Every finding on record at Manzano Del Sol by Purehealth

Based on record review and interview, the facility failed to complete and submit a Five-Day Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations) to the State Agency regarding allegations of abuse for 1 (R #5) of 1 (R #5) residents. If the facility does not submit follow-up reports, then the State Agency cannot ensure the residents are safe and free of abuse. The findings are: A. Record review of the facility's Reportable Incident, dated 09/15/25, revealed the facility submitted a report for resident-to-resident abuse to the State Survey Agency. B. Record review of State Agency's incident tracking system revealed the State Agency received an initial incident report, dated 09/15/25, from the facility regarding resident-to-resident abuse.C. Record review of facility's records revealed the records did not contain documentation to show the facility submitted a Five-Day Report to the State Survey Agency.D. On 12/12/25 at 2:37 pm during an interview, the Administrator stated she was not able to locate the facility's Five-Day Report for the report submitted to the State Survey Agency on 09/15/25. She stated it was her expectation for staff to submit the Five-Day Report within the required five days.

Cross reference to F756. Based on record reviews and interviews, the facility failed to keep a resident free from significant medication errors for 1 (R #25) of 1 (R #25) resident, when staff entered a duplicate medication order of clopidogrel (an antiplatelet; medication that prevents blood clots by preventing platelets in the blood from sticking together) and administered the clopidogrel for a period of 19 consecutive days. This deficient practice had the potential to cause severe complications including but not limited to severe bleeding and death. The findings are: A. Record review of Antiplatelet Drug Toxicity (when a drug causes harmful effects to the body due to various reasons such as overdosing), published in National Library of Medicine (NLM) and dated 06/12/23, revealed Antiplatelet Drug Toxicity can cause the following complications: - Intracranial hemorrhage (a life-threatening bleeding that occurs inside the skull when a blood vessel ruptures or leaks). - Gastrointestinal hemorrhage (blood loss from the digestive tract). - Retroperitoneal bleeding (when bleeding occurs in the space behind the lining of the abdomen). - Hemorrhagic shock (a life-threatening emergency where severe blood loss causes the body to lose too much blood volume to pump enough oxygen into the organs). B. Record review of R #25's Face Sheet revealed the resident was admitted to the facility on [DATE] with the following diagnoses: - Osteoporosis (a condition where bones become brittle and prone to breaking easily) with fracture (break) of left femur (a bone in the upper part of the left leg). - History of falling. - Anemia (low red blood cell count). - Transient ischemic attack (TIA, when blood flow to part of the brain stops for a brief period of time). C. Record review of R #25's Provider Orders revealed the following: - Dated 07/08/25, an active order for clopidogrel oral tablet, 75 milligrams (mg). Give one tablet by mouth every day in morning for cardiac (heart) health. - Dated 07/18/25 and entered by the Nurse Practitioner (NP), an active order for Plavix (a brand name of clopidogrel) oral tablet, 75 mg. Give one tablet by mouth every day at bedtime for atrial fibrillation (A-Fib; irregular heart rhythm). - Dated 07/18/25, Nurse #1 confirmed the Plavix order. - Both medication orders remained active between 07/18/25 and 08/05/25. D. Record review of R #25's Medication Administration Records (MARs) revealed the following: - Dated July 2025, staff administered the clopidogrel oral tablet 75mg and the Plavix 75 mg every day from 07/18/25 to 07/31/25. - Dated August 2025, staff administered the clopidogrel oral tablet 75mg and the Plavix 75 mg every day from 08/01/25 to 08/05/25. E. On 08/06/25 at 11:24 am, during an interview, Certified Medication Aid (CMA) #1 stated she worked morning shifts and administered R #25's morning dose of Plavix on 08/06/25. She stated she did not have access to the night shift medications list and could only view her shift's medications. She stated she was not aware R #25 received extra doses of Plavix during the night shift's medication pass. She stated giving extra doses of Plavix was considered over-medicating and could cause bleeding. F. On 08/06/25 at 11:34 am, during an interview, Nurse #1 stated she confirmed the Plavix order was dated 07/18/25, but she did not review R#25's current medications. She stated reviewing current medications was not part of the confirmation process. She stated giving an extra dose of Plavix could cause bleeding. H. On 08/06/25 at 11:53 am, during an interview, the Director of Nursing (DON) stated she expected the Nurse Practitioner to discontinue the original order when she entered a new order. She stated reviewing R #25's current medications when confirming new orders was not part of the confirmation process conducted by the nurses. I. On 08/06/25 at 12:26 pm, during an interview, the Nurse Practitioner stated she entered a new order in R #25's Electronic Health Record (EHR) for Plavix and did not stop the original clopidogrel order. She stated she wanted to change the Plavix's administration time to be during the evening medication pass instead of the original administration time during the morning medication pass. She stated she did not discontinue the original order. She stated giving an extra dose of Plavix could cause bleeding. J. On 08/06/25 at 1:32 pm, during an interview, R #25 stated she was not aware she received a double dose of Plavix for 19 consecutive days. She stated she always received Plavix once a day before she was admitted to the facility. Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified to have occurred on 07/18/25 when the NP entered a duplicated order of Plavix for R #25. The facility Administrator was notified in person on 08/06/25 at 4:10 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on 08/06/25 at 2:00 pm. Plan of Removal Corrective Action: - Residents clopidogrel has been discontinued as of 8/6/2025. Stat labs have been ordered for the resident. Nurse practitioner will assess resident 8/7/2025 and skin check has been completed. - Pharmacy completed medication order review audit for all residents on 8/6/2025. - The Medical Director will educate all providers on order review when entering new orders or changing orders. Compliance date 8/7/2025. - The physician orders will be confirmed by nursing staff based on the Standard Operating Procedure. Re-education of the SOP will be completed by 8/8/2025. - To monitor ongoing compliance, the IDT team will incorporate a daily audit of orders confirmed to ensure compliance in our daily clinical meeting. Nurse management will audit the medication orders for 5 residents weekly x4, monthly x2 to ensure compliance and report findings to the QAPI committee. - Date of compliance 8/8/2025. Implementation of the POR was verified onsite on 08/08/25, and the IJ was removed on 08/11/25 at 2:22 pm. The scope and severity was reduced from a J to an E. Implementation of the POR was verified by the following: - Record review of R #25's Provider Orders, date 08/06/25, showed the NP discontinued the clopidogrel order. - Record review of R #25's Progress Notes revealed the following:- Dated 08/06/25, Nurse #1 completed R #25's skin assessment with no concerns or complications. - Dated 08/07/25, the NP completed R #25's assessment. R #25 showed no side effects from receiving a duplicated dose of Plavix. - Record review of the facility's All Residents' Medication Orders Audit, dated 08/06/25 and completed by Consultant Pharmacist, showed residents did not have any irregularities in medication orders reviewed. - Record review of R #25's Lab Report, dated 08/07/25, showed R #25's Complete Blood Count (CBC; determines general health status, screens for, and monitors for a variety of disorders to include anemia) and platelets were within normal limits. - On 08/08/25 at 2:41 pm, during an interview, the Nurse Practitioner (NP) stated she received the provider's email on the process of prescribing new medication orders. She stated she was aware she should enter medication orders in residents' Electronic Health Record before leaving the building in order to avoid order duplication. The NP stated she should not use abbreviations when entering medication orders. - On 08/08/25 at 2:41 pm, during an interview, Attending Physician stated he received the provider's email on the process of prescribing new medication orders. He stated he should enter medication orders in residents' Electronic Health Record before leaving the building in order to avoid order duplication. The AP stated he should not use abbreviations when entering medication orders. - On 08/08/25 at 2:53 pm, during an interview, Nurse #1stated she had training on new orders confirmation process. She stated she should review residents' current medication orders before confirming new orders. She stated she should report any duplicate orders to the Unit manager, DON, and alert the pharmacy staff. - On 08/08/25 at 2:55 pm, during an interview, Nurse #2 stated he had training on new orders confirmation process. He stated he should review residents' current medication orders before confirming new orders. - On 08/08/25 at 3:09 pm, during an interview, Nurse #3 stated she had training on new orders confirmation process. She stated she should review medications route (the way a medicine is given), dose, and any duplicates. Nurse #3 stated she should ask the prescribing provider if she noticed any concerns with new orders. - On 08/08/25 at 3:19 pm, during an interview, Nurse #4 stated she had training on new medication orders confirmation process. She stated she was aware she should review current residents' medications before confirming new orders.

Cross reference to F756, F868 and F880. Based on record review and interviews, the facility failed to ensure the Medical Director (MD) participated in the Quality Assurance and Performance Improvement (QAPI; a structured framework used in healthcare to enhance the quality of care provided to patients), the Infection Prevention and Control Program (IPCP, a set of strategies and practices designed to prevent and control the spread of infections in healthcare settings), and the Medication Regimen Review (MRR) program. This failure had the potential to affect all residents at the facility. If the MD does not participate in QAPI, Infection Control, and MRR to assist in identifying, prioritizing, and correcting quality deficiencies, then the facility cannot ensure quality of care and services are consistently monitored and improved. The findings are: A. On 08/06/25 at 11:15 am, during an interview, the Nurse Practitioner stated she reviewed the facility's monthly MRRs. She stated she did not consult the Attending Physician when she responded to and acted on the Pharmacist's recommendations. B. On 08/08/25 at 2:41 pm, during an interview, the Attending Physician stated he did not review the facility's monthly MRRs or act on them. He stated the Nurse Practitioner did it. C. On 08/08/25 at 1:50 pm, during an interview, the Administrator stated she expected the Medical Director to review the facility's monthly MRRs or to instruct the Attending Physician to review them. D. On 09/11/25 at 1:31 pm, during an interview, Medical Director stated she expected the Attending Physician to review MRRs. The Medical Director stated she should have provided an oversight on the MRR process in the facility, and she should have instructed the Attending Physician to review MRRs instead of Nurse Practitioner.

Based on record review and staff interviews, the facility failed to ensure the Medical Director participated in the Quality Assurance and Performance Improvement/Quality Assurance and Assessment (QAPIQAA) Committee meetings, as required by regulation. This failure had the potential to affect all residents. If the facility does not ensure required members, including the Medical Director (MD), participate in the QAPI/QAA Committee, then the committee may not fully meet regulatory requirements for oversight of quality issues. The findings are:A. Record review of the facility's QAPI Program policy, revised September 2024, stated the QAPI/QAA Committee met monthly to review reports, evaluate data, and monitor QAPI activities. Committee membership included the Administrator, Director of Nursing, Medical Director, and at least three other staff members from different disciplines. The committee was responsible to identify quality deficiencies, develop corrective actions, and ensure ongoing compliance. B. Record review of the facility's QAPI plan, dated January 2025, showed the MD was designated as a standing member of the QAPI committee with responsibility for participation in monthly meetings. C. Record review of the facility's QAPI/QAA committee rosters showed the MD did not attend any QAPI meetings since September 2024. D. On 08/07/2025 at 12:44 PM, during an interview, the Nurse Practitioner stated she never saw the MD attend a QAPI meeting. E. On 08/11/2025 at 9:45 AM, during an interview, the Administrator stated the last time the MD attended a QAPI meeting was in September 2024. She stated the MD did not attend any monthly or quarterly QAPI meetings since September 2024. She stated the MD has Calander invites along with all staff to attend the monthly meetings along with the quarterly meetings. F. On 08/06/25 at 1:17 pm, 08/14/25 at 11:27 am, and 08/15/25 at 10:05 am, phone calls were made to the MD and call back messages for an interview were left; however, the MD did not respond to the requests for an interview.

Based on interviews and record reviews, the facility failed to ensure an effective Infection Prevention and Control program (IPCP, a set of strategies and practices designed to prevent and control the spread of infections in healthcare settings) when the facility's Medical Director (MD) failed to attend the scheduled infection control monthly meetings or be part of the program. This failure had the potential to affect all residents. If the MD does not participate in the facility's infection control program, then residents may be at an increased risk of infections due to a delay in identification and response of outbreaks. The findings are: A. Record review of the facility's Infection Control Online Meeting Invitations, dated 01/28/25, 02/04/25, 02/25/25, 03/25/25, 04/22/25, 05/27/25, and 07/16/25, revealed the MD did not participate in any of the meetings. B. On 08/08/25 at 11:04 am, during an interview, the Infection Control Preventionist (ICP) stated he worked for the facility for nine months and did not meet the MD at any of the Infection Control Meetings. The ICP stated he was not aware the MD was part of the IPCP. He stated he did not communicate with the MD or the attending physician for issues related to the IPCP. C. On 08/08/25 at 1:50 pm, during an interview, the Administrator stated she expected the MD to attend the Infection Control Meetings and be part of the IPCP.D. On 08/06/25 at 1:17 pm, 08/14/25 at 11:27 am, and 08/15/25 at 10:05 am, phone calls were made to the MD and call back messages for an interview were left; however, the MD did not respond to the requests for an interview.

