R1's history of [MEDICAL CONDITION], send him immediately for any changes noticed." The Facility's Emergency Care Procedure dated 12/03, does not address stroke or stroke like symptoms. On 4/21/14 at 10:30 AM, E1 stated he did not have any other policy/procedures. According to strokassociation.org, an American Hear Association Inc. website dated 2014, the warning signs of a stroke include: Face drooping, Arm weakness, Speech difficulty, and Time to call and get them to hospital immediately. Other symptoms include sudden confusion, sudden trouble understanding, sudden weakness or numbness of the leg, sudden trouble seeing in one or both eyes, sudden severe headache without cause. The website states "A TIA or [MEDICAL CONDITION] is a warning stroke or mini stroke that produces stroke-like symptoms. TIA symptoms usually only last a few minutes but if left untreated, people who have TIA's have a high risk of stroke. Recognizing and treating TIA's can reduce the risk of a major stroke." 2. R3 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3 was transferred to a hospital with a [DIAGNOSES REDACTED]. R3's MDS dated [DATE] documents a BIMS score of 15 with 15 being the highest cognitive function. The MDS further documents that R3 ambulates with walker and limited assistance from staff, no functional range of motion limits, and extensive assistance of one staff member for transfer, dressing, hygiene, bathing and tolieting. On 4/15/15 at 1:51 PM, during an interview with E6, Registered Nurse, RN, stated she saw R3's foot wound in March but was unable to recall which toe was receiving wound care and that R3 refuses to allow wound care. E6 stated she didn't know much about R3's right 4th toe. On 4/15/14 at 2:41 PM, during an interview, E9, RN stated she knew R3 had leg and foot problems and was being treated for [REDACTED]. E9 stated R3 was receiving Medicated Foot Soaks on her (R3) right great toe. E9 stated the right great toe just had redness but was unsure of the date she observed the redness. E9 stated that R3 refused to have toes looked at every time due to pain, but did allow staff to look "most" times. E9 stated she was afraid R3's toes would touch each other so she put a DuoDerm in between R3's third and fourth toe to keep from touching each other. R9 stated she noticed redness on 3/19/14 to the 4th toe and reported findings to oncoming nurse. On 4/15/14 at 3:20 PM, during an interview with E12, Certified Nurse Aid, stated that R3's fourth toe was red and had pus on the side in the nailbed and was getting yellow. E12 was unsure of when she first noticed R3's fourth toe change. E12 stated that the weekend before she was sent out to the hospital for her fourth toe E12 noticed R3's fourth toe was very red and draining pus. On 4/15/14 at 10:38 AM, during an interview with E10, RN, stated that treatment was started on R3's right great toe for [MEDICAL CONDITION] around 2/26/14 or 2/28/14 and R3 was getting antibiotics and medicated foot soaks three times a day for right great toe. E10 stated that R3 would refuse the toe soaks at times and the great toe was healing slowing. E10 stated that R3's treatments were changed to evening shift and fourth toe was not receiving any treatment. On 4/15/14 at 12:32 PM, during an interview, E2, Director of Nursing, stated that staff have called her and informed her on 3/28/14 that R3's toe area was red and E2 had R3 sent to the emergency room . On 4/21/14 at 10:30 AM E1, Administrator, stated that there was no documentation on R3's right 4th toe from 3/20/14 to 3/28/14, the date she was transferred out of the facility. E1 also stated he did not have any record of a fax sent over to Z3 regarding refusal R3's refusal to allow treatments to be done on her foot. On 4/21/14 at 11:45 AM, E11, Licensed Practical Nurse, stated that she monitors wounds on Monday, Wednesdays and Fridays and all of the assessments are in the electronic medical record. E11 further stated there is no other documentation or measurements. On 4/15/14 at 1:30 PM, Z3, Primary Care Physician for R3 stated he did not recall if the staff let him know that (R3) was refusing treatments to her foot. They would generally let him know this by faxing a note over to his office and there would be a record of that fax under documents in the electronic medical record. Review of the document section showed no indication of a faxed update to Z3. R3's Physician order [REDACTED]. R3's Treatment Administration History dated 3/1/14 through 3/30/14 documents and order on 3/6/14 to "apply DuoDerm to [MEDICAL CONDITION] area to right 4th toe until healed. Change Q (every) three days and PRN (as needed) " The Treatment Administration history further documents R3 to have weekly skin check on Fridays with the last skin check on 3/21/14. No documentation on the assessment or monitoring of R3's fourth toe in R3's Treatment Administration History or Weekly Skin check. Nurses' Notes dated 3/19/14 documents in part, "wound on 4th right toe with area of <1 CM with bed yellow/white in color." Nurses' Notes dated 3/20/14 document in part, "area noted to 4th toe noted, approx measurement 2 cm. MD notified. Rt toes remain reddened." Nurses' Notes dated 3/28/14 document in part "R3 4th toe on right foot red and 1/2 of toe is black and around nailbed also black and base of toe. Right foot is red with noted red streaks going from toe toward ankle." No further documentation found in R3's clinical record on the assessment or monitoring of R3's 4th toe. R3's Care Plan dated 1/16/14 does not address any problem with R3's right 4th toe. Hospital emergency room records dated 3/28/14 document in part, R3 "presents with a wound to the anterior side of right foot reporting that the 4th toe nail started out as an ingrown toenail that gradually became darker. Physical Exam: Pulses- absent dorsalis pedis pulses on the right foot and R3's 4th toe of the right foot is gangrene from the PIP joint distally. black in color. [DIAGNOSES REDACTED] extending midway up the right foot. Progress Note: Patient with clearly gangrenous toe and associated [MEDICAL CONDITION] extending up her foot. " Based on interview and record review the facility failed to assess pertinent changes in the condition of three residents (R1, R2, and R3) reviewed for nursing assessments in a sample of 4. This resulted in R1 being admitted to the Intensive Care Unit with a [DIAGNOSES REDACTED]. It also resulted in R3's [DIAGNOSES REDACTED]. 3) Per the digital admission face sheet R2 has [DIAGNOSES REDACTED]. On 4/14/14 at 10:00 AM E 8, Licensed Practical Nurse ( LPN) stated she usually works on the 300 hallway. She was working on 3/14/14, and she noted (R2) had pain and swelling to his left leg. It was dark and angry red, about the size of a baseball. (R2) stated he felt pressure like his leg wraps were still on even though they had been removed. These were new symptoms. R2 also had some discoloration to the bottom of his right lower extremity from his [MEDICAL CONDITION], but (R2's) right leg had always been light pink, this was new; it was his left leg and it was bright red. I looked up his hospital records and saw the history of a [MEDICAL CONDITION], so I called the Doctor to let her know. She ordered a STAT Venous Doppler, and to call her with the results, which I called to schedule. It was scheduled for the next day 3/15, at 5 PM. On 4/14/14 at 2:20 PM E2, DON stated, Our emergency transfer policy doesn't address what to do specifically when a [MEDICAL CONDITION] is suspected. The nurses use nursing judgement and discuss the situation with the DON, and Physician. Or we can send a resident out if the family wants them to go. I don't see any notes on the pulses or condition of his leg after the test results were in. (R2) was a big guy and it would have been difficult to get him to the hospital, and we would have to send people with him for transport due to his size. On 4/21/14 at 10:30 AM when E1 was asked about assessment and documentation on R2, he stated, " I would have liked to see more documentation on (R2's) legs and pedal pulses. I agree with you we don't document well. If we would have documented better there would be a clearer picture. On 4/14/14 at 2:20 PM E2 stated; When I look at the notes I don't see any documentation on the description of the [MEDICAL CONDITION], after the note when the Doctor was called. On 415/14 at 10:50 AM Z1, the treating Physician for R2, stated; for the Symptoms described to me for (R2) I would usually order an ultrasound, and antibiotics if I felt it was [MEDICAL CONDITION]. I will usually do a STAT Ultrasound for acute changes. I don't remember in this case if I ordered a STAT Ultrasound. Review of Nurses Notes from 3/14/14 document the discovery of the red area on R2's leg and order for a venous Doppler. There is no assessment documentation noted regarding the pulses in the leg, calf measurements, check for Homans sign or any other indicators of changes in vascularity to the legs. A nurses note on 3/15/14 documents increased redness and pressure to the right leg. The Physician was notified and ordered a Venous Doppler Study. On 3/15/14, the Doppler preliminary result is documented as being positive for a [MEDICAL CONDITION]. There is no documentation regarding a description of the leg or any assessments of pulses to the extremity, color or swelling. On 3/16/14 R2 complains of leg pain, but no documentation is seen regarding a description of the leg/legs color, size or pulses. Review of Nurses notes from 3/16/14 through 3/26/14 when nurses note document arrangements for transfer to the hospital and discharge to home do not document any assessment/description/monitoring of R2's [MEDICAL CONDITION], leg circumference temperature, color or pulses. Review of an Ultrasound report dated 3/17/14 documents that R2 had " both acute and chronic [MEDICAL CONDITION] in the left common femoral vein, bilateral popliteal veins and left profunda femoral vein." Review of R2's Plan of Care which was last updated on 3/6/14 documents a problem which includes a history of [MEDICAL CONDITION] and [MEDICAL CONDITION] Embolism. No monitoring /assessment interventions are documented on the Care Plan regarding this problem. The Facility Policy titled "Resident Assessment" dated, 12/02 documents under procedure, "Evaluation defines needs, problems, approaches, short and long-range goals. This composes the nursing care plan." Under number 3. Nurses role in evaluation ; Responsible for documentation of evaluation,. Under #4 Areas of evaluation A. Physical-function of body systems, #1. Circulatory-pulse rate regularity and strength, pallor cyanosis....coldness, color of distal parts..... The Lippincott Manual of Nursing Practice dated May 29, 2013 documents under assessment and Pathopysiologic Manifestations of Vascular Disease: Assessment includes observation of extremity Temperature, Pallor, Redness, Cyanosis, Pain, "when it occurs at rest, it indicates a more severe degree of ischemia," Exercise Tolerance, Peripheral Pulse Volume based on a scale of 1-4, Capillary Refill Time and Blood Pressure On 4/21/14 at 10:30 AM when E1 was asked about assessment and documentation on R2, he stated, " I would have liked to see more documentation on (R2's) legs and pedal pulses. I agree with you we don't document well. If we would have documented better there would be a clearer picture.