Based on observation, interview, and record review, the facility failed to ensure hazardous chemicals were stored securely and remained inaccessible to 4 (R #13, R #41, R #46 and R #55) out of 4 (R #13, R #41, R #46 and R #55) residents. If hazardous chemicals are left unattended and accessible to residents with significant cognitive impairments, then residents are at risk for accidental ingestion, misuse, or chemical contact injuries, which can result in serious harm. The findings are: A. Record review of the facility's Hazardous Areas, Devices and Equipment policy (dated 08/12/25) stated the following:- Hazardous areas, devices, and equipment in the facility would be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.- Hazardous areas included access to toxic chemicals.-Any element of the resident environment that has the potential to cause injury and was accessible to a vulnerable resident was considered hazardous.- Vulnerable residents would be identified based on functional status, medical condition, and cognitive abilities. Measures such as locks, alarms, and supervision would be implemented to ensure hazardous areas and items are not accessible to them. B. On 08/08/25 at 1:41 PM, observation revealed a container of bleach disinfectant wipes sat on a banister in the common area, and four residents sat nearby. Staff were not present in the area. R #13, R #41, R #46 and R #55 sat in their wheelchairs and watched television. C. On 08/08/25 at 1:42 PM, during an interview, Certified Nurse Aide (CNA) #1 stated the wipes should not be left out. She stated a resident could grab them and use them to wipe their face. D. On 08/08/25 at 1:59 PM, during an interview, Registered Nurse (RN) #2 stated the wipes should not be left out. She stated residents could use them improperly and unintentionally harm themselves. E. On 08/11/25 at 1:21 PM, observation revealed a container of bleach disinfectant wipes sat on a banister in the common area, and R#41 and R #55 sat nearby. Staff were not present in the area. F. Record review of R #55's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 07/02/25, revealed a diagnosis of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with cognitive impairment affecting decision-making, memory and safety awareness. R #55 Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) was 8, moderately impaired. G. Record review of R #13's MDS, dated [DATE], revealed a diagnosis of unspecified dementia with severe cognitive impairment affecting judgment, understanding, and communication. R #13 required extensive assistance with all activities of daily living. R #13's BIMS score was not determined, because the resident was rarely/never understood. H. Record review of R #41's MDS, dated [DATE], revealed a diagnosis of vascular dementia with impaired decision-making and hazard recognition. R#41's BIMS score was not determined, because the resident was rarely/never understood. I. Record review of R #46's MDS, dated [DATE], revealed diagnoses of Alzheimer's disease (a disease which causes irreversible changes in memory, thinking, and behavior) and vascular dementia with severe cognitive impairment. R #46's BIMS score was not determined, because the resident was rarely/never understood. J. On 08/11/25 at 1:22 PM, during an interview, the Director of Nursing (DON) stated it was her expectation that staff would not leave bleach wipes out. She stated residents could use the wipes as wet wipes or put them in their mouths. She stated staff should never leave the wipes out. K. On 08/11/25 at 1:30 PM, during an interview, the Administrator stated it was her expectation staff would put all cleaning chemicals away after use. She stated it was a hazard to have the wipes out, because the residents could use them on their faces or in the restroom.

Based on record reviews and interviews, the facility failed to provide routine and emergency dental services for 2 (R #4 and R #48) of 2 (R #4 and R #48) residents. If the facility does not ensure residents with identified dental pain are referred for prompt evaluation and treatment, then residents are at risk for unresolved oral pain, infection, poor nutrition, and overall decline in health and quality of life. The findings are: R #4 A. Record review of R #4's face sheet showed she was admitted to the facility on [DATE] with a diagnosis of stage three chronic kidney disease and type two diabetes. B. On 08/05/25 at 10:38 AM, during an interview, R #4 stated she did not have a dental appointment in a long time. She stated she was supposed to have dental appointments every six months, because she was on dialysis (a medical treatment which filters waste and excess fluid from the blood). C. On 08/06/25 at 2:15 PM, during an interview, Social Services stated she did not have anything to do with making any type of appointments. She stated the Patient Access Representative was the one who made the resident's appointments. D. On 08/06/25 at 2:23 PM, during an interview, the Patient Access Representative/Appointment Scheduler stated she had R #4 on her list to schedule a dental appointment. She stated R #4 went to the dentist every six months, but the resident went to the hospital when her last appointment was scheduled. The Patient Access Representative/Appointment Scheduler stated she should have rescheduled the resident's appointment right away, but she did not. E. Record review of R #4's care plan, dated 12/31/24, revealed an oral/dental health problem initiated and resolved on the same date. The resident did not have any current active dental or oral health problems or interventions. F. On 08/11/25 at 10:50 AM, during an interview, the Administrator stated oral care should be care planned. The Administrator stated residents who did not receive routine dental care could be at risk for complications due to poor dental hygiene. R #48 G. Record review of R #48's face sheet revealed an admission date of 01/28/2008 with the following diagnoses: -Hemiplegia and hemiparesis (weakness on one side of the body) -Diabetes mellitus (DM; a disease in which the body cannot make or properly use insulin). -Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) H. Record review of R#48's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/14/25, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 3, severe cognitive impairment. I. On 08/05/25 at 2:47 PM, during an interview, R #48 pointed to his front teeth and stated, hurt. J. Record review of R #48's progress notes revealed the progress notes did not contain any documentation of a dental referral, assessments, or appointments related to the resident's reported oral pain. K. On 08/10/25 at 2:46 PM, during an interview, Registered Nurse (RN) #3 stated he heard R #48 say his mouth hurt. He stated he did not document the resident's pain in the resident's progress notes. K. On 08/11/25 at 9:32 AM, during an interview, the Administrator stated staff did not make a dental appointment for R #48 following his complaint of mouth pain. She stated the resident's record did not show the resident had a dental appointment.

Based on observation, interviews and record reviews, the facility failed to ensure residents maintained a dignified existence when staff failed to assist a resident with arranging grooming services for 1 (R #50) of 1 (R #50) resident reviewed for resident rights. This deficient practice limits the residents' ability to maintain dignity, personal appearance, and quality of life and had the potential to affect all residents who relied on facility staff to arrange grooming services. If the facility fails to assist residents in arranging grooming services, this could impact the resident's dignity, potentially leading to or worsening depression. The findings are: A. Record review of the facility's Resident Rights policy, revised August 2024, stated the residents had a right to privacy, dignity, and self-determination in their care. B. Record review of facility's Dignity Policy, undated, revealed the following:- Each resident shall be cared for in a manner which promoted and enhanced his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.- When assisting with care, residents were supported in exercising their rights. Residents were groomed as they wished to be groomed, including hair styles, nails, facial hair, etc. C. Record review of R #50's Face Sheet, dated 08/08/2025, revealed the following:-The resident admitted on [DATE].-The resident had a diagnosis of assistance with personal care. -The resident had a diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). D. During an observation of R #50, the resident's hair appeared multicolored, with the previous dye color grown out. The resident's hair lengths were uneven, with some areas longer than others. E. Record review of R #50's Care Plan, dated 04/01/2024, revealed the following:-Resident used antidepressant medication related to self isolation and decreased interests in activities.-Attempt nonpharmacological interventions.-Care plan did not address personal hygiene or grooming. F. Record review of R #50's Care Conference notes revealed the following: -Dated 08/19/2021, Social Services will provide a schedule and contact information for the facility's contracted beautician.- Dated 11/02/2023, Social Services to contact the facility's contracted beautician. G. On 08/08/25 at 10:27 AM, during an interview, R #50 stated she did not receive a haircut in two years and wanted assistance arranging beautician services. The resident stated she was depressed and having her hair colored and cut would make her feel better. The resident stated her hair was a mess and she was embarrassed by her appearance. The resident stated the beautician charged a fee for the haircut, but she was willing to pay out-of-pocket for the services. R #50 stated her previous hospice company offered to arrange for her hair to be colored but she was not a resident of the hospice company any longer. R #50 stated she called the facility's beautician and left multiple voicemails, without receiving a return call. She stated a staff member told her the facility's beautician did not provide services to residents in wheelchairs. She stated the Social Services Department told her only residents who could walk, sit in her chair, and sign themselves up or have a family member assist received beautician services. H. On 08/18/2025 at 3:11 PM during an email interview, the Administrator stated the Social Services (SS) Department discussed beautician services with the resident. The Administrator stated SS arranged the appointments once a request was submitted. The Administrator stated SS reported there were not any residents at the facility who were denied beautician services by the facility contracted beautician. The Administrator stated residents could request beautician services or a family members could request beautician services for them. She stated the facility maintained a sign-up sheet for beautician and barber services for long-term care residents. The Administrator stated the Beautician was unaware of any long-term residents who was denied beautician/barber services. The Administrator stated residents who used wheelchairs could access the beautician, and she was not aware of any long-term care residents denied beautician or barber services. She stated the facility supported resident dignity and grooming by setting up appointments upon resident request and discussing grooming options during care conferences.

Based on record review and interview, the facility failed to ensure a resident's current advanced directive (a document which provides an individual's wishes for emergency and lifesaving care) was properly documented for 1 (R #7) of 1 (R #7) resident. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures. The findings are: A. Record review of R #7's Face Sheet, undated, revealed the following: -admission date of 11/18/2022.-Resident was a Full Code (attempt resuscitation). B. Record review of R #7's Medical Orders for Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves), dated 04/18/2024, revealed the following: - Code status of do not resuscitate (DNR; lifesaving measures are not desired). - Comfort measures.- Do not transfer to hospital unless comfort needs cannot be met in current location.- Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. C. Record review of R #7's Progress Notes, dated 08/03/25, revealed the resident's code status was attempt Full Code. Comfort measures: Do not transfer to hospital unless comfort needs cannot be met in current location. Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. D. Record review of R#7's Care Plan, dated 12/27/24, revealed the resident's Care Plan did not include an Advanced Directive. E. Record review of R #7's Care Conference, dated 01/15/25, revealed the resident's code status was Full Code. F. On 08/06/25 at 12:24 PM, during an interview, R #7 stated his code status was full code, and his wishes were to be resuscitated with comfort measure to relieve pain. G. On 08/08/25 at 2:56 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated R #7's physician orders indicated Full Code, and the resident's MOST form indicated the resident was DNR. LPN #1 stated she would follow the MOST form located in the binder at the nurses' station which was DNR. H. On 08/11/25 at 10:50 AM, during interview, the Administrator stated R #7's code status was Full Code, and the resident's MOST form indicated DNR. She stated MOST forms were kept at the first and second floor nurses' stations. The Administrator stated the resident's most recent care plan did not document an advanced directive. The Administrator stated failure to follow the correct code status could potentially cause harm to the resident. She stated Social Services and Nurse Management reviewed advanced directives quarterly. The Administrator stated it was her expectation advanced directives were accurate and honored the residents' wishes.

Based on record reviews and interviews, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 1 (R #66) of 1 (R #66) resident, when staff failed to ensure the resident's as needed (PRN) alprazolam (anti-anxiety medication) was prescribed for a limit of 14 days, unless there was documentation in the resident's medical record of the rationale to extend beyond 14 days. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).The findings are:A. Record review of the facility's Medication Review Regimen (MRR) policy, undated, revealed the following:- The consultant pharmacist reviewed the medication regimen of each resident at least monthly.- Resident-specific irregularities resulting from or associated with medications were documented in the resident's active record and reported to the Director of Nursing (DON), Medical Director, and Attending Physician (AP).- Recommendations were acted upon and documented by the facility staff and/or the prescriber.- Prescriber accepted and acted upon suggestion or rejected and provided an explanation for disagreeing.- The policy did not state PRN orders for psychotropic medications were limited to 14 days. B. Record review of the facility's Psychotropic Medication Use, dated September 2024, revealed PRN orders for psychotropic medications were limited to 14 days. C. Record review of R #66's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:- Muscle weakness (reduction in the power exerted by muscles),- Unsteadiness on feet (a lack of stability or coordination while walking or standing),- Cognitive communication deficit (difficulties in communication),- Need for assistance with personal care (a person requires help with daily tasks related to hygiene, grooming, and overall self-care),- Displaced intertrochanteric fracture of left femur (a break in the upper part of the left thigh bone, femur). D. Record review of R #66's Physician Orders Sheet dated 07/29/25, revealed an active order to administer alprazolam, 0.25 milligram (mg) tablet. Give one tablet every 24 hours by mouth PRN for anxiety. The order had a stop date of indefinite. E. Record review of R #66's MRR, dated 07/30/25, revealed the Pharmacist Consultant (PC) recommended limiting the use of alprazolam to a 14-day duration. The Attending Physician did not respond to PC's recommendations. F. On 08/08/25 at 1:50 pm, during an interview, the Director of Nursing (DON) stated she expected R #66's attending physician to enter a 14-day stop date for the psychotropic medication order. The DON stated she did not expect the nurses to review order end dates on psychotropic orders being confirmed. G. On 08/08/25 at 2:41 pm, during an interview, R #66's Attending Physician stated he visited and reviewed R #66's medications once a month. He stated he was not aware PRN psychotropic medications orders needed a 14-day stop date. H. On 08/11/25 at 11:33 am, during an interview, the PC stated he expected R #66's AP to enter a 14-day stop date for the alprazolam order.

Based on record reviews and interview, the facility failed to complete and submit a Five Day Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations) to the State Agency regarding allegations of neglect (the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) for 1 (R #77) of 1 (R #77) resident. If the facility does not submit follow-up reports, then the State Agency cannot assure the residents are safe and free of neglect. The findings are:A. Record review of R #77's Face Sheet revealed an initial admission date of 06/20/25 with the following diagnoses:- Cardiomyopathy (heart disease),- Type 2 diabetes mellitus (DM2, a condition which results from insufficient production of insulin, causing high blood sugar),- Unspecified Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),- Hypoxemia (low levels of oxygen in the blood),- Atherosclerosis heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls). B. Record review of the facility's Facility Reported Incident (FRI), dated 06/24/25, revealed R #77 fell shortly after admission on [DATE] and fell again later that evening. The FRI did not report the time of the falls. The FRI documented R #77 complained of pain on 06/24/25, which resulted in the diagnosis of a right femoral neck fracture (a break in the neck of the right thigh bone, located just below the ball of the right hip joint). C. Record review of R #77's Electronic Health Record, revealed R #77 was discharged to the hospital on [DATE]. Further review revealed the facility did not document any evidence the facility completed an investigation into the resident's falls or fracture of the right thigh. D. On 08/07/25 at 1:50 pm, during an interview, Director of Nursing (DON) stated she did not complete an investigation into the resident's falls, because the resident did not return to the facility after being hospitalized . The DON stated she was aware the Five Day Follow-Up report was due on the fifth day after an incident was reported to the State Agency.