Based on interview, observations and record review, the facility failed to provide a safe transfer and failed to have the personal alarm on for 2 of 6 residents in a sample of 19. This failure resulted in R1 sustaining a fractured arm from a fall when left alone without her alarm on and R6 falling from a mechanical lift on sustaining a laceration to the head followed by a rapid decline in condition and expired on [DATE]. Findings include: 1. The Admission Sheet identifies R6 as a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], R6 required extensive assist of two staff for transfers. The care plan dated [DATE] identifies R6 to be at high risk for falls and includes the intervention "mechanical lift for transfers with assist of two staff." A Fall Investigation dated [DATE] indicates "Only one C.N.A. (Certified Nurses Aide) was transferring the resident from bed to w/c (wheelchair) via mechanical lift this AM. When 2nd aide walked in the room, res (resident) was already in the sling, in the air, and positioned very incorrectly (sideways/crooked). 2nd aide tried to quickly move w/c under sling but could not do that fast enough. Resident fell to floor, hitting back of head." The report documents R6 was taken to the emergency room for treatment and returned with stitches to the back of her head. The report continues to document that the CNA responsible for the improper transfer was terminated. According to the report, the "Aide did have the straps crossed correctly on the sling, but had resident positioned incorrectly. She also admitted to (shift coordinator) that she knew she transferred in a way that was against how she was taught to do in our facility." On [DATE] at 10:30am, E2 Director of Nursing stated she had no refutation toward the fall as the CNA failed to follow policy and that all mechanical lifts are to be done with two staff and confirmed that the CNA was terminated. On [DATE] at 2:16pm, E7 and E8, CNAs, were observed to transfer R6 to bed and provide incontinent care. R6 was clearly nonresponsive during the transfer and care. Both CNA stated R6 has had a "substantial decline" in the past week and a half. According to the physician's orders [REDACTED]. The facility policy on Mechanical Lift transfers includes information on mechanical lift procedures. On [DATE] at 1:45pm, E9 Restorative Nurse/Licensed Practical Nurse provided a copy of the lift policy and stated it is the facility's policy that 2 staff assist every mechanical lift. 2. According to the MDS dated [DATE], R1 required extensive assist of one staff for mobility and has a history of falls with fractures. The MDS identifies balance deficits indicating that R1 could not go from sitting to standing, walking, turning around, going surface to surface or toilet without human assistance. The care plan dated [DATE] indicates she used a hemin walker for transfers and that her gait was unsteady due to right hemiparesis. The careplan also indicates R1 has an alarm on her wheelchair and has had numerous falls. On [DATE] at 9:45pm, the nurses notes indicate R1 was heard yelling for help and was found on the floor when the CNA entered . According to an "events detail", R1 was getting ready for bed and had an unwitnessed fall sustaining injury to her right shoulder and forearm. The event investigation does not include information as to whether the alarm was on and sounding or not. R1 was transferred to the emergency room and a fractured humerus was identified. On [DATE] at 4PM, E2, Director of Nursing stated that the CNA's were getting R1 ready for bed and had shut her chair alarm off stepping from the room to get linen supplies when R1 fell .

Based on observation, record review and interview, the facility failed to provide timely reposition, failed to identify a new pressure ulcer; and failed to measure a pressure ulcer accuately for 3 of 6 residents (R3, R10, R12) reviewed for pressure ulcers in the sample of 19. This failure resulted in a pressure sore decline for R3. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documents that R3 has short/long term memory deficits, moderate cognitive impairment, requires extensive assist of one staff for bed mobility and all transfers and is frequently incontinent of bowel. The Care Plan dated 9/29/11 documents R3 is at risk for skin breakdown due to impaired mobility, has history of skin breakdown with chronic red scarring and is a diabetic. The Care Plan goal is "area to coccyx will decrease in size." The Care Plan interventions include, in part as, air flow mattress, monitor for pain or discomfort, preventative skin care as indicated, turn and position at least every two hours and as needed and weekly skin checks. The Care Plan also documents that R3 has [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) infection to coccyx wound. On 06/30/11, the Care Plan documents that R3 had an indwelling catheter placed for coccyx wound. Documentation indicates that R3 has a history of multiple Urinary Tract Infections (UTI'S). On 10/18/11 at 10:00 am, R3 was observed laying on back in bed. At 12:35 pm, E14, CNA, transferred R3 from the bed to her wheelchair. E14 did not check R3's for incontinence at this time. R3 was taken to the dining room for lunch. On 10/19/11 at 9:00 am, R3 was sitting in her wheelchair in her room next to her bed. At 11:30 am, R3 was still in the same position in her wheelchair in her room. At 2:05 pm, R3 was observed sitting in bed on her back with the head of the bed at a 90 degree angle. At 2:43 pm, R3 was sitting up with her feet on the floor attempting to push herself up out of bed unassisted. There was a strong foul smelling odor near R3. When asked about the odor, E10, CNA, stated "That's not urine, it's her wound." On 10/19/11 at 3:40 pm, it was observed that E10 and E18, both CNA's, transferred R3 from the wheelchair to the bed. E10, CNA, stated that they were going to check R3 for incontinence and the nurse was going to change the dressings. When E10 and E18 removed the incontinent brief, there was a six inch area of brownish drainage on the incontinent brief from the pressure sore. It is noted that the wheelchair cushion is also soiled with the same brownish drainage. The area under the abdominal fold and a 6 cm slit-like open area under the right abdominal fold was observed. E10, CNA stated that she had not seen that before. It was also observed that there were two dressings on the buttocks/coccyx area with the coccyx wound was observed to be saturated with brownish drainage. When the dressings were removed, an open wound on the right buttocks, as well as an open wound on the coccyx did exist. On 01/02/11, a nurse's note documents "S/T (skin tear) to coccyx turned into open ulcer, measures 1.5 X 2.5." Documentation indicates that on 10/18/11, R3 was seen by a Specialized Wound Management (SWM) nurse for an evaluation of the coccyx wound. A SWM note documents the wound assessment as "Length 1.1 cm X Width 1 cm X Depth 0.6 cm, Undermining: 12= 0.4 cm, 3= 0.3 cm, 6= 0.6 cm, 9= 0.5 cm...Stage III pressure ulcer." The [DIAGNOSES REDACTED]. wound measured 1 cm X 1 cm X 0.2 cm with no undermining reported. On 09/27/11, the facility Weekly Infection Control Report documents that R3 has developed a new area to the right buttocks measuring 1.2 cm X 0.8 cm X 0.1 cm. There was no documentation of an assessment identifying an area under the abdominal fold until this surveyor returned on 10/20/11. The policy and procedure titled, "Protocol for Pressure Ulcer Prevention and Treatment" was reviewed on 10/20/11. It indicates under, "Principles: #7. When a resident is admitted to the facility of develops a pressure ulcer in the facility, the following will occur: A. Assess the pressure ulcer for location, size (L x W x D), wound bed, drainage (amount, color, type), odor, tunneling, undermining, wound edges and pain at site. B. Determine the ulcer's current stage of development..." During a teleconference interview conducted on 10/21/11 at 10:39 am with Z2, physician, it was reported from Z2 that R3 was a long-time patient with many co-morbidities and multiple (UTI's). Z2 reported that R3 was previously on Hospice due to End Stage [MEDICAL CONDITION], but had rallied and was subsequently removed from Hospice status. Z2 stated that he believes that R3 will be back on Hospice in the near future due to her increased [MEDICAL CONDITION] and general debility and overall decline in health. When asked if the pressure ulcers were preventible, he stated "Skin fails like any other organ." When asked if turning and repositioning would have prevented the pressure ulcers, he replied, "There's no doubt turning and repositioning would make a difference." Z2 did confirm that R3 "was either incapable or simply doesn't want to move herself" while in bed. Therefore, R3 must be repositioned by staff. Z2 responded with "Yes." 2. R12's Admission Record identifies him to have [DIAGNOSES REDACTED]. The MDS dated [DATE] identifies R12 as having cognitive impairment and being totally dependent on staff for all aspects of daily living and is occasionally incontinent of bowel and always incontinent of bladder. On 10/19/11 at 11:55am, R12 was taken to the bathroom by E13 and E21, CNA's to toilet. R12 was transferred to the toilet and found to be incontinent of a large amount of stool and his brief was saturated with urine. According to E13 and E21, R12 was last checked/toileted at 9:10am that morning almost 3 hours prior. R12 is at risk for pressure ulcers according to his care plan dated 10/13/11 with interventions to turn and reposition every two hours. 3. R10's Care Plan, goal target date 11-02-11, documented R10 was at increased risk for skin breakdown related to age and skin fragility, impaired cognition with impaired safety awareness. It was also noted on the care plan, dated 9-20-11, R10 had a deep tissue injury to her coccyx. R10's Treatment Flowsheet, dated 10-1-11 to 10-31-11, documented "Cleanse coccyx, apply Santly, cover with bordered gauze, change daily and prn (as needed)." During observation of R10's care, on 10-19-11 at 9:45a.m., R10 did not have a dressing in place on her coccyx. Interview of E16, CNA, on 10-19-11 at 9:45a.m., E16 stated R10 did not have a dressing on her coccyx when she got R10 up, around 7:00a.m., and that she did not tell anyone R10's coccyx dressing was not in place.

Based on interview and record review it was determined that the facility failed to ensure that 1 (R2) of 3 residents reviewed were free of significant medication errors. This failure resulted in R2 experiencing signs/symptoms of [MEDICAL CONDITION], such as shortness of breath, [MEDICAL CONDITION] and [MEDICAL CONDITION], for days before being hospitalized with an exacerbation of [MEDICAL CONDITION]. R2 was hospitalized twice and admitted to hospice services on [DATE]. R2 expired on [DATE]. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication. R2 was admitted to the facility on [DATE] with diagnoses, in part, of [MEDICAL CONDITIONS], hypertension, and [MEDICAL CONDITION]. R2 was assessed on the [DATE] Minimum Data Set as able to make himself understood in his ability to express his ideas and wants and having clear comprehension in his ability to understand others. According to the "Medications Flowsheet" for January and February, 2011, R2 had physician orders [REDACTED].- ,[DATE] mg ,[DATE] tablet twice a day, [MEDICATION NAME] for Hypertension- 25 mg twice a day, Lacri-lube for eye disorder twice a day, [MEDICATION NAME] for Eye disorder- 250 mg twice a day, and [MEDICATION NAME] for Hypertension- 10 mg three times per day. The "Medications Flowsheet" documented R2 did not receive the ordered 60 mg of [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE] and lacri-lube from [DATE] until [DATE]. The flowsheet that R2 did not receive [MEDICATION NAME], Klor-Con, [MEDICATION NAME], and [MEDICATION NAME] as ordered by the physician from [DATE] through [DATE]. E2, Director of Nursing, stated on [DATE] at 3:30 PM, that the pharmacy stopped sending all medications for R2 the first part of January due to payment issues. R2 received the medication until it ran out and then the medicine was not refilled. E2 confirmed that she had not contacted R2's physician regarding the medications. E1, Administrator, confirmed the information provided by E2 on [DATE]. E1 stated she was not aware until last week that R2 was not getting his medications and pharmacy should have notified her. E1 stated staff should have ordered the medication. Z2, Registered Pharmacist, stated on [DATE] at 9:30 AM, that he was not aware R2 had not been receiving his medications until [DATE]. When asked if R2 not receiving his medications were a problem for R2, Z2 stated R2 was on the medications for a reason. The [MEDICATION NAME] and [MEDICATION NAME] were the medications that could cause R2 the worst problems if he didn't get the medications. Z2 stated he wasn't sure if being off the medications caused the [MEDICAL CONDITION] exacerbation but it "didn't help". On [DATE] at 9:15 AM the notes states R2 continued to have 3 plus [MEDICAL CONDITION] with bilateral lower extremities very painful and red. R2 requested to go to the hospital. The hospital history and physical dated [DATE] documented as the "Chief Complaint" "Increased [MEDICAL CONDITION] in bilateral lower extremities. The exact duration for how long it's been going on is not known." The assessment documented "acute decompensated systolic [MEDICAL CONDITION]" with the "BNP (Brain Natriuretic peptide) 669" and "early signs of [MEDICAL CONDITION] in toes of both feet". Z1, Physician for R2, stated on [DATE] at 10:00 AM by phone that he was not aware that R2 was not receiving his medications as prescribed. Z1 stated the facility and Z3, Nurse Practitioner, had not informed him the facility had not given R2 his medications. Z1 stated he didn't know what to say and asked why R2 was not receiving his medications. Z1 stated the pharmacy should have sent the medications. The facility should have helped the resident and provided R2 with his medications. Z1 stated it was inappropriate for the facility not to inform him that R2 was not receiving the medications. Z1 stated "Of course" that the effects of R2 not receiving his medications contributed to his hospitalization . When asked if Z1 considered this neglect he stated "yes" and that R2 "should have gotten the meds". On [DATE] R2 was readmitted to the hospital with [REDACTED]. The history and physical dated [DATE] noted the chief complaint was "shortness of breath". The report noted R2 was "found to have acute on chronic systolic [MEDICAL CONDITION] exacerbation and was admitted to the intermediate intensive care unit". The "Discharge Summary" dated [DATE] noted "the patient's sister stated that this has been a gradual decline over the last few months...". The "Discharge Summary noted R2 was medically stable on discharge with his heart failure exacerbation controlled. [MEDICATION NAME] was increased from 60 mg to 80 mg. R2 was readmitted to the facility on [DATE] on hospice. On [DATE] at 2:34 AM the nurses notes states R2 was found expired at 1:30 AM. The State "Certificate of Death" dated [DATE] and signed by Z7 noted the "Immediate Cause" of death as "[MEDICAL CONDITION]". The Immediate Jeopardy was identified to have begun on [DATE] when staff failed to provide medications to R2 and then failed to assess, monitor, and implement interventions for a decline in R2's condition according to their policies and procedures. E1, Administrator, and E2, Director of Nursing, were informed of the Immediate Jeopardy on [DATE] at 2:55 PM. The Facility took the following actions to remove the Immediacy: 1. All licensed nursing staff was in-serviced on [DATE] and [DATE]. Topics were neglect, medication errors and pharmacy services. The nursing staff was informed that medications are to be available for administration as ordered, and may require the pharmacy emergency run medications or the facility assume financial responsibility. 2. All private pay resident ' s medications and pharmacy services have been reviewed and no problems have been found as of [DATE] 3. The Pharmacy was contacted by the Administrator and it was agreed that medication non-coverage issues are to be reported directly to the Administrator as of [DATE] 4. The Quality Assurance Committee has reviewed the Policy for Pharmaceutical Procedures and changes will be made accordingly 5. On [DATE] licensed nursing staff was in serviced on proper assessing of resident and of resident ' s condition including physical assessment and vital signs and determining resident ' s outcome and changing interventions if needed. 5. The Administrator and/or designee shall be responsible for ensuring continued compliance and will be responsible for overseeing the implementation of the above Plan. Based on record review and interview the facility failed to administer intravenous antibiotics to 1 (R1) of 2 residents on sample reviewed for medication of 5 sampled residents. The findings include: R1 was admitted to the facility on [DATE] with diagnoses, in part, of debility, intractable back pain, hypertension, and depression. On [DATE] R1 was admitted to the hospital for increased lethargy and confusion according to the hospital history and physical. R1 was found to have a urinary tract infection and pneumonia. R1 was discharged to the facility on [DATE] at 6:00 PM with orders for Intravenous (IV)Antibiotics of [MEDICATION NAME] in [MEDICATION NAME] piggyback, 3.375 grams/50 milliliters every 6 hours. E2, Director of Nursing, stated on [DATE] that there were issues with R1's IV's. E2 stated R1 returned to the facility on the weekend with orders for IV antibiotics and there was no registered nurse at the facility to administer the IV. The physician was called and told him they couldn't do the IV and asked for an oral medication The physician refused. The physician was called again to discontinue the IV order or send R1 back to the hospital but the physician refused. E2 confirmed that the physician did not discontinue the IV order. E2 stated that the physician was called off hours and told him the "IV (was) not happening" and he was angry. The facility called Hospice and requested an order for [REDACTED]. A Discharge Summary from Z6, physician, dated [DATE], documents R1 was discharged to the facility with an intravenous (IV) acces port on [DATE], after hospital treatment for [REDACTED]. Z6's admission orders [REDACTED]. Also ordered, the antibiotic [MEDICATION NAME] in [MEDICATION NAME] piggyback; 3.375 grams/50 ml IV every 6 hours for the continued treatment of [REDACTED]. On [DATE], at 2:50 PM, E2, Director of Nursing, (DON) stated, "We were not prepared for the IV [MEDICATION NAME] ordered to continue for (R1) on [DATE], when she returned from the hospital. She (R1), had a IV access port. No one was available at that time to start an IV." E2 confirmed R1 never received the IV [MEDICATION NAME] because the hospice nurse came on [DATE], and an order was obtained for the oral antibiotic, [MEDICATION NAME]. The Nurses Note, dated [DATE], confirms a physician was notified and twice refused to discontinue the IV [MEDICATION NAME] as ordered. The Nurses Note, dated [DATE], at 6:00 PM, reads, "Spoke with DON once again and discussed what MD (medical doctor) had said. Decided we would wait till ABT (antibiotic) came from pharmacy and after hospice came in AM (morning) and see what hospice wanted to do." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE], at 1:50 PM, Z1, Physician reported Z6, Physician discharged R1 from the hospital on [DATE] with the order for IV [MEDICATION NAME]. Z1 reported he would not have discontinued the IV [MEDICATION NAME] and the facility should be capable of administering an IV antibiotic. Z1 reported he has had problems with his residents at the facility receiving medications as ordered. Z1 reported R1 should have received the IV [MEDICATION NAME], and he would never refuse to send any resident to the hospital. On [DATE], at 2:45 PM, Z6, Physician reported he does not remember the specifics of R1's discharge on [DATE]. Z1 reported if he discharged a resident to a nursing home with an IV antibiotic he would expect the hospital and the receiving facility to coordinate the discharge care so R1 could receive the IV medications as ordered. Z1 stated, "The nursing home is required to be prepared for IV therapy for a resident." Z1 confirmed he would not have discontinued the IV [MEDICATION NAME], and was not aware she did not receive it. Z1 reported he would never send her back to the hospital to just receive IV medication. Z1 reported the facility's DON should have been available to start the IV. The facility's policy and procedure, entitled, 'Administration of an Intermittent Infusion', documents a physician's orders [REDACTED]. The facility's policy entitled, 'Medication Administration', reads, "Objective; 1. To provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified [DIAGNOSES REDACTED].