Based on record review, observation, and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 2 (R #6 and R #23) of 2 (R #6 and R #23) residents. If staff do not complete an accurate assessment of residents, then staff may not provide adequate care and treatment of the resident's needs. The findings are: R #6 A. Record review of R #6's Face Sheet, undated, revealed the following: -Resident admission date of 06/14/2023.-Primary diagnosis of Alzheimer's disease (a disease which causes irreversible changes in memory, thinking, and behavior).-Diagnosis of atrial fibrillation (A-Fib; irregular heart rhythm). B. On 08/07/25 at 1:29 PM, during an observation, revealed R #6 had missing and broken teeth. C. Record review of R #6's Care Plan, dated 02/12/24, revealed oral care was not care planned. D. Record review of R #6 annual MDS, dated [DATE], revealed the following: -Resident was dependent on staff for oral hygiene. -Resident did not have natural teeth. E. Record review of R #6's Progress Notes, dated 02/20/25, revealed the Director of Nursing (DON) documented R #6 had problems with teeth. The record did not state what kind of problems the resident had with their teeth. G. On 08/18/25 at 10:34 AM, during an interview with DON, she stated R #6 had natural teeth. The DON stated she could not recall what problems the resident experienced in the resident progress notes, dated 02/20/2025. The DON stated the Annual MDS dated , 06/07/2025, was coded correctly. The DON stated she was responsible for the review and accuracy of the MDS. R #23 H. Record review of R #23's Face Sheet, undated, revealed and admission date of 04/30/2024 with the following diagnoses:- Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease) - Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body).- Cerebral infarction (stroke). I. Record review of R #23's Annual MDS, dated [DATE], revealed the resident had clear speech. J. Record review of R #23's Care plan, dated 05/08/24, revealed the following: -Resident had communication problem. -Resident responded to yes/no questions appropriately and used a communication board. -Monitor/document for physical/nonverbal indicators of discomfort or distress. -Resident will communicate non-verbally her feelings related to emotional state. -Resident will maintain daily routine of communicating nonverbally. K. On 08/05/25 at 10:06 AM during an observation, R #23 was nonverbal. L. On 08/05/25 at 10:30 AM during an interview, Dietary Aide #1 stated R #23 was nonverbal and could answer simple questions by moving her head yes, no or with thumbs up, thumbs down. M. Record review of R #23's Progress Notes revealed the following: - Dated 03/04/25, resident was nonverbal and communicated by nodding her head yes and no and used a thumbs up gesture. - Dated 04/23/25, resident had a diagnosis of aphasia. The resident did not verbally communicate but pointed to express herself. The resident appeared to be able to interact non-verbally, as evidenced by waving at others.- Dated 07/02/25, resident had a diagnosis of aphasia due to cerebrovascular disease, which likely contributed to her non-verbal status. - Dated 08/10/25, social history was unobtainable at this time secondary to resident's nonverbal status. O. Record review of R #23's Social Services Assessment, dated 05/03/24, revealed resident was non-verbal due to stroke. P. On 08/18/25 at 10:34 AM, during an interview, the DON stated R #23 was nonverbal. The DON stated the Annual MDS, dated [DATE], was incorrectly coded, and facility staff should have coded the resident's MDS as the resident did not speak. The DON stated she was responsible for the review and accuracy of R #23's Annual MDS.

Based on record reviews and staff interviews, the facility failed to develop and implement a complete baseline care plan within 48 hours of admission for 1 (R #73) of 1 (R #73) resident. If the facility fails to implement a complete baseline care plan within 48 hours of admission for residents, then the resident may be at risk of serious falls, hospital transfers, and worsening of clinical status. The findings are: A. Record review of the facility's Care Plans- Baseline Policy, dated 08/2024, revealed a comprehensive care plan may be used in place of the baseline care plan, provided the comprehensive care plan was developed within 48 hours of the resident's admission. B. Record review of R #73's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:- Muscle weakness (reduction in the power exerted by muscles),- Unsteadiness on feet (a lack of stability or coordination while walking or standing),- Cognitive communication deficit (difficulties in communication),- Need for assistance with personal care (a person requires help with daily tasks related to hygiene, grooming, and overall self-care). C. Record review of R #73's medical record revealed the facility did not develop the resident's care plan within 48 hours of admission (due 08/03/25). The resident's baseline care plan was dated 08/04/25. D. On 08/07/25 at 11:44 am, during an interview, the Unit Manager (UM) #2 stated any resident admitted late Friday afternoon or over the weekend would have a baseline care plan completed on the following business day. UM #2 stated it was her expectation for Unit Managers to complete the baseline care plans. She stated floor nurses were not expected to do resident care plans. She stated floor nurses were not in the habit of making care plans, because Unit Managers did them per Director of Nursing's (DON) directive. UM #2 stated she could not provide a reason why R #73's baseline care plan was not completed within 48 hours. She stated she did not work on the weekends. She stated her records showed R #73 was admitted to facility at 6:01 pm on Friday, 08/01/25. E. On 08/08/25 at 1:50 pm, during an interview, the DON stated nursing leadership was responsible to create baseline care plans and comprehensive care plans. She stated floor nurses did not have the time to create care plans for the residents and were not efficient at doing care plans. She stated there were not any expectations for weekend staff to cover Friday admissions, and the nurse leadership would complete the care plans on the following business day. The DON stated she did not know when the 48 hour time frame would start to complete basic care plans, and she was not aware weekends counted towards the timeframe.

Based on observation, interview, and record review, the facility failed to develop and implement resident focused, comprehensive care plans to address the oral hygiene needs for 1 (R #6) of 1 (R #6) resident. This deficient practice is likely to place the residents at risk for inadequate routine dental care, pain, infection, and complications to underlying conditions and prescribed medications. The findings are:A. Record review of R #6's Face Sheet, undated, revealed the following: -Resident admission date of 06/14/2023. -Primary diagnosis of Alzheimer's disease (a disease which causes irreversible changes in memory, thinking, and behavior). -Diagnosis of atrial fibrillation (A-Fib; irregular heart rhythm). B. On 08/09/25 at 11:35 AM, during an observation, R #6's front teeth were missing. C. Record review of R #6's Progress Notes, dated 04/08/25, revealed the following: -Staff did not perform oral care for the resident. Resident independent in oral care. -The resident experienced disorganized thinking. -The resident had severe cognitive impairment. D. Record of R #6's Progress Notes, dated 02/25/25 revealed the resident experienced problems with their teeth. E. Record review of R #6's Care Plan, dated 06/23/2023, revealed the care plan did not address dental services or oral care. F. On 08/11/25 at 10:50 AM, during an interview, the Administrator stated R #6 did not receive dental services since admission to the facility. The Administrator stated it was her expectation for resident's oral care to be care planned, so the resident could receive routine dental services. The Administrator stated the resident could be at risk for complications due to poor dental hygiene if residents did not have oral hygiene and services care planned. G. On 08/18/25 at 10:34 AM, during an interview, the Director of Nursing (DON) stated residents did not require a care plan for dental services or oral hygiene. She stated dental/oral hygiene care planning would be created if the resident had an infection or other issues with the oral cavity. The DON stated staff who provide direct resident care can access the residents' care plan for dental hygiene under activities of daily living. The DON stated the nursing department was responsible to create and update each residents' care plan. She stated R #6 did not have a plan for dental services or oral hygiene anywhere in the care plan.

Cross reference to F760 and F605. Based on record reviews and interviews, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #66) of 1 (R #66) residents reviewed for unnecessary medications when the Attending Physician (AP) and the Medical Director (MD) failed to review, respond to, and act on the Consultant Pharmacist (CP)'s identified irregularities (the use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and that impedes or interferes with achieving the intended outcomes of pharmaceutical services) sent monthly via Medication Regimen Reviews (MRRs, pharmacy review of the medication a resident receives). If physicians do not review, respond to, and act on CP's identified irregularities, then it could result in adverse consequences related to medication therapy. The findings are:A. Record review of the facility's Medication Utilization and Prescribing - Clinical Protocol policy, dated 08/2024, revealed the Consultant Pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medication regimens that were not supported based on clinical signs or symptoms. B. Record review of the facility's MRR policy, undated, revealed the following:- The Consultant Pharmacist performed a comprehensive review of each resident's medication regimen and clinical record at least monthly. - The Consultant Pharmacist identified irregularities (the use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, or impedes/interferes with achieving the intended outcomes of pharmaceutical services) through a variety of sources, including the resident's clinical record, pharmacy records, and other applicable documents. C. Record review of R #66's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:- Muscle weakness (reduction in the power exerted by muscles),- Unsteadiness on feet (a lack of stability or coordination while walking or standing),- Cognitive communication deficit (difficulties in communication),- Need for assistance with personal care (a person requires help with daily tasks related to hygiene, grooming, and overall self-care),- Displaced intertrochanteric fracture of left femur (a break in the upper part of the left thigh bone, femur). D. Record review of R #66's Physician Orders Sheet, dated 07/29/25, revealed an active order to administer alprazolam (anti-anxiety medication) 0.25 milligram (mg) tablet. Give one tablet every 24 hours by mouth as needed (PRN) for anxiety. The order had a stop date of indefinite. E. Record review of R #66's MRR dated 07/30/25, revealed the Pharmacist Consultant (PC) recommended limiting the use of alprazolam to a 14-day duration. The Attending Physician did not respond to Pharmacist Consultant's recommendations. F. On 08/08/25 at 2:41 pm, during an interview, R #66's Attending Physician stated he visited and reviewed R #66's medications once a month. He stated he was not aware PRN psychotropic medications orders needed a 14-day stop date. G. On 08/11/25 at 11:33 am, during an interview, the Pharmacist Consultant stated he expected R #66's AP to enter a 14-day stop date for the alprazolam order.

Based on observation, record review, and staff interviews, the facility failed to: - Ensure resident refrigerators were maintained in a clean and sanitary condition. - Label and date food items in the refrigerators. This failure had the potential to affect 1 (200-unit ) out of 1 (200-unit) unit refrigerators. If the facility does not maintain refrigerators in a safe and sanitary manner, then residents are at risk of consuming spoiled or contaminated food, which could result in foodborne illness or decline in health.The Findings are:A. Record review of the facility's policy titled Food Storage and Sanitation, revised April 2024 ,revealed the following:- All food items stored in resident refrigerators were to be labeled and dated upon placement.- Refrigerators would be cleaned on a scheduled basis and kept free of spills, grime, and food residue.- Staff were responsible for monitoring to ensure food storage and appliances remained sanitary and safe for resident use. B. On 08/05/2025 at 8:30 AM, during an observation, the interior of the 200-unit resident refrigerators located in the common area was grimy, sticky, and had brown fluid pooled on the bottom under the clear drawers. Further observation revealed an unopened can of V8 juice, two Sprite zeros, and eight unopened pudding packs which were not labeled with a resident's name. C. On 08/11/2025 at 1:17 PM, during an interview, the Unit Manager stated the refrigerators should be cleaned, and all food should be labeled with resident name. D. On 08/11/2025 at 2:00 PM, during an interview, the Administrator stated it was her expectation for all items in the resident refrigerators to be labeled with the resident's name. She stated the refrigerator should be clean and free from dirt or spills.

Based on record review and interview, the facility failed to ensure a comprehensive Minimum Data Set Assessment (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #1) of 1 (R #1) residents reviewed for accurate MDS Assessments. If resident assessments are not complete and accurate, the facility could misidentify clinical complications and fail to provide adequate care to treat the resident's medical condition. The findings are: A. Record review of R #1's admission MDS, dated [DATE], indicated the resident did not have any pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) upon admission. B. Record review of R #1's progress notes, dated 05/26/24, revealed R #1 had a pressure ulcer to coccyx (tail bone) which measured 2 centimeters (cm) by 1.4 cm by 0.2 cm on admission. C. Record review of R #1's progress notes, dated 06/06/24, revealed R #1 had a stage 3 pressure ulcer (full thickness skin loss that extends into deeper tissue and fat but not into muscle, tendon, or bone) at the time of discharge. D. Record review of R 1's discharge MDS Assessment, dated 06/06/24, indicated the resident did not have any pressure ulcers upon discharge. E. On 01/30/24 at 12:11 pm, during an interview with the Director of Nursing (DON), she stated R #1 had a pressure ulcer on his coccyx at admission and at discharge, staff incorrectly coded R #1's MDS.