Based on record review and interview it was determined that the facility failed to acquire and administer medications and to collaborate with a licensed pharmacist for 2 (R1, R2) of 3 residents on the sample of 5 reviewed. This failure resulted in R2 experiencing an exacerbation of congestive heart failure, edema and cellulitis with Methicillin resistant Staph Aureus of the feet. R2 was hospitalized twice and was admitted to hospice. R2 expired on 3/7/11. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 3/7/11, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication. 1. Z2, Registered Pharmacist, stated on 3/2/11 at 9:30 AM, that he was not aware R2 had not been receiving his medications until 3/1/11. Z2 was surprised nursing staff had not informed him. Z2 did review R2's medications in January and February however, he did not review the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Z2 stated a problem with the billing for R2's medications was given as a reason for R2 not receiving the medications. Z2 stated R2 had a different pharmacy than the facility used. R2 used a mail order pharmacy and he was unsure about the billing problems. Z8, Biller from facilities pharmacy, stated on 3/10/11 at 12:55 PM by phone that she was shocked when she was told of the situation with R2 and had never seen it happen before. Z8 stated the process is simple and the facility has to tell the pharmacy what the resident needs. Z8 stated the medications were being sent out in 3 day batches. When the "Do Not Send" was sent to the facility there was paperwork the facility should have filled out to continue the medication. The facility should have continued paying for the medication until it could have been worked out with the power of attorney. Some insurances will go back 90 days to reimburse for the medications. No one in authority called the pharmacy from the facility to ask why the medications were not being sent or they would have been sent. The "Medications Flowsheet" documented R2 did not receive the ordered 60 mg of Lasix from 1/29/11 until 2/15/11, Lisinopril from 1/1/11 until 2/15/11, Coreg from 1/21/11 until 2/15/11, Isosorbide Dinitrate 2/1/11 until 2/15/11, Levodopa from 2/2/11 until 2/15/11 and lacri-lube from 1/26/11 until 2/15/11. The flowsheet that R2 did not receive Allopurinol, Klor-Con, Lansoprazole, and Synthroid as ordered by the physician from 1/1/11 through 2/14/11. E2, Director of Nursing, stated on 2/28/11 at 3:30 PM, that the pharmacy stopped sending all medications for R2 the first part of January due to payment issues. R2 received the medication until it ran out and then the medicine was not refilled. The family had been called and they stated they had an arrangement with the pharmacy due to the R2's status was private pay. E2 gave the family printed material on choosing a Medicare plan but did not receive an answer. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. E2 confirmed that the medications with circles on the medication administration sheet noted R2 had not received the meds. E2 stated it was her understanding R2 would have to pay for his meds to receive them. E2 stated "So the facility is responsible to pay for (R2's) meds?" E2 confirmed that she had not contacted R2's physician regarding the medications or called the pharmacy. E2 stated on 3/8/11 at 2:57 PM that R2 had a mail order pharmacy plan which is different that the facility pharmacy. She told the family that the facility "doesn't do mail order". E2 stated they would send a 3 month supply and they couldn't keep that many medications around. When informed that other facilities keep a 3 month supply for residents E2 stated "Not in my facility". E2 stated the family could not bring in the medications as it was against the Departments regulations. The facility pharmacy could not bill the mail order pharmacy and get reimbursed from the mail order pharmacy. The facility pharmacy could not supply the medications without payment. The family was suppose to pay the facility pharmacy privately for R2 to get his medications. E2 printed off medication plans for the family and handed the plans to the family. E2 stated on 2/14/11, Valentines Day, the family paid the bill and the "Do Not Send" was taken off the facility pharmacy bill for R2. R2 received his medications on 2/15/11. E2 stated R2 was on Medicare when he first came in and received his medications without a problem for 3 months. E1, Administrator, confirmed the information provided by E2 on 2/28/11. E1 stated she was not aware until last week that R2 was not getting his medications and pharmacy should have notified her. E1 stated staff should have ordered the medication. E4, Licensed Practical Nurse (LPN), stated on 3/2/11 that R2 was not receiving his medications due to a billing problem. The pharmacy was faxed with the medication request but they did not send the meds. E4 stated that everyone was aware that R2 was not getting his meds. E4 could not recall if she had told the physician R2 was not getting his medications. Z3, Nurse Practitioner for Z1, stated on 3/3/11 at 2:00 PM by phone that she had been told several weeks after the fact that R2 was not receiving his medications. R2 had not been getting the medications for about 3 weeks. The facility was trying to get the family to order the medications. Z1, Physician for R2, stated on 3/2/11 at 10:00 AM by phone that he was not aware that R2 was not receiving his medications as prescribed. Z1 stated the facility and Z3, Nurse Practitioner, had not informed him the facility had not given R2 his medications. Z1 stated he didn't know what to say and asked why R2 was not receiving his medications. Z1 stated the pharmacy should have sent the medications. The facility should have helped the resident and provided R2 with his medications. Z1 stated it was inappropriate for the facility not to inform him that R2 was not receiving the medications. Z1 stated "Of course" that the effects of R2 not receiving his medications contributed to his hospitalization . When asked if Z1 considered this neglect he stated "yes" and that R2 "should have gotten the meds". R2 was hospitalized from [DATE] until 2/26/11. The hospital history and physical dated 2/21/11 documented "acute decompensated systolic congestive heart failure" with the "BNP (Brain Natriuretic peptide) 669" and "early signs of cellulitis in toes of both feet" as the assessment. Lab results dated 2/21/11 noted "heavy growth" of Methicillin Resistant Staph Aureus (MRSA) of the right foot. There is no documentation regarding R2 not receiving the medication at the facility. R2 was readmitted to the hospital on [DATE] until 3/4/11. The history and physical dated 3/2/11 noted the chief complaint was "shortness of breath". The report noted R2 was "found to have acute on chronic systolic congestive heart failure exacerbation and was admitted to the intermediate intensive care unit". It was noted that R2 had a history of [REDACTED]. R2 was readmitted to the facility on [DATE] on hospice and expired on 3/7/11. The Immediate Jeopardy was identified to have begun on 1/1/11 when staff failed to provide medications to R2 and then failed to assess, monitor, and implement interventions for a decline in R2's condition according to their policies and procedures. E1, Administrator, and E2, Director of Nursing, were informed of the Immediate Jeopardy on 3/7/11 at 2:55 PM. The Facility took the following actions to remove the Immediacy: 1. All licensed nursing staff was in-serviced on 3/1/11 and 3/2/11. Topics were neglect, medication errors and pharmacy services. The nursing staff was informed that medications are to be available for administration as ordered, and may require the pharmacy emergency run medications or the facility assume financial responsibility. 2. All private pay resident ' s medications and pharmacy services have been reviewed and no problems have been found as of 3/2/11 3. The Pharmacy was contacted by the Administrator and it was agreed that medication non-coverage issues are to be reported directly to the Administrator as of 3/2/11 4. The Quality Assurance Committee has reviewed the Policy for Pharmaceutical Procedures and changes will be made accordingly 5. On 3/7/11 licensed nursing staff was in serviced on proper assessing of resident and of resident ' s condition including physical assessment and vital signs and determining resident ' s outcome and changing interventions if needed. 5. The Administrator and/or designee shall be responsible for ensuring continued compliance and will be responsible for overseeing the implementation of the above Plan. Based on interview and record review, the facility failed to administer medication as ordered by the physician for 1 (R1) of 3 residents reviewed for medication errors of 5 sampled residents. Findings include: A Discharge Summary from Z6, physician, dated 12/04/10, documents R1 was discharged to the facility with an intravenous (IV) access port on 12/04/10, after hospital treatment for [REDACTED]. Z6's admission orders [REDACTED]. Also ordered, the antibiotic Zosyn in dextrose piggyback; 3.375 grams/50 ml IV every 6 hours for the continued treatment of [REDACTED]. On 3/07/11, at 2:50 PM, E2, Director of Nursing, (DON) stated, "We were not prepared for the IV Zosyn ordered to continue for (R1) on 12/04/10, when she returned from the hospital. She (R1), had an IV access port. No one was available at that time to start an IV." E2 confirmed a Registered Nurse or a Licensed Practical Nurse trained to provide IV therapy was not available on 12/04/10 at 5:00 PM. E2 confirmed R1 never received the IV medications ordered by Z6. On 3/08/11, at 2:45 PM, Z6, who ordered the IV therapy, confirmed the skilled facility is licensed to provide IV therapy, if needed for residents. Z6 reported E2, DON should have immediately arranged for the medication to be given as ordered. Z6 reported he never discontinued the IV medication he ordered for R1.

Based on record review and interview it was determined that the facility failed to assess, monitor, and implement interventions for a decline in condition for 1 (R2) of 3 residents reviewed for a decline in condition in a sample of 5. This failure resulted in R2 experiencing signs/symptoms of [MEDICAL CONDITION], such as shortness of breath, [MEDICAL CONDITION] and [MEDICAL CONDITION], for days before being hospitalized with an exacerbation of [MEDICAL CONDITION]. R2 was also diagnosed with [REDACTED]. R2 was hospitalized twice and admitted to hospice services on [DATE]. R2 expired on [DATE]. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication The "Medications Flowsheet" documented R2 did not receive the ordered 60 mg of [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE] and lacri-lube from [DATE] until [DATE]. The flowsheet for [DATE] through February 14, 2011 noted during this time frame, R2 did not receive [MEDICATION NAME], Klor-Con, [MEDICATION NAME], and [MEDICATION NAME] as ordered by the physician. Review of the medical record nurses and nurse practitioner notes documented the following failure to assess, monitor and implement interventions for R2: [DATE] R2 complained of shortness of breath. Oxygen levels were ,[DATE] % . The physician was called and ordered R2 to the hospital if the oxygen levels were under 94%. The next note states the Power of Attorney was notified and did not want R2 to go to the hospital. R2 declined to go to the hospital. There is no documentation the physician was notified that R2 was not sent to the hospital. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]-There was no documentation in the nurses notes from [DATE] until [DATE]. The next note on [DATE] noted R2 had a poor appetite only. . . [DATE]-There is no documentation in the nurses notes from [DATE] until [DATE]. The next note on [DATE] noted that R2 was short of breath and could not catch his breath. The oxygen saturation levels were 82%. Oxygen was placed on R2. There is no documentation the physician was notified. E1, Administrator, confirmed on [DATE] that the physician was not notified. [DATE]-The next nurses note was [DATE] at 3:05 AM and stated R2 continued to have episodes of shortness of breath with respirations becoming labored at times. Pitting [MEDICAL CONDITION] was noted to bilateral lower extremities. There was no documentation the physician was notified. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]- A blister was noted that popped on the right second toe. A fax was sent to Z1 noting triple antibiotic ointment and Band-Aid was applied. "Dr. will advise if he would like a different tx (treatment) or with any orders". [DATE]-At 5:41 AM the nurses notes documented that R2 was awake and yelling most of the shift. Bilateral [MEDICAL CONDITION] to lower extremities was noted. Toes were noted as puffy and tight with superficial red marks on the second and third toes of each foot. R2's face was puffy with some shortness of breath on exertion. There is no documentation the physician was notified. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]- More than 4 hours later at 10:09 AM the physician was called and ordered a chest x-ray and oxygen for shortness of breath. R2 was noted to be very confused and lethargic and slumped in his chair. Bilateral 2 plus [MEDICAL CONDITION] was noted with blisters on his feet. The note states "Resident ok with going to hospital however we are awaiting call back from POA (family)". R2 was not sent to the hospital until [DATE]. [DATE]-At 1:17 AM, the oxygen saturation level for R2 was documented at 86% and his lips were cyanotic. Oxygen was applied. The physician was not notified. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]-the note by E4 states "Recorded as Late Entry on [DATE] 09:14 AM" that no return call from R2's power of attorney regarding the [DATE] request by R2 to go to the hospital. E4 confirmed on [DATE] that the family did not call back so R2 was not sent to the hospital. [DATE]- Z3 noted on the "Physician Quality Reporting Initiative (PQRI) Physician Quality Measures" that "Medications are ordered but resident has not received for over one month due to family refusal to pay for his medications/select an insurance plan that will pay in LTC (Long Term Care) facility". There was no further documentation regarding the lack of medications on the report, hospitalization , shortness of breath, [MEDICAL CONDITION] or [MEDICAL CONDITION]. [DATE]-noted [MEDICAL CONDITION] remains to bilateral lower extremities and the facial [MEDICAL CONDITION] appeared to be reduced. The next note was on [DATE]. [DATE]-at 5:49 AM the nursing notes indicated R2 had 3 plus [MEDICAL CONDITION] to both legs and his feet were red and painful. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]- at 9:15 AM the notes states R2 continued to have 3 plus [MEDICAL CONDITION] with bilateral lower extremities very painful and red. The physician was called and ordered R2 be sent to the emergency room per his request. [DATE]- at 1:52 PM noted R2 was admitted to the hospital for "[MEDICAL CONDITIONS] "BNP" (brain natruretic peptide) up over 600". ,[DATE]//11- At 6:00 PM, R2 was readmitted to the facility. The nursing notes dated [DATE] at 12:57 PM noted R2 was returning to the facility. It noted R2 toes were scabbed over but positive for [MEDICAL CONDITION] Resistant Staph Aureus. No [MEDICAL CONDITION] was noted. R2 was on isolation [MEDICAL CONDITION]. R2 had an order for [REDACTED]. [DATE]-no complaints noted. [DATE]-At 5:22 PM the nurses notes documented no shortness of breath but 1 plus [MEDICAL CONDITION] was noted. [DATE]-At 2:51 PM one plus [MEDICAL CONDITION] with no shortness of breath was noted. There is no documentation the physician was notified. [DATE]-At 1:22 AM shortness of breath on exertion and ,[DATE] plus [MEDICAL CONDITION] to bilateral lower extremities noted. There is no documentation the physician was notified. [DATE]-At 3:36 AM the nurses notes states "At present there is no [MEDICAL CONDITION] in lower extrems (extremities) or feet". [DATE]-At 8:35 AM a fax was sent to Z7, Hospice Physician, requesting a chest Xray due to coughing and course crackles bilaterally. R2 was not admitted to Hospice services until [DATE]. [DATE]-At 8:46 AM the power of attorney refused the Xray. One to two plus [MEDICAL CONDITION] was noted. [DATE]-At 10:04 AM the nurses notes dated [DATE] at 10:04 AM documented that Z1, primary care physician, had been called to request an order for [REDACTED]. [DATE]-At 4:52 PM the Xray was done and at 6:37 PM the results noted pneumonia. The physician was called and while awaiting a call back at 7:56 PM, R2's oxygen saturation levels were noted to be 84% on room air. Shortness of breath was noted and R2 was sent to the hospital per nursing judgement. R2 was admitted to the hospital with [REDACTED]. R2 was observed on [DATE] at 11:30 AM sitting in his room with the oxygen cannula in his nose. R2 and had labored breathing and was asked if he was having trouble breathing. R2 stated "Yeah, It's a little better with oxygen on." E3, Certified Nurse Aide and Shift Coordinator, was asked to check the portable oxygen cannister and a red light indicating the cannister was out of oxygen appeared. E3 called E4, Licensed Practical Nurse, who came to the room and stated R2 was not on continuos oxygen but as needed. E4 was informed R2 had stated he was having trouble breathing. Oxygen saturation levels were checked and were 99%. E4 refilled the cannister. R2's orders are for oxygen at 2 liters as needed to keep oxygen saturation levels above 92%. E2 stated on [DATE] that R2 only had an order for [REDACTED]. The history and physical dated [DATE] noted the chief complaint was "shortness of breath". The report noted R2 was "found to have acute on chronic systolic [MEDICAL CONDITION] exacerbation and was admitted to the intermediate intensive care unit". It was noted that R2 had a history of [REDACTED]. The "Discharge Summary" dated [DATE] noted "the patient's sister stated that this has been a gradual decline over the last few months...". The "Discharge Summary noted R2 was medically stable on discharge with his heart failure exacerbation controlled. [MEDICATION NAME] was increased from 60 mg to 80 mg. R2 was readmitted to the facility on [DATE] on hospice. [DATE]- 1:30 PM R2 returned to the facility with no [MEDICAL CONDITION] noted. R2 was receiving a gastrostomy tube feeding. R2 was admitted to hospice services. Z9, Admitting Hospice Nurse, stated on [DATE] at 10:07 AM by phone that R2 was started on 0.5 ml of [MEDICATION NAME] every 2 hours as needed. Z9 stated she only saw R2 at admission and at that time he did not need a scheduled pain medication. Z9 stated R2 would grimace with movement but calmed quickly and didn't need a scheduled pain medication. According to the "Physician order [REDACTED]./ml: 10 mg =0.5 ml". According to the MAR, R2 received 0.5 ml of [MEDICATION NAME] two times on [DATE] and 1 time on [DATE]. The "Pain Assessment" dated [DATE] noted R2 had facial expressions of pain. The evaluation notes there is a "High Probability of Pain" but notes the the symptoms, intensity and site as "unknown". The interventions are not listed nor are the medications. [DATE]- 1:18 AM as needed [MEDICATION NAME] 0.5 milliliter was given for moaning and crying out. R2's catheter had been removed at 9:23 PM and R2 had not voided since then. [DATE]-9:30 AM-R2 did void. Responding to verbal commands and touch. [DATE]-5:06 PM noted R2 was up to bedside chair. No complaints of pain or discomfort noted. [DATE]- 9:39 AM R2 complained of pain and PRN (as needed) [MEDICATION NAME] was given and "tolerated well". R2 was responding to verbal commands. E4, LPN, stated on ,[DATE]/ 11 at 11:40 AM stated R2 was doing better on readmission on [DATE]. E4 stated on [DATE] the hospice nurse, Z10, had called to check on R2 and she told him R2 she didn't think R2 was comfortable and was moaning. E4 stated Z10 increased the [MEDICATION NAME] to 1 ml every 2 hours scheduled. Z10, Hospice Nurse, stated on [DATE] at 10:40 AM by phone that she had been told by E4 that R2 was moaning in between doses of 0.5 ml of [MEDICATION NAME]. Z10 stated R2 was actively dying based on information told to her by E4. Z10 stated she was the nurse on call and had never seen R2. Z10 stated she did not do a pain assessment but just went by what E4 was telling her. Z10 stated that it was usual to up the dose to that amount due to the state R2 was in. [DATE]- 10:14 AM the hospice nurse changed the [MEDICATION NAME] order from 1 ml PRN to 1 ml every two hours. [DATE]-5:42 PM R2 was noted as alert with no signs or symptoms of distress or discomfort. [DATE]-7:38 PM R2 was resting comfortably. "Non-verbal at this time. Responds to touch only". [MEDICATION NAME] was administered as ordered. Respirations were 14. Oxygen saturation levels were 95%. [DATE]-10:13 PM No signs or symptoms of discomfort or distress noted. [MEDICATION NAME] given. There are no nurses notes until 2:34 AM on [DATE]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. [DATE]-2:34 AM R2 was found expired at 1:30 AM. The State "Certificate of Death" dated [DATE] and signed by Z7 noted the "Immediate Cause" of death as "[MEDICAL CONDITION]". The Immediate Jeopardy was identified to have begun on [DATE] when staff failed to provide medications to R2 and then failed to assess, monitor, and implement interventions for a decline in R2's condition according to their policies and procedures. E1, Administrator, and E2, Director of Nursing, were informed of the Immediate Jeopardy on [DATE] at 2:55 PM. The Facility took the following actions to remove the Immediacy: 1. All licensed nursing staff was in-serviced on [DATE] and [DATE]. Topics were neglect, medication errors and pharmacy services. The nursing staff was informed that medications are to be available for administration as ordered, and may require the pharmacy emergency run medications or the facility assume financial responsibility. 2. On [DATE] licensed nursing staff was in serviced on proper assessing of resident and of resident ' s condition including physical assessment and vital signs and determining resident ' s outcome and changing interventions if needed. 3. The Administrator and/or designee shall be responsible for ensuring continued compliance and will be responsible for overseeing the implementation of the above Plan. Based on observation, record review and interview, the facility failed to ensure that one (R1) of 3 residents reviewed for following physician orders, in the sample of five, followed an ordered treatment to immobilize the left leg for treatment of [REDACTED]. Findings include: The physician's orders [REDACTED]. The current Minimum Data Set, (MDS) assesses R1 requires extensive assistance with ambulation with poor sitting and standing balance. The Nurses Note of [DATE], at 4:30 PM documents R1 returned from the hospital with a fracture to the left ankle. A physician's orders [REDACTED]. R1's physician's orders [REDACTED]. On [DATE], at 10:20 AM, R1 was in bed. The immobilizer boot was located on the floor next to the bedside stand. At 11:20 AM the immobilizer boot remained on the floor. At 11:30 AM, R1 was in a wheelchair with the boot applied to her left lower leg. At 1:30 PM, R1 was transferred to bed. The immobilizer boot was removed and placed in her wheelchair. On [DATE], at 1:38 PM, E7, Licensed Practical Nurse (LPN), stated, "She (R1) only wears it (immobilizer boot) when she is up in the chair and out of bed. (R1) can bear weight a little bit. She's has had it since October, and we have been trying to DC (discontinue) it." The Treatment Administration Record (TAR), for ,[DATE] shows failure to daily document the immobilizer boot for R1 was applied or removed as ordered by the physician. R1's Care Plan, dated [DATE], fails to address the fall of R1 on [DATE], R1's fracture to the left ankle or the treatment with the immobilizer boot. On [DATE], at 1:50 PM, Z1, R1's physician, confirmed he did not discontinue the immobilizer boot for R1's left lower extremity.