Based on record review and interview, the facility failed to provide quality of care for 1 (R #1) of 1 (R #1) resident reviewed for dehydration and nutrition when: 1. Staff failed to identify the decrease in nutritional intake and weight loss for R #1 as a change in condition. 2. Staff delayed to send R #1 to the hospital for two days after significant change in vitals. These deficient practices likely resulted in R #1's admission to the hospital with dehydration, urinary tract infection and sepsis (severe infection). The findings are: A. Record review of R #1's face sheet indicated she was admitted on [DATE] with the following diagnoses: - Fetal alcohol syndrome (condition in a child that results from alcohol exposure during the mother's pregnancy), - Severe intellectual disabilities [intelligence quotient (IQ) below 70 and deficits in at least two adaptive behaviors that affect everyday, general living], - Urinary tract infection, - Retention of urine (not fully draining urine from your bladder), - Dysphagia (difficulty swallowing). - This is not all inclusive list of diagnoses. B. Record review of the physician's orders for R #1 revealed the following, an order for house supplement (nutritional drink which includes carbohydrates, protein, fat, vitamins, and minerals and meant to provide a boost of nutrition to someone who is unable to get what they need from regular eating) four times a day for poor intake start date 01/26/24; and to weigh every Tuesday in the morning start date 04/23/24. C. Record review of the nursing progress notes for R #1, dated 04/12/24, indicated R #1 did not eat or drink much. On admission to the facility, staff had a conversation with the resident's Guardian (a person who is legally responsible for the care of another person) about hospice. Staff entered an order on 04/12/24 for hospice to evaluate R #1 since the resident declined over the past several months and continued to decline. D. Record review of a progress note for R #1 written by the Registered Dietician, dated 04/12/24, revealed R #1's weight was 143 pounds. Significant weight gain of 8 pounds (5.9%) in 1 day, likely due to inaccuracy. Weight fluctuated but trending decline. Close to weight at admission. Average intake 40 percent (%) with recent decline to below 25%. House supplement four times per day at 85% intake. Continue current plan of care. Continue weekly weight and referral to hospice. E. Record review of a nutritional progress note written by the Registered Dietician (RD) for R #1, dated 04/19/24, indicated the resident weighed 136 pounds (lbs), which was a 10 lb weight loss in 30 days. The resident's average intake was around 35 percent (%). The resident received a house supplement four times a day, and her intake averaged 95%. The resident is dependent on staff and required eating assistance She also required encouragement and supervision during and between mealtime for fluid, food, and snacks. F. Record review of the care plan for R #1, indicated the following care plan items: - R #1 had a communication problem due to a weak and absent voice, rarely or never understood, and rarely or never understands. - Initiated date 04/26/24, R #1 should be up in a wheelchair and in the dining room for all meals. The care plan directed staff to monitor weights weekly, poor intakes during meals, hydration, and supplements. - Acitivities of daily living (ADL) - R #1 was totally dependent on facility staff for bathing, bed mobility, dressing, eating, and personal hygiene. - R #1 had bladder incontinence, urinary retention, and recurrent urinary tract infections. - Monitor fluid intakes and for urinary tract infection (UTI) such as pain, burning, blood tinged urine, cloudiness, no output, urine color, change in eating, mental status and vitals. G. Record review of the Medication Administration Record (MAR) for R #1, dated 05/01/24 to 05/10/24, indicated staff documented the following: - Staff gave the resident 40 supplements. - R #1 drank 100 percent (%) of 22 of them. - R #1 drank 50% of 9 of them - R #1 drank 25% or less of 9 of them. H. Record review of the meal consumption percentages for R #1 indicated staff documented the following: - 05/14/24, one meal at 0-25%. - 05/13/24, two meals at 0-25%. - 05/12/24, one meal refused and two meals at 0-25%. - 05/11/24, one meal at 0-25% and one meal at 26-50%. - 05/10/24, one meal at 0-25% and one meal at 26-50%. - 05/09/24, one meal at 0-25% and one meal at 51-75%. - 05/08/24, one meal at 0-25% and one meal at 51-75%. - 05/07/24, two meals at 0-25%. - 05/06/24, staff did not document the resident's consumption percentages. - 05/05/24, one meal documented at 0-25%. - 05/04/24, one meal at 26- 51% and one meal at 76-100%. - 05/03/24, one meal at 51-76% and two meals at 76-100%. - 05/02/24, two meals at 76-100%. - 05/01/24, two meals at 76-100%. - 04/30/24, one meal at 0-25%. I. Record review of the daily, total fluid consumption percentage during meals and supplements for R #1 indicated staff documented the following: (The average woman should drink between 91 and 95 ounces per day of water/fluid): - 05/14/24, for two meals 960 cc / 32.5 ounces (oz). - 05/13/24, for one meal 80 cc / 2.70 oz. - 05/12/24, for two meals 960 cc / 32.5 oz. - 05/11/24, for two meals 900 cc / 34.93 oz. - 05/10/24, for two meals 1080 cc / 36.51 oz. - 05/09/24, for three meals 1200 cc / 40.56 oz. - 05/08/24, for two meals 360 cc / 12.17 oz. - 05/07/24, for two meals 240 cc / 8.11 oz. - 05/06/24, staff did not document the resident's consumption percentages. - 05/05/24, for one meal 200 cc / 6.76 oz. - 05/04/24, for two meals 760 cc / 25.69 oz. - 05/03/24, for two meals 960 cc / 32.5 oz. - 05/02/24, for two meals 960 cc / 32.5 oz. - 05/01/24, for two meals 960 cc / 32.5 oz. - 04/30/24, for one meal 480 cc / 16.23 oz. J. Record review of weights in the electronic medical record for R #1 indicated the resident weighed the following: - On 05/09/24, 125.0 lbs. - On 05/07/24, 127.0 lbs. - On 04/30/24, 140.0 lbs. - On 04/19/24, 143.0 lbs. - On 04/15/24, 136.0 lbs. K. Record review of the nursing progress notes for R #1 indicated the following: - On 05/10/24, staff called the resident's guardian. The resident had significant (a greater than 5% weight loss in 30 days) weight loss of 13 lbs (9.3% body weight loss) in a week. Resident recently started pocketing food and drink (where food is held in the mouth, especially in the cheeks, without being swallowed), and she had an average food intake of less than 25% in the past week. Supplement intakes two weeks ago were at 95% but declined to ~ 65% this week. Will collaborate with nursing, Speech-Language Pathology (SLP), and dietary department to offer additional supplements and snacks. The resident likes root beer. Staff should offer supplement with root beer, additional root beer float , additional supplement, and boost pudding (nutritional supplement in a pudding format) or magic cup (nutritional supplement in a frozen format) when available would be beneficial. - On 05/12/24, Certified Nursing Assistant (CNA) reported to the nurse on-call that the resident was warm to touch. Staff took the resident's vital signs on 05/12/24 at 9:36 pm, and they were as follows: Blood pressure (BP; normal blood pressure for adults ages 20 and older is 120/80): 123/68, heart rate [HR; normal heart rate in an individual is 60 to 100 beats per minute (bpm)]: 138 bpm, respiration rate (RR; rate of breathing. Normal RR 16 to 20 breaths per minute): 37, oxygen saturation (O2 sat; measure of how much oxygen is traveling through your body in your red blood cells. Normal O2 sat is between 95% and 100%): 79 to 85% room air (RA), temperature [temp; normal temperature for adults is in the range of 97 degrees ( ) Fahrenheit (F) to 99 F]: 100.5 F. The resident's urine appeared to have some blood clots and sediments. The resident's skin was warm to touch and was clammy. Staff removed all blankets off the resident and placed supplemental oxygen via nasal cannula (NC; medical device to provide supplemental oxygen therapy to people who have lower oxygen level) at 4 liters per minute (L/min) via NC. Staff attempted to give the resident her scheduled medications, including Tylenol, to decrease elevated temperature; however, resident did not swallow the medication. The resident kept her mouth open and did not listen to verbal instructions. In order to prevent the resident from choking or aspirating (to breathe in or to breathe a substance into your lungs by accident), staff cleaned the resident's mouth with a toothette (disposable, single-use sponges attached to a stick and used for oral care) to remove medication mixed with yogurt. L. Record Review of the physician orders for R #1, dated 05/14/24, indicated an order to transfer R #1 to hospital immediately for possible sepsis (serious infection). Patient had a fever yesterday, and now she had tachycardia (increased heart rate), hypoxia (low oxygen), hypernatremia (having too much sodium in the blood), acute kidney injury (AKI; a sudden decrease in kidney function that develops rapidly over a few hours or days. It may be fatal.), and hyperglycemia (high blood sugar). M On 06/18/24 at 12:30 pm during interview with Nurse Practitioner (NP), she stated she was aware of R #1's condition on 05/13/24. She stated the on-call physician made the decision not to send the resident to the emergency room and placed orders for an IV, labwork, and antibiotics instead. She stated R #1's vitals were more stable later when she came to see R #1 on the 05/13/24, and she wanted to wait to see what the lab work indicated. The NP stated the resident's lab work came back on 05/14/24. She said the resident's vitals were not stable on 05/14/24, and the lab results indicated the resident had high neutrophils (white blood cells; if high it may be due to medical conditions like infection.) The NP stated she decided to send R #1 out to the hospital. She stated she probably should have sent R #1 out to the hospital sooner. N. On 06/17/24 at 12:37 pm, during an interview with the Tribal Services Guardian, she stated R #1 was malnourished and dehydrated when she was admitted to the hospital on 05/14/24. The Guardian stated the facility called sometime in April and told her they wanted to get a hospice consult. She stated she was surprised, because the facility did not give her the impression that R #1 had declined to the point of needing hospice. The Guardian stated hospice denied R #1, because there was not a reason for her to be on hospice. She stated she received mixed messages from the facility about R #1's weight and food intakes. She stated R #1 ate 80 % of her meals; yet, R #1 still lost weight. The guardian stated R #1 required full assistance with eating her meals, (meaning she required full assistance with eating and drinking and was not able to feed or intake any fluids on her own) O. On 06/18/24 at 9:20 am, during an interview with the Registered Dietician (RD), she stated she reviewed all documentation related to the resident's food and hydration intakes, spoke to staff, and reviewed the resident's weights when she made assessments for residents. The RD reviewed R #1's intake percentages for April and May and stated that she would not think R #1 would continue to lose that much weight. The RD stated, that to her knowledge, the staff assisted the resident with eating in the resident's room. She stated that once a resident declined to the point of not eating, the staff usually considered hospice. P. On 06/17/24 at 9:55 am, during an interview with CNA #8, she stated she assisted R #1 with eating a few time, and she was taught to give R #1 a bite of food and then a sip of water. She stated the food and fluids would come out of the side of the resident's mouth, and sometimes the resident would not swallow her food at all. CNA #8 stated this went on for about one month prior to the resident going out to the hospital. She stated she assisted the resident with eating in her room, not the dining room, and it took around thirty minutes. CNA #8 stated the resident liked to eat in her room. CNA #8 was not aware of the signs of dehydration. Q. On 06/17/24 at 12:45 pm, during an interview with the Tribal Services Director/Guardian, she stated R #1 was admitted to the hospital on Tuesday, 05/14/24, and she was told R #1 was still dehydrated on Friday, 05/17/24. The Guardian stated the resident had a urinary tract infection [UTI; an infection in any part of the urinary system, usually the bladder or urethra (the tube that lets urine leave your body)], kidney stones [when a solid piece of material (renal calculus) develops in the urinary tract], and her electrolytes (keep your nervous system and muscles functioning and your internal environment balanced) were totally off. She stated the hospital was not able to draw any labs on the resident, because she was so dehydrated. She stated the hospital voiced concerns about medical neglect because of the condition R #1 was in when she arrived at the hospital. The Guardian stated she was often given mixed messages about R #1's food intakes and weight loss when she spoke to the facility staff, like one conversation would be that she has gained weight and the next would be that she needed to go on hospice. She stated the resident was totally dependent on staff for all food and fluid intakes. She also stated R #1 was still in the hospital, and now she had a gastrostomy tube (G-tube; a tube surgically inserted through the abdomen into the stomach and used to provide fluids, nourishment, and medications). R. On 06/17/24 at 1:20 pm, during an interview with the Hospital Social Worker (HSW), she stated R #1 was very sick when she showed up to the hospital . The HSW stated R #1 was not eating or drinking, and the doctor decided to place a feeding tube. She stated that was the only way the resident would get nutrition, because she had not been eating or drinking enough. The HSW stated there were also concerns the resident might aspirate. S. On 06/17/24 at 4:02 pm, during an interview with the Hospital Physician, she stated R #1 was admitted to the hospital with high sodium levels, a urinary infection, kidney stones, and sepsis due to an infection. She stated she spoke to someone (unknown person) from the facility,and they told her R #1 had not been eating for approximately six weeks. The Physician stated it was not acceptable for a person, who is not on hospice, to not eat much for around six weeks. She stated the resident was dehydrated and required 13 liters of fluid. She stated this seemed like neglect to her. T. On 06/17/24 at 10:14 am, during an interview with the Director of Nursing (DON), she stated they talked to the R #1's Guardian sometime in April, and they suggested Hospice services. The DON stated the facility felt like the resident was declining and was at end of life, due to R #1 not eating and her weight loss. She stated the resident did not receive Hospice services, and she was not sure why. The DON stated that when R #1 did not go on hospice services, the facility wasn't able to do anything else for R #1. The DON stated how do you make someone eat? She stated the resident was on supplements and was assisted with eating. U. On 06/18/24 at 10:22 am, during an interview with Nurse #5, she stated sometimes R #1 ate in the dining room and sometimes in her room. She stated sometimes the CNAs did not get the resident out of bed, and that is why she ate in her room. She stated R #1 stopped eating and was pocketing her food, but she was not sure for how long. The nurse stated the resident also pocketed her medications. V. On 06/18/24 at 1:07 am, during an interview with Speech Therapy (ST), she stated R #1 needed full assistance with eating. She stated the resident did not have issues with fluids, but she did pocket her food when she ate. The ST stated she worked with staff on this and showed them how to use the toothette (soft piece of foam on stick to assist with oral issues) to swipe the food away and to limit the pocketing. ST stated she trained the CNAs on that shift and the information was passed along to the next shift. The ST stated did not conduct a full training with all the staff around this issue. She stated staff needed to take the time with R #1 when she ate. She stated R #1 needed to be in an upright position so the food would not trickle out of her mouth. She stated if staff had the resident in an upright position and utilized the toothette, then R #1 would not have the issue of pocketing her food or trickling out the side of the mouth. The ST stated when she saw staff assisting R #1 with eating the resident was usually in bed.

35632 Based on record review and interview, the facility failed to prevent an accident and to provide a safe transfer when the facility failed to: 1. Ensure beds were locked. 2. Ensure staff used equipment correctly 3. Ensure staff supervised residents needing help during transfers. 4. Ensure staff used the lift properly and with the appropriate equipment. These failures had the potential to affect 4 (R #5, R #21, #34, and R #58) out of 4 (R #5, R #21, R #34, R #58) residents reviewed for falls. These deficient practices could likely result in the residents falling and injuring themselves. The findings are: Findings for R #21 A. Record review of the face sheet for R #21 revealed the resident was admitted to the facility on [DATE] with multiple diagnoses to include: - Hypotension (low blood pressure), - Anemia (deficiency of healthy red blood cells in blood and they carry oxygen to all parts of the body), - Depression (sadness and loss of interest), - Malnutrition (not taking enough calories). B. Record review of the care plan for R #21, dated 04/18/24, indicated the following: - The resident was at risk for falls due to weakness and deconditioning, opioid use, and cognition. - Ensure to provide a safe environment: Bed locked and tray table with personal items within reach. C. Record review of the nursing progress notes for R #21, dated 05/06/24 at 1:04 pm, revealed the resident had a fall on 04/17/24. Staff documented a late entry: The Nursing Assistant (NA) reported to the Nurse that R #21 was found on the floor next to his bed. The Nurse went in the resident's room, and R #21 lay on his right side with his blanket and pillow under him. Medication Technician/Certified Nursing Assistant (CNA) reported that R #21 stated he reached for his water, and the bed moved. The CNA stated the bed was not locked when she checked it. D. On 05/10/24 at 9:33 am, during an interview with Nurse #3, she stated R #21 was on floor when she entered the room. She stated the bed was little higher than normal, and the bed control was on the other side of the bed. Nurse #3 stated the CNA told her the bed was not locked. Nurse #3 stated there was a lever at the foot of the bed that staff can push with their foot to lock the bed and keep it from moving. Nurse #3 stated the CNA told her R #21 said he reached for his water and fell out of bed. She stated there were several reasons staff move the beds in resident rooms, like changing the sheets on the bed and housekeeping will move them to clean. E. On 05/09/24 at 1:18 pm, during an interview with CNA #8, she stated the residents' bed need to be locked at all times. CNA #8 stated they unlock the beds to move them sometimes, but staff should relock the bed when they are finished. She stated if the bed was unlocked when a resident tried to get out of bed or reach for something, then the bed could shift causing the resident to fall. F. On 05/09/24 at 1:46 pm, during an interview with the Administrator, she stated that she would expect to see an investigation into a fall to indicate the bed was unlocked. but she did not see one for R #21's fall from the bed. She expects that any staff who moves the bed for any reason to relock it so it doesn't move. Ensuring staff used equipment correctly G. Record review of the comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by the facility staff) for R #34, dated 04/23/24, revealed R #34 was totally dependent on staff for assistance. R #34 could not use both her upper and lower extremities and required the assistance of two staff and a Hoyer lift for transfers. H. Record review of a progress note in the electronic medical record for R #34, dated 04/22/24, revealed staff documented R #34 fell from the Hoyer lift (medical equipment designed to lift and transfer patients from one place to another) when staff transferred him from his bed to his wheelchair. The record also revealed the Hoyer lift grazed R #34's head when it tipped over. I. Record review of the incident report for R #34's fall, dated 05/02/24, revealed the Director of Nursing (DON) documented certified nursing aide (CNA) #1 and CNA #2 assisted R #34 with a transfer from his bed to his wheelchair using the Hoyer lift on 04/22/24. The report revealed the Hoyer lifts legs were under the resident's wheelchair as the CNAs transferred the resident. The report further revealed CNA #1 pulled hard on R #34 to assist him into his wheelchair, the Hoyer lift tipped over, R #34 landed in his wheelchair hard, and the Hoyer lift grazed the resident's head. An injury was not reported. J. Record review of the facility's in-service training for proper usage of Hoyer lifts, dated 04/26/24, showed CNA #1 and CNA #2 attended the class at the facility on that date. K. On 05/06/24 at 12:54 pm, during an interview with R #34, he stated he fell into his wheelchair when the Hoyer lift tipped over on 04/22/24, when staff transferred him from his bed and into his wheelchair. R #34 stated the Hoyer hit his head but did not cause any injury. R #34 stated he did not think the CNAs used the Hoyer lift correctly, because it should never tip over when used right. R #34 further stated while he was in the air, above his wheelchair, in the Hoyer lift, one of the CNAs pulled on him hard, which caused his weight to shift and the Hoyer lift tipped over. L. On 05/07/24 at 11:35 am, during an interview with the DON, she stated the only way a Hoyer can tip over during operation is if staff use it incorrectly. The DON investigated the incident and found that one of the CNAs moved R #34 while he was being lifted in the Hoyer instead of moving the Hoyer. Ensure staff supervised residents needing help during transfers M. Record review of the progress note in the electronic medical record for R #58, dated 05/04/2024, revealed the resident fell on to the floor when staff transferred her from the wheelchair to a shower chair on 05/04/24. N. Record review of the comprehensive MDS for R #58, dated 04/29/24, revealed R #58 required supervision or touching assistance from staff during transfers from wheelchair to shower chair. Staff to provide verbal cues, touching, steadying, and contact guard assistance as the resident transfers from one chair to another. O. Record review of the care plan for R #58, dated 04/26/24, revealed R #58 was at risk for falls related to reduced mobility with the intervention of reminders about safety. P. Record review of the fall investigation for R #58's fall, dated 05/04/24, revealed CNA #3 witnessed R #58 slide out of her wheelchair in the shower room, and R #58 stated I forgot to lock my brakes. The resident had a new bruise to the back of her right forearm and a small scrape on her right elbow. Staff assisted the resident back into her chair, and the resident continued with her shower. Q. On 05/06/24 at 3:05 pm, during an interview with R #58, she stated she slipped out of her wheelchair in the shower room while she transferred herself to the shower chair. R #58 stated she forgot to lock her wheelchair brakes, and that is why she slipped out onto the floor. R #58 did not remember if CNA #3 reminded her to lock her wheelchair brakes or not. R #58 further stated CNA #3 and herself were in the shower room during the incident. R. On 05/9/24 at 11:07 am, during an interview with the DOR (Director of Rehabilitation), he stated that since R #58 required supervision or touching assistance during transfers, CNA #3 should have verbally asked R #58 to lock her wheelchair before transferring or the CNA should have locked the wheelchair. Findings for R #5 S. On 05/06/24 at 8:45 am, during an interview with R #5, she stated recently staff transferred her from the wheelchair to her bed with a Hoyer lift. She said the Hoyer lift tilted, and she fell on the floor. She stated she refused to go to the hospital, because she was not hurt. R #5 stated she thinks the fall had something to do with the sling, but she was not sure. T. Record review of the incident report for R #5, dated 03/25/24, revealed staff documented they transferred the resident from the shower chair to her bed using a Hoyer lift. The Hoyer lift tipped to the left, and the resident fell to the floor. The CNAs assisted with the transfer. Resident did not hit her head and refused to go to the hospital. In the witness section it revealed we were transferring resident from the shower chair to the bed using a Hoyer lift, and when we moved residents legs, the Hoyer titled over to the left side. U. On 05/07/24 at 11:35 am, during an interview with the DON, she stated the only way a Hoyer can tip over during operation is if staff use it incorrectly. V. On 05/09/24 at 1:46 pm, during an interview with the Administrator, she stated she would expect to see an investigation into a fall that included a Hoyer lift. She stated staff completed an incident report for the Hoyer lift incident with R #5, but she could not find an investigation of why it happened.

Based on observation and interviews, the facility failed to: 1. Ensure expired supplies were not kept with unexpired supplies. 2. Ensure staff documented the medication refrigerator temperatures. These deficient practices are likely to result in all 11 residents who resided on the 100 hall, as identified on the census list provided by the Executive Director (ED) on [DATE], to have expired supplies that have lost either their potency or effectiveness used on them, or to receive medication that has lost either their potency or effectiveness. The findings are: Ensure expired supplies were not kept with unexpired supplies. A. On [DATE] at 9:25 am, observation of 100 hall medication room revealed a Medstream dressing change kit expired on [DATE]. The expired supplies were stored with other non-expired supplies and not in the area used for the disposal of expired supplies. B. On [DATE] at 9:30 am, during an interview, medication technician (MT) #1 confirmed the supplies were expired. MT #1 stated it was expected the nursing staff to go through the medication storage rooms from time to time and remove any expired or soon to expire supplies. Ensure staff documented temperatures for medication refrigerator. C. Record review of the 100 hall medication room's refrigerator temperature logs revealed staff did not document the temperatures as follows: 1. [DATE] am or pm. 2. [DATE] am or pm. 3. [DATE] am or pm. 4. [DATE] am. D. On [DATE] at 9:25 am, during observation of the 100 hall medication room refrigerator, insulin and other medications that required refrigeration were in the refrigerator. Further observation revealed an analog (dial type) temperature gauge and a digital temperature sensor inside the refrigerator. E. On [DATE] at 1:32 pm, during an interview with the Director of Nursing (DON), she stated staff must check all medication storage rooms refrigerator and freezer temperatures once a day and document the temperatures on the temperature log. She stated staff checked to make sure the refrigerators maintained a temperature range of 36 to 46 degrees Fahrenheit, which preserved temperature controlled medications.