Based on record review and interview it was determined that the facility neglected to provide prescribed medications over an extended period and failed to assess, monitor, and implement interventions for a decline in condition for 1 (R2) of 3 residents reviewed for medication errors in a sample of 5. This neglect resulted in R2 experiencing signs/symptoms of [MEDICAL CONDITION], such as shortness of breath, [MEDICAL CONDITION] and [MEDICAL CONDITION], for days before being hospitalized with an exacerbation of [MEDICAL CONDITION]. R2 was also diagnosed with [REDACTED]. R2 was hospitalized twice and admitted to hospice services on [DATE]. R2 expired on [DATE]. This failure resulted in an Immediate Jeopardy. . While the immediacy was removed on [DATE], the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication. The findings include: 1. R2, was admitted to the facility on [DATE] with diagnoses, in part, of [MEDICAL CONDITIONS], hypertension, and [MEDICAL CONDITION]. R2 was assessed on the [DATE] Minimum Data Set as able to make himself understood in his ability to express his ideas and wants and having clear comprehension in his ability to understand others. According to the "Medications Flowsheet" for January and February, 2011, R2 had physician orders [REDACTED].- ,[DATE] mg ,[DATE] tablet twice a day, [MEDICATION NAME] for Hypertension- 25 mg twice a day, Lacri-lube for eye disorder twice a day, [MEDICATION NAME] for Eye disorder- 250 mg twice a day, and [MEDICATION NAME] for Hypertension- 10 mg three times per day. E2, Director of Nursing, stated on [DATE] at 3:30 PM, that the pharmacy stopped sending all medications for R2 the first part of January due to payment issues. R2 received the medication until it ran out and then the medicine was not refilled. The family had been called and they stated they had an arrangement with the pharmacy due to the R2's status was private pay. E2 gave the family printed material on choosing a Medicare plan but did not receive an answer. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. E2 confirmed that the medications with circles on the medication administration sheet noted R2 had not received the meds. E2 stated it was her understanding R2 would have to pay for his meds to receive them. E2 stated "So the facility is responsible to pay for (R2's) meds?" E2 confirmed that she had not contacted R2's physician regarding the medications or called the pharmacy. E2 stated on [DATE] at 2:57 PM that R2 had a mail order pharmacy plan which is different that the facility pharmacy. She told the family that the facility "doesn't do mail order". E2 stated they would send a 3 month supply and they couldn't keep that many medications around. E2 stated the family could not bring in the medications as it was against the Departments regulations. When informed other facilities do 3 month supplies of meds E2 stated "Not in my facility". The facility pharmacy could not bill the mail order pharmacy and get reimbursed from the mail order pharmacy. The facility pharmacy could not supply the medications without payment. The family was suppose to pay the facility pharmacy privately for R2 to get his medications. E2 printed off medication plans for the family and handed the plans to the family. E2 stated on [DATE], Valentines Day, the family paid the bill and the "Do Not Send" was taken off the facility pharmacy bill for R2. R2 received his medications on [DATE]. E2 stated R2 was on Medicare when he first came in and received his medications without a problem for 3 months. E1, Administrator, confirmed the information provided by E2 on [DATE]. E1 stated she was not aware until last week that R2 was not getting his medications and pharmacy should have notified her. E1 stated staff should have ordered the medication. E4, Licensed Practical Nurse (LPN), stated on [DATE] that R2 was not receiving his meds due to a billing problem. The pharmacy was faxed with the medication request but they did not send the meds. E4 stated that everyone was aware that R2 was not getting his meds. E4 could not recall if she had told the physician R2 was not getting his medications. Z2, Registered Pharmacist, stated on [DATE] at 9:30 AM, that he was not aware R2 had not been receiving his medications until [DATE]. Z2 was surprised nursing staff had not informed him. Z2 did review R2's medications in January and February however, he did not review the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Z2 stated a problem with the billing for R2's medications was given as a reason for R2 not receiving the medications. When asked if R2 not receiving his medications were a problem for R2, Z2 stated R2 was on the medications for a reason. The [MEDICATION NAME] and [MEDICATION NAME] were the medications that could cause R2 the worst problems if he didn't get the medications. Z2 stated he wasn't sure if being off the medications caused the [MEDICAL CONDITION] exacerbation but it "didn't help". Z8, Biller from facility's pharmacy, stated on [DATE] at 12:55 PM by phone that she was shocked when she was told of the situation with R2 and had never seen it happen before. Z8 stated the process is simple and the facility has to tell the pharmacy what the resident needs. Z8 stated the medications were being sent out in 3 day batches. When the "Do Not Send" was sent to the facility there was paperwork the facility should have filled out to continue the medication. The facility should have continued paying for the medication until it could have been worked out with the power of attorney. Some insurances will go back 90 days to reimburse for the medications. No one in authority called the pharmacy from the facility to ask why the medications were not being sent or they would have been sent. The "Medications Flowsheet" documented R2 did not receive the ordered 60 mg of [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE] and lacri-lube from [DATE] until [DATE]. The flowsheet that R2 did not receive [MEDICATION NAME], Klor-Con, [MEDICATION NAME], and [MEDICATION NAME] as ordered by the physician from [DATE] through [DATE]. Review of the nurse and nurse practitioner notes documented the following instances of failure to notify the physician, assess, monitor and implement interventions for R2: [DATE]- R2 was noted to have severe congestion in the left lung and a severe cough. The physician ordered a chest Xray, [MEDICATION NAME] 500 mg for 7 days, [MEDICATION NAME] Pearles 100 mg three times per day. The [MEDICATION NAME] was taken from the emergency box and the power of attorney contacted to inform him the [MEDICATION NAME] was not covered by R2's insurance. The power of attorney agreed to pay privately for the [MEDICATION NAME], however, according to the January Medication Flowsheet, R2 did not receive the [MEDICATION NAME] Pearles. There were no vitals or oxygen saturation levels documented in the nurses notes or vital matrix [DATE]-occasional moist cough and decreased lung sounds were noted. Oxygen saturation levels were ,[DATE]%. [DATE]- R2 complained of shortness of breath at 3:38 PM. Oxygen levels were ,[DATE] % . The physician was called and ordered R2 to be sent to the hospital if the oxygen levels were under 94%. The next note at 3:47 PM states the Power of Attorney was notified and did not want R2 to go to the hospital. R2 declined to go to the hospital. At 9:34 PM the oxygen saturation levels were ,[DATE]%. There is no documentation the physician was notified that R2 was not sent to the hospital. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]-There was no documentation in the nurses notes from [DATE] until [DATE]. The next note on [DATE] noted R2 had a poor appetite only. There are no vital signs documented from [DATE] until [DATE]. [DATE]-Z3, nurse practitioner for Z1, noted on the "Physical Assessment and Care Plan Review" on [DATE] "Not getting meds because (family) has not selected a Medicare Part D plan so (pharmacy) not delivering his meds". There was no other documentation by Z3 regarding R2 not receiving his medications. There is no documentation of shortness of breath , [MEDICAL CONDITION] or [MEDICAL CONDITION]. There is no documentation Z1, Physician, was notified. . [DATE]-There is no documentation in the nurses notes from [DATE] until [DATE]. The next note on [DATE] noted that R2 was short of breath and could not catch his breath. The oxygen saturation levels were 82%. Oxygen was placed on R2 and a nebulizer treatment was given. There is no documentation the physician was notified. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] that the physician was not notified. E2 stated on [DATE] that they gave the oxygen and nebulizer treatment to R2 and "You wouldn't call the doctor every time you gave someone with a headache an aspirin". [DATE]-The next nurses note was [DATE] at 3:05 AM and stated R2 continued to have episodes of shortness of breath with respirations becoming labored at times. Oxygen saturation levels were 97%. Lungs were noted to be clear bilaterally. Pitting [MEDICAL CONDITION] was noted to bilateral lower extremities. There was no documentation the physician was notified. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]-All previous medications were restarted. Z1, Physician, stated on [DATE] that he was not aware that R2 had not been receiving his medication nor that it was restarted. [DATE]- A blister was noted that popped on the right second toe. A fax was sent to Z1 noting triple antibiotic ointment and Band-Aid was applied. "Dr. will advise if he would like a different tx (treatment) or with any orders". There is no documentation that the physician received the fax nor was there a response. [DATE]-At 5:41 AM the nurses notes at 5:41 AM documented that R2 was awake and yelling most of the shift. Bilateral [MEDICAL CONDITION] to lower extremities was noted. Toes were noted as puffy and tight with superficial red marks on the second and third toes of each foot. R2's face was puffy with some shortness of breath on exertion. There is no documentation the physician was notified. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. There were no vitals or oxygen saturation levels documented. [DATE]- At 10:09 AM the physician was called and ordered a chest x-ray and oxygen for shortness of breath. R2 was noted to be very confused and lethargic and slumped in his chair. Bilateral 2 plus [MEDICAL CONDITION] was noted with blisters on his feet. Oxygen saturation levels were 93%. Slight crackles/diminished lung sounds bilaterally were noted. The note states "Resident ok with going to hospital however we are awaiting call back from POA (family)". R2 was not sent to the hospital until [DATE] according to the nurses notes. [DATE]-At 12:55 PM wheezing was noted with oxygen saturation levels at 95% with oxygen. There are no further nurses notes until [DATE] at 1:17 AM. [DATE]-At 1:17 AM, the oxygen saturation level for R2 was documented at 86% and his lips were cyanotic. Oxygen was applied and the oxygen . The physician was not notified. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]-At 4:09 AM R2 complained of pain around the gastrostomy tube site. There was no documentation of vitals. [DATE]-the note by E4, Licensed Practical Nurse, states "Recorded as Late Entry on [DATE] 09:14 AM" that no return call from R2's power of attorney regarding the [DATE] request by R2 to go to the hospital. E4 confirmed on [DATE] that the family did not call back so R2 was not sent to the hospital nor did she call the physician. [DATE]- Z3 noted on the "Physician Quality Reporting Initiative (PQRI) Physician Quality Measures" that "Medications are ordered but resident has not received for over one month due to family refusal to pay for his medications/select an insurance plan that will pay in LTC (Long Term Care) facility". There was no further documentation regarding the lack of medications on the report, hospitalization , shortness of breath, [MEDICAL CONDITION] or [MEDICAL CONDITION]. There are no vitals done from [DATE] at 2:10 PM until [DATE] 10:39 AM according to the nurses notes and the "Vitals Results". There are no oxygen saturation levels done after [DATE] at 1:17 AM thru [DATE] when R2 was admitted to the hospital. [DATE]-at 2:51 PM noted [MEDICAL CONDITION] remains to bilateral lower extremities and the facial [MEDICAL CONDITION] appeared to be reduced. The next nurses note was on [DATE]. [DATE]-at 5:49 AM the nursing notes indicated R2 had 3 plus [MEDICAL CONDITION] to both legs and his feet were red and painful. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. No vitals were done until 10:39 AM and no oxygen saturation levels noted. [DATE]- at 9:15 AM the notes states R2 continued to have 3 plus [MEDICAL CONDITION] with bilateral lower extremities very painful and red. R2 requested to go to the hospital. The physician was called and ordered R2 be sent to the emergency room per his request. [DATE]- at 1:06 PM stated "(staff) called from (hospital) requesting information about residents medications. Told her that resident is a self pay resident, and all his medications were on mail delivery only. We would only get small supply of medications from (pharmacy) (free medications) every so often, but not long enough to keep resident on a constant cycle of medication. Until last week we did not have permission from his (family) (POA) to get medications from our (pharmacy). Therefore, we did not have a continuos supply. We recently got a 30 day supply of all medications, and the billing has been taken care of. DON aware of conversation and situation" [DATE]- at 1:52 PM noted R2 was admitted to the hospital for "[MEDICAL CONDITIONS] "BNP" (brain natruretic peptide) up over 600". The transfer sheet sent by the facility with R2 to the hospital on [DATE] did not document that R2 had not had his medications for an extended period. The "Current Orders" sent to the hospital listed all his medications including the medications he did not receive. Z5, emergency room Manager, stated on [DATE] at 11:30 AM by phone that they had called the facility for report and found out about the medications then. The "Emergency Nursing Record" dated [DATE] documented "Staff reports [MEDICAL CONDITION] to bilat (bilateral) lower extremities x (times) 1 week. Also report sores to toes (with) [MEDICAL CONDITION]. 