The facility failed to identify a significant weight loss for a resident. The resident has past issues with vomiting and the vomiting became more frequent the last three weeks than it had previously. Speech therapy was involved and had downgraded her diet and resident was currently on a puree diet. This did not solve the vomiting issue and resident continued to vomit food and liquids. Resident frequently declined to eat and became excessively thirsty, staff would give resident water, but she would frequently throw it up. Resident was last weighed on 05/05/19 and weighed 160.6 lbs. (pounds). Resident was weighed on 06/07/19 and weighed 134.2 lbs. From 05/05/19 to 06/07/19 the Registered Dietician (RD) was not aware the resident had a decline with eating or that she was vomiting more frequently. The Resident was not weighed even though staff were aware of the decline in resident's food and fluid intake. This resulted in a 26-pound weight loss in 33 days. This resulted in an immediate jeopardy (IJ) at a scope and severity of K (an immediate jeopardy level, pattern, of resident health and safety) being identified on 06/10/19. The facility took corrective action by providing an acceptable Plan of Removal 06/11/19 at 10:15 am. Based on the Plan of Removal, the interventions included: 1. Resident receiving house supplement 2.0 three times per day, fortified foods with lunch and dinner and will be weighed weekly. 2. All residents reviewed for weight loss and interventions were put into place as needed. 3. Training for all nursing staff to include: a. Utilizing the change in condition tool. b. Utilizing the Stop and Watch Tool c. Staff training on marking percentages of food and fluid intake instead of just marking N/A (not applicable) so point click care will trigger intake alerts for the RD. d. Daily review of 24-hour report, change in condition and stop and watch alerts, including nausea and vomiting. e. Ensuring that Kardex is updated when care plans are updated. f. Ensuring that all [DIAGNOSES REDACTED]. 4. Weekly audits of meal intakes by Nutrition Risk Committee. Weekly summary showing results of improvement opportunities. Audits will be completed weekly for three months or substantial compliance is established. Based on the Plan of Removal, the Scope and Severity was reduced from the level K to a level H. Based on record review, interview, and observation the facility failed to identify a significant weight loss for 1 (R # 3) of 7 (R #s 3, 6, 32, 59, 38, 20, 34) residents looked at for Nutritional and Hydration. This deficient practice allowed R #3 to have a 26 lb. weight loss without facility staff noticing the weight loss resulting in the resident not maintaining, to the extent possible, acceptable parameters of nutritional and hydration status. The findings are: A. On 06/07/19 at 8:18 am, an observation was made of R #3 calling out for water. Certified Medication Assistant (CMA) #1 called out to R #3 that he would be there in a minute. CMA #1 asked another staff member to take R #3 some water and she did. A minute later R #3 was calling out for more water. Upon entering R #3's room it was observed that R #3 had some glasses on the night stand with water in them. R #3 called out again asking for more water, stating she needed more water. B. Record review of R #3's restorative note dated 04/05/19, Resident continues on restorative program for sit to stand and also for transfers and nail care. She had not felt well for several weeks now and had a two-week period where she was having daily emesis and refusing to get out of bed or go to the dining room. She is feeling a little better this week and up and about more often. She is very pale and does complain of abdominal pain still. She is also tiring very easily and not always able to complete the program. Will ask MD if we can do some labs to rule out any acute problems. C. Record review of R #3's nursing progress note dated 05/02/19 indicated that Resident had x (times) 2 emesis (vomiting) during shift after lunch at 1400 (2:00 pm). Vomit appeared to have whole chunks of food that appeared to be unmasticated, mostly orange in color. Resident states she drank a lot of orange juice during lunch and observed to have consumed 50% of meal. Advised resident to either decrease intake or stop consumption of all acidic drinks such as coffee and orange juice to decrease nausea and vomiting, explained why acidic drinks can cause nausea and vomiting . D. Record review of R #3's restorative note dated 05/03/19, (name of resident) is spending a lot of time in bed. She continues to have N&V (nausea and vomiting) throughout the days. Getting new meds. Will continue program to maintain strength and endurance. E. Record review of the nursing progress notes dated 05/08/19 indicated that Resident had an episode of N/V this shift. VS (vital signs) were taken and within normal limits . F. Record review of the eAdmin Record in the progress notes indicated that R #3 received nausea and vomiting medication on: 1. 04/29/19 17:29 (5:29 pm) [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 2. 04/30/19 1:19 am [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 3. 05/08/19 10:39 am [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 4. 05/08/19 11:18 am [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 5. 05/12/19 5:33 am [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 6. 05/12/19 15:45 (3:45 pm) [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 7. 05/14/19 6:45 am [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 8. 05/14/19 13:15 (1:15 pm) [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 9. 05/15/19 4:15 am [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 10. 05/15/19 7:17 am [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 11. 05/19/19 22:24 (10:24 pm) [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 12. 05/19/19 23:24 (11:24 pm) [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 13. 05/21/19 20:32 (8:32 pm) [MEDICATION NAME] Tablet 12.5 mg every 6 hours as needed. 14. 05/21/19 21:58 (9:58 pm) [MEDICATION NAME] Tablet 12.5 mg every 6 hours as needed. 15. 05/24/19 16:01 (4:01 pm) [MEDICATION NAME] Tablet 12.5 mg every 6 hours as needed. 16. 05/24/19 17:45 (5:45 pm) [MEDICATION NAME] Tablet 12.5 mg every 6 hours as needed. 17. 05/29/19 8:17 am [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. 19. 05/29/19 9:52 am [MEDICATION NAME] Tablet 4 mg every 6 hours as needed. G. Record review of R #3's nursing progress note dated 05/27/19 indicated that the resident has not eaten any of her breakfast or lunch, only water, is still drinking large amounts of water and sleeping . H. Record review of R #3's nursing progress notes dated 05/28/19 indicated that the resident drank several glasses of water, and took 4 bites of her breakfast, she then vomited most of everything she ate and drank. I. Record review of R #3's physician's progress note dated 05/30/19 . 05/28/19 now drinking large quantities of liquids then vomiting repeatedly. DC (discontinue) [MEDICATION NAME] and resume [MEDICATION NAME]. Pt went to GI (Gastrointestinal) appt (appointment) but they refused her insurance and suggested she go to the other GI group(s) - she was actually scheduled for upper endoscopy (a nonsurgical procedure used to examine a person's digestive tract) on 05/21 (2019) and it apparently was canceled on that date after she arrived. J. Record review of R #3's restorative note dated 05/31/19 Not doing well with restorative program. Tired all the time. No energy and is still vomiting quite a bit. Staff has been educated on need to remind her to sip fluids slowly and 'NO' juice as it causes N&V . K. Record review of R #3's nursing progress notes dated 06/02/19 indicated that Resident continue drinking a lot of water, CNA give around 3oz (ounces) at one time and encourage to drink slowly, resident drank around 18 oz every meal and still asking for water. L. On 06/07/19 at 10:25 am, during an interview with CMA #1, he stated that he has no idea what is going on with R #3. She wants water all the time, but if she drinks too much she will throw it up. So, they try to limit her water intake to smaller amounts. M. On 06/07/19 at 10:28 am, during an interview with Certified Nursing Assistant (CNA) #10, she stated that R #3 had declined and stated it had been about one month ago. She used to go to the dining room for meals and she also used to stand up for them. She no longer does that (able to stand up). N. On 06/07/19 at 10:30 am, during an interview with Registered Nurse (RN) #1, she stated that R #3 had missed her Gastrointestinal appointment on 05/21/19. She answered no that as of yesterday the appointment had not been rescheduled. She stated that the Clerk would have more information. RN #1 also added that R #3 was declining but agreed that R #3 was not on hospice. O. On 06/07/19 at 10:33 am, during an interview with Licensed Professional Nurse (LPN) #9, he stated that he had worked with R #3 a lot since Dec (YEAR) when she (the resident) arrived at the facility. He stated that she had always refused to get out of bed for him and that she is very fatigued, declining, and is not really eating. P. On 06/07/19 at 10:36 am, during an interview with CNA #5, she stated that yes, she (R #3) used to get up and go to the dining room to eat. She stated that since last Tuesday she had stopped standing up. CNA #5 added that R #3 was only eating oatmeal now, stating She wants lots of water and they are just giving small amounts at a time because when she drinks lots of water she throws it back up. Q. On 06/07/19 at 11:45 am, during an interview with the[NAME] Clerk, she stated that she schedules all appointments for the long-term care part of the facility. She stated that she had been calling trying to get results back from R #3's endoscopy. She stated that R #3 went to her GI appointment on 05/21/19 and had an Endoscopy done. She indicated that she was aware that there was an insurance issue when R #3 arrived for her appointment on 05/21/19 but that she thought they had still done the endoscopy on her. She stated that she had called several times trying to get back the results and they tell her that they will send it to the physician. The[NAME] Clerk also stated that she was aware that R #3 was very sick, and that the physician needs the results back, so they know what is wrong with her. She stated that she was not aware of any GI appointments needing to be rescheduled for R #3. R. On 06/07/19 at 11:11 am, during an interview with the Business Office, she stated that R #3 did not have an insurance change. She stated that there is nothing in her record that would indicate an issue with her insurance or why an appointment would have been canceled because of an insurance discrepancy. S. On 06/07/19 at 11:45 am during a follow up interview with the Business Office, she stated that the particular insurance that R #3 had is the one insurance that they would not accept and that this is why she was not seen at her appointment on 05/21/19. T. On 06/07/19 at 12:29 pm during an interview with the Registered Dietician, he stated that he is familiar with her. He stated that when R #3 first arrived at the facility back in (MONTH) (YEAR), she began to lose weight. She was put on supplements and he was following her. After her weight stabilized he was no longer actively following her. He was aware that on 5/12/19 she was changed from mechanical soft to a puree diet because of difficulty with chewing and swallowing. He stated that this recommendation came from one of the nurses on the floor. He stated that he had not recently assessed R #3 and he was not aware of her current weight. He stated that she is due to be weighed since the last time she was weighed was on 05/05/19. The RD also stated that she had not triggered for acute weight loss at this time but that she had triggered the first time after she arrived. U. On 06/07/19 at 12:05 pm, during an interview with the Director of Nursing (DON) a request was made for R #3 to be weighed. The DON stated that they would weigh R #3 and report what the resident weighed. R #3 weighed 133.5 lbs. and was weighed by mechanical lift scale. A second weight was done four hours later, and R #3 weighed 134.0 lbs. and was weighed by mechanical lift scale. R #3 had a weight loss of 26 lbs. from 05/05/19 to 06/07/19. V. On 06/07/19 at 2:02 pm, during an interview with the DON she stated that the physicians were involved in R #3's care, so she felt like everything was being handled. She stated that staff have been concerned and have been letting the physicians know what is going on. She stated that there have been medication changes and also changes to her diet. She has gone from a regular diet, to mechanical soft, to puree due to the swallowing concerns. The DON stated that she was not aware of the missed GI appointment. She stated that knowing today that she has lost 26 lbs. and that she never had her GI appointment, she thinks that she needs to be sent out to the hospital and is waiting to hear back from the Medical Director. W. On 06/10/19 at 2:16 pm, during an interview with the Medical Director, he stated that R #3 came in with some of her issues. She came in with an [MEDICAL CONDITION] Stricture ([MEDICAL CONDITION] stricture describes a narrowing or tightening of the esophagus, the esophagus is the tube that brings food and liquids from your mouth to your stomach) and had to be dilated (an endoscope goes through your mouth into your esophagus, stomach, and small intestine. Once they see the strictured area, they will place a [MEDICATION NAME] into the esophagus. The [MEDICATION NAME] is a long, thin tube with a balloon at the tip. Once the balloon inflates, it will expand the narrowed area in the esophagus). She also had issues with nausea and vomiting. He stated that he had been made aware of the nausea and vomiting a couple of months ago and that the extent of the nausea and vomiting became worse towards the end of May. He was aware that when she came to the facility she was supposed to have an 8-week follow-up appointment and it was never made. He was also aware that R #3 missed her 05/21/19 GI appointment due to insurance issues X. On 06/10/19 at 2:40 pm during an interview with RN #8 and RN #3 neither of them was aware that R #3 had a [DIAGNOSES REDACTED]. Y. Record review of the comprehensive care plan dated 12/24/18 indicated that resident was care planned for Gastrointestinal issues such as a GI bleed [MEDICAL CONDITION] there was no mention in the care plan of the [MEDICAL CONDITION] Stricture. Based on interview and observation, the facility failed to manage the hydration program for 2 (R #34 and R #38) of 2 (R #34, and R #38) residents reviewed for hydration. This deficient practice can result in serious health complications for any resident without adequate hydration. The findings are: A. On 06/03/19 at 8:55 am, during an interview, R #34 stated they fill up his water jug once a day unless he asks for more. He stated if he does not ask, they do not refill it. B. On 06/03/19 9:02 am, during an interview, R #38 stated her jug is full now, but she had been asking since 3:00 in the morning for water. She stated that there is a schedule for the distribution of water, but it is on their schedule when they want to bring it. C. Record review of the task section indicated that resident consumption at meals of food and drink are all documented. There is no documentation for fluids taken outside of meal times. D. Record review of R #38's care plan indicated the resident is at risk for dehydration, and one of the interventions is to refill resident room water pitcher with fresh ice and water after meals. E. On 6/7/19 at 8:27 am, during an interview, CMA #1 (Certified Medical Assistant) stated they do not document water distribution to the residents. CMA #1 stated after breakfast the hydration cart goes around to give residents water. CMA #1 stated they do not document it, usually someone just does it. CMA #1 stated they do not assign anyone to complete the task. F. On 6/7/19 at 8:33 am, during an interview, the administrator stated she will check with the DON (Director of Nursing) to see if they document anywhere for hydration. She stated the hydration cart does go around during the day, however they do not document it to her knowledge. G. On 6/7/19 at 8:46 am, during an interview, RN #1 (Registered Nurse) stated staff does not document hydration distribution for the hydration cart of each resident. RN #1 stated they usually go around with the hydration cart between breakfast and lunch for the residents, but it is not assigned to a specific person to complete the task or document anywhere. H. Record review of the Nutrition/ Hydration Management Policies and Procedures indicate: POLICY TITLE: Food and Nutrition Services Last Revision date 12/2017 PURPOSE: To routinely assess nutritional status of residents and monitor nutrition and hydration risk POLICY: The location offers sufficient fluid intake to maintain proper hydration and health. Hydration: 2. Offer sufficient fluid intake to maintain proper hydration and health. a. A goal of 1,500 milliliters (ccs) beverages per day is recommended but not always required to maintain hydration status. b. When indicated, a specific mealtime and snack distribution of beverages and other fluids will be determined for the resident. 3. Employees will monitor resident's intake of drinks and other fluids at meals through observation, offer alternative fluids and make changes as necessary. Fluids at meals may be recorded in (Point Click Care) PCC-P[NAME] (Point of Care) per location process. This task can be completed by nursing, by food and nutrition services or be a shared task depending on available employees in the location. See the Meal Intake Monitoring procedure. Fluids at snack times will be recorded in PCC-P[NAME] per care plan. 4. Fresh water will be available to the residents at bedside unless contraindicated.