4+ [MEDICAL CONDITION] noted to bilat lower extremities. Multiple open areas noted to toes on both feet. Pt (patient) c/o (complains of) pain to feet. Rates pain ,[DATE]...". The emergency room record noted R2 received 60 mg of IV [MEDICATION NAME] and 1 gram [MEDICATION NAME]. The record noted R2 was admitted due to [MEDICAL CONDITION] exacerbation and foot ulcers. There was no documentation in the emergency room notes regarding R2 not receiving his medications. The hospital history and physical dated [DATE] documented as the "Chief Complaint" "Increased [MEDICAL CONDITION] in bilateral lower extremities. The exact duration for how long it's been going on is not known." The hospital note also noted R2 had multiple superficial excoriation in the bilateral lower extremities and toes. The feet were noted to be swollen and red. The history and physical also noted R2 had a past medical history of [REDACTED]. The assessment documented "acute decompensated systolic [MEDICAL CONDITION]" with the "BNP (Brain Natriuretic peptide) 669" and "early signs of [MEDICAL CONDITION] in toes of both feet". Cardiac enzymes were within normal limits. Lab results dated [DATE] noted "heavy growth" of [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) of the right foot. There is no documentation regarding R2 not receiving the medication at the facility. The discharge summary dated [DATE] noted an arterial doppler study showed moderate to severe distal ischemia in the bilateral lower extremities. R2 was [MEDICATION NAME] with intravenous (IV) [MEDICATION NAME] and his breathing and mental status improved. R2 received IV [MEDICATION NAME] for [MEDICAL CONDITION]. R2 was discharged back to the facility on [DATE]. There is no documentation regarding R2 not receiving his medications at the facility. According to the Mosby's manual of Diagnostic and Laboratory Tests, 3rd edition, the BNP is used to identify patients with [MEDICAL CONDITION]. Normal findings for BNP is less that 100 pg/ml (milliliter). Critical values are greater that 100 pg/ml. The test explanations for BNP states "The higher the levels of BNP are, the more severe the [MEDICAL CONDITION]". R2's BNP was 669. Z3, Nurse Practitioner for Z1, stated on [DATE] at 2:00 PM by phone that she had been told several weeks after the fact that R2 was not receiving his medications. R2 had not been getting the medications for about 3 weeks. The facility was trying to get the family to order the medications. Z3 stated she had done a brief exam on R2 when she filled out the forms on [DATE] and [DATE] and had not noted any problems with R2. Z3 had not seen any [MEDICAL CONDITION] on his feet on both exams. Z3 stated she had told Z1, Physician, about the medications for R2 but did not document anything about it. Z1 seemed distracted and was not paying attention when she told him. When asked if not getting his medications contributed to R2 going to the hospital, Z3 stated it "didn't help". Z1, Physician for R2, stated on [DATE] at 10:00 AM by phone that he was not aware that R2 was not receiving his medications as prescribed. Z1 stated the facility and Z3, Nurse Practitioner, had not informed him the facility had not given R2 his medications. Z1 stated he didn't know what to say and asked why R2 was not receiving his medications. Z1 stated the pharmacy should have sent the medications. The facility should have helped the resident and provided R2 with his medications. Z1 stated it was inappropriate for the facility not to inform him that R2 was not receiving the medications. Z1 stated "Of course" that the effects of R2 not receiving his medications contributed to his hospitalization . When asked if Z1 considered this neglect he stated "yes" and that R2 "should have gotten the meds". Review of the medical record nurses notes documented the following: ,[DATE]//11- At 6:00 PM, R2 was readmitted to the facility. The nursing notes dated [DATE] at 12:57 PM noted R2 was returning to the facility. It noted R2 toes were scabbed over but positive for [MEDICAL CONDITION] Resistant Staph Aureus. No [MEDICAL CONDITION] was noted. R2 was on isolation [MEDICAL CONDITION]. R2 had an order for [REDACTED]. [DATE]-no complaints noted. [DATE]-At 5:22 PM the nurses notes documented no shortness of breath but 1 plus [MEDICAL CONDITION] was noted. [DATE]-At 2:51 PM one plus [MEDICAL CONDITION] with no shortness of breath was noted. There is no documentation the physician was notified. [DATE]-At 1:22 AM shortness of breath on exertion and ,[DATE] plus [MEDICAL CONDITION] to bilateral lower extremities noted. There is no documentation the physician was notified. [DATE]-At 3:36 AM the nurses notes states "At present there is no [MEDICAL CONDITION] in lower extrems (extremities) or feet". [DATE]-At 8:35 AM a fax was sent to Z7, Hospice Physician, requesting a chest Xray due to coughing and course crackles bilaterally. R2 was not admitted to Hospice services until [DATE]. The primary care physician was not notified. [DATE]-At 8:46 AM the power of attorney refused the Xray. One to two plus [MEDICAL CONDITION] was noted. [DATE]-At 10:04 AM the nurses notes dated [DATE] at 10:04 AM documented that Z1, primary care physician, had been called to request an order for [REDACTED]. [DATE]-At 4:52 PM the Xray was done and at 6:37 PM the results noted pneumonia. The physician was called and while awaiting a call back at 7:56 PM, R2's oxygen saturation levels were noted to be 84% on room air. Shortness of breath was noted and R2 was sent to the hospital per nursing judgement. R2 was admitted to the hospital with [REDACTED]. R2 was observed on [DATE] at 11:30 AM sitting in his room with the oxygen cannula in his nose. R2 and had labored breathing and was asked if he was having trouble breathing. R2 stated "Yeah, It's a little better with oxygen on." E3, Certified Nurse Aide and Shift Coordinator, was asked to check the portable oxygen cannister and a red light indicating the cannister was out of oxygen appeared. E3 called E4, Licensed Practical Nurse, who came to the room and stated R2 was not on continuous oxygen but as needed. E4 was informed R2 had stated he was having trouble breathing. Oxygen saturation levels were checked and were 99%. E4 refilled the cannister. R2's orders are for oxygen at 2 liters as needed to keep oxygen saturation levels above 92%. E2 stated on [DATE] that R2 only had an order for [REDACTED]. The history and physical dated [DATE] noted the chief complaint was "shortness of breath". The report noted R2 was "found to have acute on chronic systolic [MEDICAL CONDITION] exacerbation and was admitted to the intermediate intensive care unit". It was noted that R2 had a history of [REDACTED]. The "Discharge Summary" dated [DATE] noted "the patient's sister stated that this has been a gradual decline over the last few months...". The "Discharge Summary noted R2 was medically stable on discharge with his heart failure exacerbation controlled. [MEDICATION NAME] was increased from 60 mg to 80 mg. R2 was readmitted to the facility on [DATE] on hospice. Review of the medical record nurses notes documented the following: [DATE]- 1:30 PM R2 returned to the facility with no [MEDICAL CONDITION] noted. R2 was receiving a gastrostomy tube feeding. R2 was admitted to hospice services. Z9, Admitting Hospice Nurse, stated on [DATE] at 10:07 AM by phone that R2 was started on 0.5 ml of [MEDICATION NAME] every 2 hours as needed. Z9 stated she only saw R2 at admission and at that time he did not need a scheduled pain medication. Z9 stated R2 would grimace with movement but calmed quickly and didn't need a scheduled pain medication. According to the "Physician order [REDACTED]./ml: 10 mg =0.5 ml". According to the MAR, R2 received 0.5 ml of [MEDICATION NAME] two times on [DATE] and 1 time on [DATE]. The "Pain Assessment" dated [DATE] noted R2 had facial expressions of pain. The evaluation notes there is a "High Probability of Pain" but notes the the symptoms, intensity and site as "unknown". The interventions are not listed nor are the medications. [DATE]- 1:18 AM as needed [MEDICATION NAME] 0.5 milliliter was given for moaning and crying out. R2's catheter had been removed at 9:23 PM and R2 had not voided since then. [DATE]-9:30 AM-R2 did void. Responding to verbal commands and touch. [DATE]-5:06 PM noted R2 was up to bedside chair. No complaints of pain or discomfort noted. [DATE]- 9:39 AM R2 complained of pain and PRN (as needed) [MEDICATION NAME] was given and "tolerated well". R2 was responding to verbal commands. E4, LPN, stated on ,[DATE]/ 11 at 11:40 AM stated R2 was doing better on readmission on [DATE]. E4 stated on [DATE] the hospice nurse, Z10, had called to check on R2 and she told him R2 she didn't think R2 was comfortable and was moaning. E4 stated Z10 increased the [MEDICATION NAME] to 1 ml every 2 hours scheduled. Z10, Hospice Nurse, stated on [DATE] at 10:40 AM by phone that she had been told by E4 that R2 was moaning in between doses of 0.5 ml of [MEDICATION NAME]. Z10 stated R2 was actively dying based on information told to her by E4. Z10 stated she was the nurse on call and had never seen R2. Z10 stated she did not do a pain assessment but just went by what E4 was telling her. Z10 stated that it was usual to up the dose to that amount due to the state R2 was in. [DATE]- 10:14 AM the hospice nurse changed the [MEDICATION NAME] order from 1 ml PRN to 1 ml every two hours. [DATE]-5:42 PM R2 was noted as alert with no signs or symptoms of distress or discomfort. [DATE]-7:38 PM R2 was resting comfortably. "Non-verbal at this time. Responds to touch only". [MEDICATION NAME] was administered as ordered. Respirations were 14. Oxygen saturation levels were 95%. [DATE]-10:13 PM No signs or symptoms of discomfort or distress noted. [MEDICATION NAME] given. There are no nurses notes until 2:34 AM on [DATE]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. [DATE]-2:34 AM R2 was found expired at 1:30 AM. The State "Certificate of Death" dated [DATE] and signed by Z7 noted the "Immediate Cause" of death as "[MEDICAL CONDITION]". The Immediate Jeopardy was identified to have begun on [DATE] when staff failed to provide medications to R2 and then failed to assess, monitor, and implement interventions for a decline in R2's condition according to their policies and procedures. E1, Administrator, and E2, Director of Nursing, were informed of the Immediate Jeopardy on [DATE] at 2:55 PM. The Facility took the following actions to remove the Immediacy: 1. All licensed nursing staff was in-serviced on [DATE] and [DATE]. Topics were neglect, medication errors and pharmacy services. The nursing staff was informed that medications are to be available for administration as ordered, and may require the pharmacy emergency run medications or the facility assume financial responsibility. 2. All private pay resident ' s medications and pharmacy services have been reviewed and no problems have been found as of [DATE] 3. The Pharmacy was contacted by the Administrator and it was agreed that medication non-coverage issues are to be reported directly to the Administrator as of [DATE] 4. The Quality Assurance Committee has reviewed the Policy for Pharmaceutical Procedures and changes will be made accordingly 5. On [DATE] licensed nursing staff was in serviced on proper assessing of resident and of resident ' s condition including physical assessment and vital signs and determining resident ' s outcome and changing interventions if needed. 5. The Administrator and/or designee shall be responsible for ensuring continued compliance and will be responsible for overseeing the implementation of the above Plan.