The facility failed to follow through with a Gastrointestinal (GI referring collectively to the stomach and small and large intestines) follow up appointment for resident to be scheduled in 8 weeks following discharge from the hospital. The did not follow up after an appointment on 05/21/19 for the resident to see [MEDICATION NAME] and have an Endoscopy (diagnostic procedure used to examine the small intestine (small bowel)) was canceled due to insurance issues. The facility failed to find another clinic that would accept the resident's insurance. Facility staff were aware of the missed appointment except for the[NAME] Clerk, who thought the Endoscopy was completed and tried to retrieve the results of that test. The[NAME] Clerk did not attempt to find another GI clinic that took the resident's insurance because she thought the test was done. This resulted in an immediate jeopardy (IJ) at a scope and severity of J (an immediate jeopardy level, pattern, of resident health and safety) as identified on 06/10/19. The facility took corrective action by providing an acceptable Plan of Removal 06/11/19 at 10:15 am. Based on the Plan of Removal, the interventions included: 1. Resident had an Endoscopy appointment scheduled on 06/11/19. 2. Minimum Data Set (MDS) coordinators or designees will review current resident for appointments contained in admission paperwork and order and give the lost to the unit secretary or designee to schedule. 3. Training for all nursing staff and Unit Secretaries before leaving for the end of the day or starting a new shift; to review paperwork from appointments and the expectation of receiving paperwork or making a follow-up call if no information returned to the facility. a. An appointment checklist made for the unit secretaries/nurses to alert them to questions to ask when an appointment is verified or scheduled. b. On return from physician, nurse will review paperwork from appointment for orders and future appointments and give a copy to the unit secretaries. c. Interdisciplinary Team (IDT) will review new admissions for [DIAGNOSES REDACTED]. 4. Weekly audits to determine if all appointments have been made and audit to determine if appointments were kept. Review for appropriate follow-up from the appointments. Audits will be completed weekly x 3 months or substantial compliance is established. Results of the audit will be presented to the QA (Quality Assurance) committee monthly for review and recommendations. of meal intakes by Nutrition Risk Committee. Weekly summary showing results of improvement opportunities. Audits will be completed weekly x three months or substantial compliance is established. Based on the Plan of Removal, the Scope and Severity was reduced from the level J to a level G. Based on record review and interview the facility failed to: 1. make a follow up appointment after resident was released from the hospital 2. have better communication between Nursing Staff, the[NAME] Clerk, Transport and Management 3. find another clinic that accepts resident's insurance and schedule an appointment for 1 (R #3) of 1 (R #3) resident reviewed for diagnostic testing. This deficient practice allowed R #3 to experience nausea and vomiting, swallowing issues, weight loss and to go for 6 months without a GI appointment and Endoscopy which may have identified a reoccurrence of [MEDICAL CONDITION] Stricture ([MEDICAL CONDITION] stricture describes a narrowing or tightening of the esophagus) and had to be dilated (The [MEDICATION NAME] is a long, thin tube with a balloon at the tip. Once the balloon inflates, it will expand the narrowed area in the esophagus) and might have provided resident some relief from her symptoms. The findings are: Findings related to Physician's Notes/Orders: A. Record review of R #3's physician's progress notes dated 12/20/18 indicated that discharge summary from 12/12/18 suggested Urology follow-up for [MEDICAL CONDITION]. (Name of local Hospital) GI to see in 4 weeks-they will call (name of facility), no appointments are showing as of 12/20/18, facility to call. In the [DIAGNOSES REDACTED]. Persistent episodes of vomiting are concerning. B. Record review of R #3's physician's progress notes dated 12/28/18 indicated that In the [DIAGNOSES REDACTED]. C. Record review of R #3's physician's progress notes dated 01/02/19 indicated that In the [DIAGNOSES REDACTED]. Addendum dated 01/04/19 called (name of hospital) GI no appointment is scheduled. Referral is in. D. Record review of R #3's physician's progress notes dated 03/27/19 indicated that In the [DIAGNOSES REDACTED]. In the Plan Section of the note: Monitor nausea -history of GI bleed and [MEDICAL CONDITION] stricture. E. Record review of R #3's physician's progress notes dated 04/22/19 indicated that the resident is having issues with nausea again. Nursing reports R #3 throwing up whole chunks of food. In the [DIAGNOSES REDACTED]. GI consult already ordered. F. Record review of the (name of hospital) after visit summary indicated that R #3 was seen by a physician on 04/25/19, diagnosed with [REDACTED]. G. Record review of R #3's physician orders [REDACTED]. Resident to be up and ready for transport at 0700 (7:00 am). H. Record review of R #3's physician's progress notes dated 05/06/19 indicated in the [DIAGNOSES REDACTED]. Having nausea and vomiting, EGD (Esophagogastroduodenoscopy (EGD) is a test to examine the lining of the esophagus, stomach, and first part of the small intestine) on 05/21/19 (name of hospital) GI. I. Record review of R #3's physician's progress notes dated 05/30/19 indicated in the History of Present Illness: Patient went to GI appointment, but they refused her insurance and suggested she go to other GI group. She was scheduled for upper Endoscopy on 05/21/19 and it was canceled on that date after she arrived. Nursing is reporting that she is continuing to have vomiting, she typically drinks copious amounts of liquids and then vomits including her solid food. R #3 is having issues with nausea again. Per nursing reports R #3 throwing up whole chunks of food. In the [DIAGNOSES REDACTED]. Facility is trying to get an alternate GI follow-up. Findings related to Nursing and Restorative Progress Notes: J. Per record review of R #3's Restorative note dated 04/05/19: Resident continues restorative program for sit to stand and also for transfers and nail care. She had not felt well for several weeks now and had a two-week period where she was having daily emesis and refusing to get out of bed or go to the dining room. She is feeling a little better this week and up and about more often. She is very pale and does complain of abdominal pain still. She is also tiring very easily and not always able to complete the program. Will ask MD (medical doctor) if we can do some labs to rule out any acute problems. K. Per record review of R #3's nursing progress note dated 05/02/19: Resident had x 2 emesis (vomiting) during shift after lunch at 1400 (2:00 pm). Vomit had whole chunks of food that appeared to be unmasticated, mostly orange in color. Resident states she drank a lot of orange juice during lunch and observed to consumed 50% of meal. Advised resident to either decrease intake or stop consumption of all acidic drinks such as coffee and orange juice to decrease nausea and vomiting, explained why acidic drinks can cause nausea and vomiting . L. Per record review of R #3's restorative note dated 05/03/19: (Name of resident) is spending a lot of time in bed. She continues to have N&V (nausea and vomiting) throughout the days. Getting new meds. Will continue program to maintain strength and endurance. M. Per record review of R #3's nursing progress notes dated 05/08/19: Resident had episode of N/V this shift. VS (vital signs) were taken and within normal limits . N. Per record review of R #3's nursing progress note dated 05/27/19: the resident has not eaten any of her breakfast or lunch, only water, is still drinking large amounts of water and sleeping . O. Record review of R #3's nursing progress notes dated 05/28/19 indicated the resident drank several glasses of water, took 4 bites of her breakfast, and then vomited most of everything she ate and drank. P. Record review of R #3's restorative note dated 05/31/19 Not doing well with restorative program. Tired all the time. No energy and is still vomiting quite a bit. Staff has been educated on need to remind her to sip fluids slowly and 'NO' juice as it causes N&V . Q. On 06/07/19 at 10:30 am, during an interview with Registered Nurse (RN) #1, she said that R #3 had missed her Gastrointestinal appointment on 05/21/19 and that as of yesterday the appointment had not been rescheduled. She stated the Clerk would have more information. R. On 06/07/19 at 11:45 am, during an interview with the[NAME] Clerk, she stated she schedules all appointments for the long-term care part of the facility. She stated that she had been calling trying to get results back from R #3's Endoscopy (a nonsurgical procedure used to examine a person's digestive tract). She stated that R #3 went to her GI appointment on 05/21/19 and had an Endoscopy done. She indicated that she was aware that there was an insurance issue when R #3 arrived for her appointment on 05/21/19 but they did the Endoscopy on her. She said she called several times for results and was told they would send it to the physician. The[NAME] Clerk added she was aware that R #3 was very sick, and the physician needs the results back, so they know what is wrong with her. She stated that she was not aware the need to reschedule any GI appointments R #3. S. On 06/07/19 at 11:11 am, during an interview with the Business Office, she stated that R #3 did not have an insurance change. She stated that there is nothing in her record that would indicate an issue with her insurance or why an appointment would have been canceled because of an insurance discrepancy. T. On 06/07/19 at 11:45 am, during a follow up interview with the Business Office, she stated that the insurance that R #3 had been the one insurance that they would not accept and therefore she was not seen at her appointment on 05/21/19. U. On 06/07/19 at 2:02 pm during interview, the DON said that the physicians were involved in R #3's care, so she felt like everything was being handled. She stated that staff have been concerned and have been letting the physicians know what is going on. The DON stated that she was not aware of the missed GI appointment. She stated that knowing today, that she has lost 26 pounds and that she never had her GI appointment she thinks that she needs to be sent out to the hospital and is waiting to hear back from the Medical Director. V. On 06/10/19 at 2:16 pm, during an interview with the Medical Director, he stated that R #3 came in with some of her issues. She came in with an [MEDICAL CONDITION] Stricture ([MEDICAL CONDITION] stricture describes a narrowing or tightening of the esophagus) and had to be dilated (The [MEDICATION NAME] is a long, thin tube with a balloon at the tip. Once the balloon inflates, it will expand the narrowed area in the esophagus). She also had issues with nausea and vomiting. He stated that he had been made aware of the nausea and vomiting a couple of months ago and that the extent of the nausea and vomiting became worse towards the end of (MONTH) (2019). He was aware that when she came to the facility she was supposed to have an 8-week follow-up and an appointment was never made. He was also aware that R #3 missed her 05/21/19 GI appointment due to insurance issues.

During pre-sample selection of the annual recertification survey, water temperatures were checked using digital thermometers throughout the facility. Water temperatures in resident restrooms, shower rooms, eye washing stations and in the therapy room ranged from 127 degrees Fahrenheit (F) to 155 degrees Fahrenheit. Interview with staff and residents confirmed that water temperatures tended to be hot and this had been an ongoing issue, although no residents have ever been burned. Observation of the facility Mechanical Room revealed that the mixing valve was set at 120 degrees and record review of weekly temperature audits did not document water temperatures exceeding 116 degrees F. However, interview with the maintenance technician revealed that water temperatures were being documented on the audit sheets after the hot and cold water was combined. These deficient practices resulted in Immediate Jeopardy (IJ) being identified. The facility Interim Administrator and Assistant Interim Administrator were notified of the IJ on 04/24/18 at 11:04 am. The second plan of removal was submitted and accepted on 04/25/18. The scope and severity was lowered from L, level 4 to F, level 2. The Plan of Removal included: 1. Hot water valves were adjusted to limit the amount of hot water input to healthcare residents. 2. Contracted plumbers were contacted to assess the hot water system and found that it was missing a valve on the hot water bypass, scheduled for correction on 04/25/18. 3. Hot water was assessed every 2 hours until temperature stabilized below 110 degrees and then every shift for 72 hours. 4. The therapy room water supply which is operated by a different boiler was restricted from resident use until it can be corrected. Therapy staff notified to take additional precautions when using water supply. 5. Maintenance personnel responsible for gauging the hot water temperature was observed for correct practice. 6. Hot water temperature will be logged daily for 90 days then weekly thereafter. 7. Until hot water temperature was corrected, all staff was notified to take additional precaution to supervise residents during shower and bathroom use. All working staff was instructed to immediately report any concerns with water temperatures to the maintenance Supervisor or Administrator and document it in the Maintenance log. Based on observation, interview and record review, the facility failed to ensure that the facility was free from accident hazards by not ensuring that water temperatures were within a safe range for all 86 residents identified on the census list provided by the Director of Nursing (DON) on 04/23/18. If water temperatures are too hot, then residents are likely to be a risk of seriously burning themselves. The findings are: A. On 04/23/18 at 9:28 am observation of the hot water from the bathroom facet in room [ROOM NUMBER] revealed a temperature of 125 degrees Fahrenheit. B. On 04/23/18 at 10:43 am observation of the hot water from the bathroom faucet in room [ROOM NUMBER] revealed a temperature of 135.3 degrees Fahrenheit. C. On 04/23/18 at 10:44 am observation of the hot water from the bathroom faucet in guest bathroom on the second floor revealed a temperature of 130.1 degrees Fahrenheit. D. On 04/23/2018 at 11:04 am during facility observation, the following room temperatures were noted: 1. First floor shower room by room [ROOM NUMBER] the sink was turned on to hot and allowed to run for 60 seconds and the temperature was measured at 134.4 degrees. The shower head was turned on to hot and allowed to run for 60 seconds and the water temperature was measured at 127.6 degrees. 2. room [ROOM NUMBER] bathroom sink the water was turned on and allowed to run for 30 seconds and the water temperature was measured at 128.8 degrees. 3. room [ROOM NUMBER] bathroom sink the water was turned on and allowed to run for 30 seconds and the water temperature was measured at 126.5 degrees 4. In the rehabilitation treatment area, the kitchen sink water was turned to hot and allowed to run for 30 seconds. The water temperature was measured at 155.1 degrees. Above the kitchen sink was a sign which read Caution water temperature 120 degrees. The bathroom sink was turned to hot and allowed to run for 30 seconds and the water temperature was measured at 129.1 degrees. E. On 04/23/18 02:50 pm during interview with R #388 she said the water in her room [ROOM NUMBER] can get too hot if you leave it on too long. F. On 04/24/18 at 7:58 am observation of the hot water from the bathroom facet in room [ROOM NUMBER] revealed a temperature of 134.5 degrees Fahrenheit. G. On 04/24/18 at 8:18 am during interview with the Maintenance Supervisor (MS), he stated that water temperature audits are taken weekly by the Maintenance Technician (MT). He stated We also check the eye wash stations (a specialized sink used to cleanse the eyes of chemical exposure). We are really particular about that. We don't want super hot water going into someone's eyes. We pick rooms at random. He stated that water temperatures should not exceed 109 degrees F (Fahrenheit). H. Record review of the maintenance Weekly Inspection dated 04/23/18 revealed the following temperatures: First floor front hall- shower 115 degrees F and sink 116 degrees F room [ROOM NUMBER]: 114 degrees F room [ROOM NUMBER]: 113 degrees F First Floor back hall- shower 114 degrees F and sink 116 degrees F room [ROOM NUMBER]: 114 degrees F room [ROOM NUMBER]: 113 degrees F 2nd Floor Front Hall: shower 114 degrees F and sink 116 degrees sink room [ROOM NUMBER]: 115 degrees F room [ROOM NUMBER]: 116 degrees F 2nd Floor Back Hall: shower 113 degrees F and sink 115 degrees F room [ROOM NUMBER]: 113 degrees F Room: 2220: 115 degrees F Eye wash temperatures 67- 69 degrees F I. On 04/24/18 at 8:26 am observation of the hot water from the bathroom facet in room [ROOM NUMBER] revealed a temperature of 131.8 degrees Fahrenheit. J. On 04/24/18 at 8:30 am during observation the water temperature from the bathroom facet in room [ROOM NUMBER] was 129.2 degrees Fahrenheit. K. On 04/24/18 at 08:32 am during observation the water temperature from the bathroom facet in room [ROOM NUMBER] was 129.3 degrees Fahrenheit. L. On 04/24/18 at 08:33 am during observation the water temp from the bathroom facet in room [ROOM NUMBER] was 128.4 degrees Fahrenheit. M. On 04/24/18 at 8:33 am during interview with R #392 she said the water temperature in the shower is real hot. N. On 04/24/18 8:37 am observation of the hot water from the eyewash station across from room [ROOM NUMBER] revealed a temperature of 122.2 degrees Fahrenheit. O. On 04/24/18 at 8:38 am during interview with Environmental Services Director (ESD), he confirmed that sinks and showers water temperatures are checked weekly. When asked what is considered an acceptable range, he stated We don't want it to go over, 120 (degrees). When asked if there has ever been problems with the temperature being too hot, he stated that occasionally they try and adjust it through the mixing valves. During observation of the mechanical Room with the ESD, he confirmed that mixing valve temperature was set at 120 degrees, so the water in residents' rooms should not exceed 120 degrees. The ESD confirmed however that if the mixing valve goes bad, it (water temperatures) could be inaccurate. P. On 04/24/18 at 8:44 am during observation and interview with the MS, the hot water from the bathroom faucet in room [ROOM NUMBER] revealed a temperature of 129.4, bathroom faucet of room [ROOM NUMBER] revealed temperature of 129.1 degrees Fahrenheit. room [ROOM NUMBER] revealed a temperature of 129.6 degrees Fahrenheit. Eye wash station front hall second floor revealed a temperature of 128.8 degrees Fahrenheit. Hot water from bathroom faucet in room [ROOM NUMBER] reveals a temperature of 128 degrees Fahrenheit, shower room [ROOM NUMBER]st floor sink faucet reveals a temperature of 132.2 degrees Fahrenheit and room [ROOM NUMBER] hot water from bathroom faucet revealed a temperature of 127.9 degrees Fahrenheit. MS stated. We got big trouble, temperatures are to hot. Q. On 04/24/18 at 8:52 am observation of the hot water from the eyewash station across from room [ROOM NUMBER] revealed a temperature of 130.2 degrees Fahrenheit. R. On 04/24/18 at 9:12 am during interview with the MT, he confirmed that he checks water temperatures every week. Most recently, yesterday (04/23/18). He confirmed that the sink temperatures get more hot but that the water (temperature) can be adjusted. Yesterday I was checking and it was 120. I never had that number (before). MT confirmed that when he checks the water temperatures, he open the hot water faucet until it gets hot, then he adds cold water. Once he is able to find a reasonable hot water temperature that he thinks would be comfortable to the residents, he records that temperature. S. On 04/24/2018 at 9:25 am during interview with Physical Therapist Assistant (PTA) #1, he observed as the kitchen sink water temperature was measured he confirmed the water temperature was much to hot. He stated that the kitchen sink was only used occasionally by residents or staff during training. He stated the bathroom sink was used by residents when needed and residents used the sink with and without staff supervision as needed. T. On 04/24/2018 at 9:44 am during observation, the eye wash station (a specialized sink used to cleanse the eyes of chemical exposure) located near room [ROOM NUMBER] was turned on by pressing a foot pedal which activated the hot water. After 30 seconds the water temperature was measured at 127 degrees F. U. On 04/24/2018 at 9:44 am during interview with Liced Practical nurse (LPN) #2, she stated the eye wash station is used when or if some chemical splashes into the eyes. She stated she would want to use cool to luke warm water. She was asked to demonstrate the use of the sink. She pressed her foot to the hot water pedal and allowed the water to run for a brief time then took her foot off the hot pedal and moved it to press both the cold and hot pedals. LPN #2 was asked to press only the hot pedal and she noted that the water was hot. The temperature was then measured and again it was 127 degrees F. LPN #2 stated I would not want to use this with this hot of water. It might burn my eyes. She stated she has experienced a chemical splash to her eyes and had to use a similar eye wash station and stated she was very familiar with the sink and it's operation. V. On 04/24/18 at 9:52 am during interview with Certified Nurse Aide (CNA) #1, he stated that the water in residents' shower room can be pretty hot at times. W. On 04/24/18 at 10:01 am during interview with R# 26 regarding water temperatures, It could get hot enough to burn but I don't put up with that. He confirmed that he adjusts the water temperature to not be so hot. X. On 04/24/18 at 10:07 am during interview with CNA #3, he stated that Sometimes the water in these showers is too hot. Sometimes it's hard to adjust. CNA #3 stated that R #64 complained the shower was too hot this morning. He stated that it took him 15 minutes to adjust the water to the right temperature- I was adding cold and it was still too hot. Y. On 04/24/18 at 10:28 am during interview with MS, regarding how MT stated he takes the water temperatures, he confirmed he didn't know how MT was trained but he (MS) was unaware of the water temperatures issues. MS also confirmed that the intent of water temperature audit was to determine unsafe water temperatures. Z. During interview on 04/24/18 at 10:36 am R #393 revealed that In the shower this morning (name of staff) couldn't get the shower to cool off, it took 5 min to get it right. (Name of staff) protected me from getting burned. AA. On 04/24/18 at 1:40 pm during interview, the facility Administrator stated that he asked the MT to demonstrate how he takes water temperatures, and MT demonstrated it correctly (documenting the temperature of the hot water). During interview with the MT, when asked about what he stated earlier (documenting the water temperature of the hot and cold combined), he stated Why would I do that. MT continued to state that he does mix the hot and cold water although he was unable to state the reason he does that. MT stated now that he only documents the temperature of the hot water on the weekly audit sheet. The MT stated that he took water temperatures yesterday (04/23/18) at around 10:00 am. .