Based on record review and interview it was determined that the facility failed to notify the physician for 2 (R1 and R2) of 3 residents in a sample of 5 regarding a change in the resident's condition and failure to provide medications as ordered. This failure resulted in R2 experiencing signs/symptoms of [MEDICAL CONDITION], such as [MEDICAL CONDITION] and [MEDICAL CONDITION], for days before being hospitalized with an exacerbation of [MEDICAL CONDITION]. R2 was hospitalized twice and admitted to hospice services on [DATE]. R2 expired on [DATE]. Findings include: The findings include: 1. R2 was admitted to the facility on [DATE] with diagnoses, in part, of [MEDICAL CONDITIONS], hypertension, and [MEDICAL CONDITION]. The "Medications Flowsheet" documented R2 did not receive the ordered 60 mg of [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE], [MEDICATION NAME] [DATE] until [DATE], [MEDICATION NAME] from [DATE] until [DATE] and lacri-lube from [DATE] until [DATE]. The flowsheet for [DATE] through February 14, 2011 noted during this time frame, R2 did not receive [MEDICATION NAME], Klor-Con, [MEDICATION NAME], and [MEDICATION NAME] as ordered by the physician. E2, Director of Nursing, and E1, Administrator, confirmed on [DATE] that the physician had not been contacted regarding the medications. 2. Review of the nurse and nurse practitioner notes for R2 documented the following changes and failure to notify the physician: [DATE]- R2 was noted to have severe congestion in the left lung and a severe cough. The physician ordered a chest Xray, [MEDICATION NAME] 500 mg for 7 days, [MEDICATION NAME] Pearles 100 mg three times per day. The [MEDICATION NAME] was taken from the emergency box and the power of attorney contacted to inform him the [MEDICATION NAME] was not covered by R2's insurance. The power of attorney agreed to pay privately for the [MEDICATION NAME], however, according to the January Medication Flowsheet, R2 did not receive the [MEDICATION NAME] Pearles. There was no physician notification. [DATE]- R2 complained of shortness of breath at 3:38 PM. Oxygen levels were ,[DATE] % . The physician was called and ordered R2 to the hospital if the oxygen levels were under 94%. The next note at 3:47 PM states the Power of Attorney was notified and did not want R2 to go to the hospital. R2 declined to go to the hospital. At 9:34 PM the oxygen saturation levels were ,[DATE]%. There is no documentation the physician was notified that R2 was not sent to the hospital. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]-Z3, nurse practitioner for Z1, noted on the "Physical Assessment and Care Plan Review" on [DATE] "Not getting meds because (family) has not selected a Medicare Part D plan so (pharmacy) not delivering his meds". There was no other documentation by Z3 regarding R2 not receiving his medications. There is no documentation of shortness of breath , [MEDICAL CONDITION] or [MEDICAL CONDITION]. There is no documentation Z1, Physician, was notified. . [DATE]-The next note on [DATE] noted that R2 was short of breath and could not catch his breath. The oxygen saturation levels were 82%. Oxygen was placed on R2 and a nebulizer treatment was given. There is no documentation the physician was notified. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] that the physician was not notified. E2 stated on [DATE] that they gave the oxygen and nebulizer treatment to R2 and "You wouldn't call the doctor every time you gave someone with a headache an aspirin". [DATE]-The next nurses note was [DATE] at 3:05 AM and stated R2 continued to have episodes of shortness of breath with respirations becoming labored at times. Oxygen saturation levels were 97%. Lungs were noted to be clear bilaterally. Pitting [MEDICAL CONDITION] was noted to bilateral lower extremities. There was no documentation the physician was notified. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]-All previous medications were restarted. Z1, Physician, stated on [DATE] that he was not aware that R2 had not been receiving his medication nor that it was restarted. [DATE]- A blister was noted that popped on the right second toe. A fax was sent to Z1 noting triple antibiotic ointment and Band-Aid was applied. "Dr. will advise if he would like a different tx (treatment) or with any orders". There is no documentation that the physician received the fax nor was there a response. [DATE]-At 5:41 AM the nurses notes at 5:41 AM documented that R2 was awake and yelling most of the shift. Bilateral [MEDICAL CONDITION] to lower extremities was noted. Toes were noted as puffy and tight with superficial red marks on the second and third toes of each foot. R2's face was puffy with some shortness of breath on exertion. There is no documentation the physician was notified. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. There were no vitals or oxygen saturation levels documented. [DATE]- At 10:09 AM the physician was called and ordered a chest x-ray and oxygen for shortness of breath. R2 was noted to be very confused and lethargic and slumped in his chair. Bilateral 2 plus [MEDICAL CONDITION] was noted with blisters on his feet. Oxygen saturation levels were 93%. Slight crackles/diminished lung sounds bilaterally were noted. The note states "Resident ok with going to hospital however we are awaiting call back from POA (family)". R2 was not sent to the hospital until [DATE] according to the nurses notes. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]-At 1:17 AM, the oxygen saturation level for R2 was documented at 86% and his lips were cyanotic. Oxygen was applied and the oxygen . The physician was not notified. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]-the note by E4, Licensed Practical Nurse, states "Recorded as Late Entry on [DATE] 09:14 AM" that no return call from R2's power of attorney regarding the [DATE] request by R2 to go to the hospital. E4 confirmed on [DATE] that the family did not call back so R2 was not sent to the hospital. [DATE]-at 2:51 PM noted [MEDICAL CONDITION] remains to bilateral lower extremities and the facial [MEDICAL CONDITION] appeared to be reduced. The next nurses note was on [DATE]. [DATE]-at 5:49 AM the nursing notes indicated R2 had 3 plus [MEDICAL CONDITION] to both legs and his feet were red and painful. E1, Administrator, and E2, Director of Nursing, confirmed on [DATE] at 10:55 AM that the physician was not notified. [DATE]- at 1:52 PM noted R2 was admitted to the hospital for "[MEDICAL CONDITIONS] "BNP" (brain natruretic peptide) up over 600". ,[DATE]//11- At 6:00 PM, R2 was readmitted to the facility. No [MEDICAL CONDITION] was noted. R2 had an order for [REDACTED]. [DATE]-At 5:22 PM the nurses notes documented no shortness of breath but 1 plus [MEDICAL CONDITION] was noted. There is no documentation the physician was notified. [DATE]-At 2:51 PM one plus [MEDICAL CONDITION] with no shortness of breath was noted. There is no documentation the physician was notified. [DATE]-At 1:22 AM shortness of breath on exertion and ,[DATE] plus [MEDICAL CONDITION] to bilateral lower extremities noted. There is no documentation the physician was notified. [DATE]-At 8:35 AM a fax was sent to Z7, Hospice Physician, requesting a chest Xray due to coughing and course crackles bilaterally. R2 was not admitted to Hospice services until [DATE]. Primary care physician was not notified. At 10:04 AM the nurses notes dated [DATE] at 10:04 AM documented that Z1, primary care physician, had been called to request an order for [REDACTED]. R2 was readmitted to the facility on [DATE] on hospice services and expired on [DATE]. 2. The History and Physical (H&P), dictated by Z1, physician, on [DATE], and the Discharge Summary dictated by Z6, physician, on [DATE], documents R1 was treated at the hospital from [DATE] until she was discharged to the facility on [DATE] for the [DIAGNOSES REDACTED]. The H&P documents R1 received intravenous (IV) antibiotic therapy with [MEDICATION NAME] 3.375 milligrams every six hours. The facility's physician's orders [REDACTED]. The Order Report documents an end date for [MEDICATION NAME] of [DATE]. On [DATE], at 2:50 PM, E2, Director of Nursing, (DON) stated, "We were not prepared for the IV [MEDICATION NAME] ordered to continue for (R1) on [DATE], when she returned from the hospital. She (R1), had a IV access port. No one was available at that time to start an IV." E2 confirmed R1 never received the IV [MEDICATION NAME] because the hospice nurse came on [DATE], and an order was obtained for the oral antibiotic, [MEDICATION NAME]. The Nurses Note, dated [DATE], confirms a physician was notified and twice refused to discontinue the IV [MEDICATION NAME] as ordered. The Nurses Note, dated [DATE], at 6:00 PM, reads, "Spoke with DON once again and discussed what MD (medical doctor) had said. Decided we would wait till ABT (antibiotic) came from pharmacy and after hospice came in AM (morning) and see what hospice wanted to do." On [DATE], at 1:50 PM, Z1, Physician reported Z6, Physician discharged R1 from the hospital on [DATE] with the order for IV [MEDICATION NAME]. Z1 reported he would not have discontinued the IV [MEDICATION NAME] and the facility should be capable of administering an IV antibiotic. Z1 reported he has had problems with his residents at the facility receiving medications as ordered. Z1 reported R1 should have received the IV [MEDICATION NAME], and he would never refuse to send any resident to the hospital. On [DATE], at 2:45 PM, Z6, Physician reported he does not remember the specifics of R1's discharge on [DATE]. Z1 reported if he discharged a resident to a nursing home with an IV antibiotic he would expect the hospital and the receiving facility to coordinate the discharge care so R1 could receive the IV medications as ordered. Z1 stated, "The nursing home is required to be prepared for IV therapy for a resident." Z1 confirmed he would not have discontinued the IV [MEDICATION NAME] and was not aware she did not receive it. Z1 reported he would never send her back to the hospital to just receive IV medication. Z1 reported the facility's DON should have been available to start the IV.

Based on record review and interview it was determined that the facility failed to review and report clinically significant drug irregularities to the attending physician and pharmacist for 1 (R2) of 3 residents reviewed on a sample of 5. This failure resulted in R2 experiencing an exacerbation of congestive heart failure, edema and cellulitis with Methicillin resistant Staph Aureus of the feet. R2 was hospitalized twice for exacerbations of congestive heart failure, admitted to hospice and then expired on [DATE]. The findings include: Z2, Registered Pharmacist, stated on [DATE] at 9:30 AM, that he was not aware R2 had not been receiving his medications until [DATE]. Z2 was surprised nursing staff had not informed him. Z2 did review R2's medications in January and February however, he did not review the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Z2 stated a problem with the billing for R2's medications was given as a reason for R2 not receiving the medications. When asked if R2 not receiving his medications were a problem for R2, Z2 stated R2 was on the medications for a reason. The Lisinopril and Lasix were the medications that could cause R2 the worst problems if he didn't get the medications. Z2 stated he wasn't sure if being off the medications caused the congestive heart failure exacerbation but it "didn't help". Z8, Biller from facilities pharmacy, stated on [DATE] at 12:55 PM by phone that she was shocked when she was told of the situation with R2 and had never seen it happen before. Z8 stated the process is simple and the facility has to tell the pharmacy what the resident needs. Z8 stated the medications were being sent out in 3 day batches. When the "Do Not Send" was sent to the facility there was paperwork the facility should have filled out to continue the medication. The facility should have continued paying for the medication until it could have been worked out with the power of attorney. Some insurances will go back 90 days to reimburse for the medications. No one in authority called the pharmacy from the facility to ask why the medications were not being sent or they would have been sent. The "Medications Flowsheet" documented R2 did not receive the ordered 60 mg of Lasix from [DATE] until [DATE], Lisinopril from [DATE] until [DATE], Coreg from [DATE] until [DATE], Isosorbide Dinitrate [DATE] until [DATE], Levodopa from [DATE] until [DATE] and lacri-lube from [DATE] until [DATE]. The flowsheet that R2 did not receive Allopurinol, Klor-Con, Lansoprazole, and Synthroid as ordered by the physician from [DATE] through [DATE]. E2, Director of Nursing, confirmed on [DATE] that R2 had not received his medications and was aware that he had not. E4, Licensed Practical Nurse, confirmed on [DATE] that R2 had not received his medication and "everyone knew" he was not getting his medications due to a billing problem. Both stated that they had not informed the attending physician R2 was not receiving his medications. Review of the monthly "Consultation Report" from the pharmacy services done by Z2 and dated [DATE] and [DATE] did not identify that R2 was not receiving medications. The physician was not contacted by Z2 regarding R2 not receiving his medications. Z3, Nurse Practitioner for Z1, stated on [DATE] at 2:00 PM by phone that she had been told several weeks after the fact that R2 was not receiving his medications. R2 had not been getting the medications for about 3 weeks. The facility was trying to get the family to order the medications. Z3 stated she had done a brief exam on R2 when she filled out the forms on [DATE] and [DATE] and had not noted any problems with R2. Z3 had not seen any edema on his feet on both exams. Z3 stated she had told Z1, Physician, about the medications for R2 but did not document anything about it. Z1 seemed distracted and was not paying attention when she told him. When asked if not getting his medications contributed to R2 going to the hospital, Z3 stated it "didn't help". Z1, Physician for R2, stated on [DATE] at 10:00 AM by phone that he was not aware that R2 was not receiving his medications as prescribed. Z1 stated the facility and Z3, Nurse Practitioner, had not informed him the facility had not given R2 his medications. Z1 stated he didn't know what to say and asked why R2 was not receiving his medications. Z1 stated the pharmacy should have sent the medications. The facility should have helped the resident and provided R2 with his medications. Z1 stated it was inappropriate for the facility not to inform him that R2 was not receiving the medications. Z1 stated "Of course" that the effects of R2 not receiving his medications contributed to his hospitalization . When asked if Z1 considered this neglect he stated "yes" and that R2 "should have gotten the meds". R2 was hospitalized from [DATE] until [DATE]. The hospital history and physical dated [DATE] documented "acute decompensated systolic congestive heart failure" with the "BNP (Brain Natriuretic peptide) 669" and "early signs of cellulitis in toes of both feet" as the assessment. Lab results dated [DATE] noted "heavy growth" of Methicillin Resistant Staph Aureus (MRSA) of the right foot. There is no documentation regarding R2 not receiving the medication at the facility. R2 was readmitted to the hospital on [DATE] until [DATE]. The history and physical dated [DATE] noted the chief complaint was "shortness of breath". The report noted R2 was "found to have acute on chronic systolic congestive heart failure exacerbation and was admitted to the intermediate intensive care unit". It was noted that R2 had a history of [REDACTED]. R2 was readmitted to the facility on [DATE] on hospice and expired on [DATE].