The facility failed to ensure that a resident was appropriately and safely discharged from the facility. A resident who was evaluated by a psychologist who determined that he lacked the decisional capacity to make complex medical decisions and further lacked the capacity to refuse placement, was allowed to discharge from the facility AMA (against medical advice) to his home, where he lived alone, and three days later was found deceased in his home by the police department. This deficient practice resulted in an Immediate Jeopardy (IJ) at a Scope and Severity of K being identified on [DATE] at 2:17 pm. The Administrator was notified at this time and a Plan of Removal was requested. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 4:08 pm. Interventions included: 1. Prior to their next shift, Social Services, Nursing Case Managers, Administration, and Therapy will be trained on the following: a. Team meetings will be held to discuss discharge locations for all residents. b. If the safety of a discharge is questionable, the Ombudsman, MD (medical director), and psychologist will be notified. The notification, recommendations, and outcome will be documented in the resident's chart. If indicated, a team meeting will be held to discuss recommendations. c. If a resident chooses to discharge Against Medical Advice, the Ombudsman, MD, psychologist, and APS (adult protective services) will be contacted. The notification will be documented in the resident's chart. The charge nurse or designee will complete the Progress Note-Discharge Against Medical Advice, the Progress Note-in regards to Teaching Resident/Family (if applicable) stating that the resident/family have been educated by the charge nurse/designee regarding risk and concerns of discharge in current medical condition, the Discharge Medication List, and the Discharge Summary. Social Services, or designee, will complete and review any relevant portions of the progress notes. Social Services, or designee will contact AMA resident the day after discharge to determine if resident is safe and in an attempt to offer any needed community resources. 2. All licensed nursing staff will be trained on the policy and procedure to follow if a resident chooses to discharge after hours, to include communication to MD, Administration, and Nursing Administration, and completion of documentation (the Progress Note-Discharge Against Medical Advice, the Progress Note-in regards to Teaching Resident/Family (if applicable) stating that resident/family have been educated by the charge nurse/designee regarding risks and concerns of discharge in current medical condition, the Discharge Medication List, and the Discharge Summary.) Based on the Plan of Removal provided by the Administrator, the IJ was lifted on [DATE] at 4:08 pm. This resulted in the scope and severity being reduced from level K to level H. Based on record review and interview, the facility failed to ensure residents were appropriately discharged to a safe environment for 1 (R #121) of 3 (R #s 121, 230, and 231) residents reviewed for unsafe discharge. The facility allowed R #121 to leave AMA, knowing that he lacked the decisional capacity to refuse placement. This deficient practice resulted in R #121's death. The findings are: A. Record review of the Admission Record indicated R #121 was admitted to the facility on [DATE] and discharged on [DATE] to private home/apartment with no home health services. R #121's medical [DIAGNOSES REDACTED].), [MEDICAL CONDITION] (abnormal fast heartbeat), essential hypertension (high blood pressure), pain, and [DIAGNOSES REDACTED] (low potassium level). B. On [DATE] at 9:33 am and 11:53am, during interviews with the Social Services Director (SSD), she stated she was involved with the discharge planning of R #121. The SSD stated she called Adult Protective Services (APS) on [DATE] before the R #121 left the building to let them know about his unsafe discharge and that he was signing himself out AMA (against medical advice). The SSD stated that R #121 had a nephew however, he refused to answer or return the facility's phone calls and refused to work with staff during the discharge planning. The SSD confirmed that facility staff drove R #121 to his house after he was discharged and called a locksmith to have his locks changed because R #121's nephew had his key. The SSD stated that for difficult or unsafe discharges she typically follows up with the resident or representative with a phone call to ensure their wellbeing. The SSD stated that she did not follow up with R #121 after his discharge. The SSD stated that the Case Manager and the Administrator were involved with R #121's discharge. She stated R #121 was not able to discharge safely, but he refused to stay at the facility. C. On [DATE] at 10:39 am, during an interview with the Adult Protective Services (APS) Supervisor, she confirmed that there were two reports made on behalf of R #121. One report was from R #121's nephew dated [DATE] and the other was made by the [MEDICAL TREATMENT] Social Worker (from the [MEDICAL TREATMENT] clinic where R #121 received [MEDICAL TREATMENT]) dated [DATE]. The APS Supervisor stated that she did a search in their database of R #121's name and the day he was discharged ([DATE]) and verified there were no reports made by the facility on [DATE]. The APS Supervisor stated that every call or report that comes in through the intake hotline is recorded. D. On [DATE] at 10:47 am and at 2:20 pm, during interviews with the Administrator, she stated that the facility staff contacts APS anytime they have a resident discharge AMA or an unsafe discharge. The Administrator stated she informed her staff to contact APS regarding R #121's discharge and her staff informed her that they did. The Administrator confirmed that R #121's attending physician should have been notified of his AMA discharge. The Administrator stated that R #121 had a nephew who they were trying to contact to help find placement for R #121, but he stated he didn't want to be involved in his uncle's care anymore. The Administrator stated they generally do not provide transportation for discharged residents however they made an exception for R #121. She also stated that when R #121 left the building he was no longer considered a resident of the facility and the facility drove him home to honor his choice to go home. The Administrator stated they don't usually change the locks on resident homes, but on this occasion, she approved it. The Administrator was asked if R #121 was competent to make his own decisions, she stated, My understanding is that to declare someone incompetent it would need a psych eval (psychological evaluation). We didn't have documentation that he wasn't able to make his own decisions. The Administrator confirmed that social services should have made an attempt to contact R #121 according to their policy, but she does not know if anyone did. When asked if she felt this was a safe discharge, she stated, I think, it was a place he was comfortable with, where he wanted to be. I don't know if I would necessarily say safe, it wasn't my ideal. E. Record review of the Release from Responsibility for Discharge form signed by R #121 on [DATE] with Case Manager/Registered Nurse (Case Manager/RN) signing as a witness. The form stated, This is to certify that I, (R #121) am leaving (Name of Facility and Address of Facility) against the advice of the attending physician and the center administration. F. On [DATE] at 11:24 am, during interview the Medical Director and also R #121's attending physician confirmed he was not notified before R #121 discharged AMA on [DATE]. G. On [DATE] at 1:55 pm, during interview the Case Manager/RN, stated that she worked very closely with R #121 to get a safe placement for him. The Case Manager/RN stated that R #121 was his own Power of Attorney (POA) and refused any transfers to any long-term care facilities. The Case Manager/RN stated I think he had some confusion. At times, he was competent, but if he truly understood his medical situation, I don't think he understood. Was it necessarily a safe discharge, of course not, but that's out of my control. H. On [DATE] at 1:43 pm, during interview with RN #1, she stated that R #121's nephew didn't want him to go home, because he felt R #121 was unsafe at his home. RN #1 also stated that R #121 could not transfer himself to the toilet, he could only dress himself from the waist up, and he could not stand or walk at all. RN #1 confirmed that he was going to [MEDICAL TREATMENT] and was a diabetic. I. On [DATE] at 10:10 am, during an interview with the Maintenance Technician, he confirmed he followed the facility van driving R #121 to his house. He stated that he waited with the van driver and R #121 for about 25 minutes for the lock smith to change the locks. The Maintenance Technician stated that after the locks were changed, he helped R #121 into his home. The Maintenance Technician stated they helped R #121 walk up the stairs into his home and placed him on the couch. J. On [DATE] at 10:13 am, during interview, the Maintenance Director confirmed the locks were changed at R #121's home. The Maintenance Director confirmed that at the directive of the Administrator, he was told to call and hire locksmith to have the lock changed because his nephew had his key. K. On [DATE] at 10:54 am, during interview, the [MEDICAL TREATMENT] Social Worker from the [MEDICAL TREATMENT] clinic where R #121 received [MEDICAL TREATMENT] stated that R #121 was in a wheelchair, he was not able to walk, he could not transfer into a chair, could not take his own medications, and could not get to his [MEDICAL TREATMENT] appointments. The [MEDICAL TREATMENT] Social Worker stated, He was nursing home material. Over the past year he has declined, the thing that changed was that he was in total kidney failure. Every time he went home from the hospital he would end up back at the hospital. The [MEDICAL TREATMENT] Social Worker stated that during his most recent hospital stay, a psychological evaluation was done on [DATE] and it found that R #121 did not have the decisional capacity to make complex medical decisions and that he could not refuse placement. The [MEDICAL TREATMENT] Social Worker confirmed that she e-mailed the findings from this psychological evaluation to the Admissions Coordinator (AC) at the facility on [DATE]. The [MEDICAL TREATMENT] Social Worker verified that she talked to the AC by phone on the day she e-mailed the information and verified that he received it. She stated, I was very clear and had multiple conversations (with AC) about not discharging him (R #121) because there was nobody there to help him. I couldn't have been more clear. The [MEDICAL TREATMENT] Social Worker stated that she was trying to get R #121 a guardian and suggested to his family that they should get a guardian as well as a POA to make medical decisions. The [MEDICAL TREATMENT] Social Worker stated the facility allowed R#121 to go home and less than 72 hours later, he was deceased . She also stated the facility staff said they were respecting his rights, but he didn't have the ability to make decisions. L. Record review of the e-mail sent to the AC from the [MEDICAL TREATMENT] Social Worker on [DATE] and then forwarded to the Case Manager/RN on [DATE] revealed an attachment containing two documents: a psychiatric consult note completed on [DATE] and another psychiatric consult note completed on [DATE]. The body of the e-mail stated Hi (Name of AC), I appreciate your assistance with this. This attachment is a psychiatric consult note performed by (Name of Psychologist from Hospital's Psychiatry Department) dated [DATE]. Record review of the psychiatric consult note dated [DATE] stated, He has had multiple hospitalization s for related issues over the past month, after being discharged home each time. Psychiatry asked to evaluate patient's decisional capacity to participate in discharge planning or to participate in complex medical decisions. Last week we determined that patient lacks decisional capacity to make complex medical decisions and further lacks capacity to refuse placement. Patient has failed less restrictive measures multiple times in the past month and with PT/OT (physical/occupational therapy) currently recommending SNF (skilled nursing facility) placement. Record review of the psychiatric consult note dated [DATE] stated, Final report: We were asked to evaluate patient's decisional capacity on 2 occasions during this hospitalization , and he was found to lack decisional capacity on both occasions. M. On [DATE] at 11:09 am, during an interview with the AC, he confirmed that he received the documentation from the [MEDICAL TREATMENT] Social Worker's e-mail and forwarded it to the Case Manager/RN. He stated that he did not read the whole document, but was aware it related to R #121 not being able to make good decisions for himself. The AC verified speaking with the [MEDICAL TREATMENT] Social Worker over the phone about her concerns which included R #121 not being able to get to his [MEDICAL TREATMENT] appointments and not being able to make his own medical decisions. N. On [DATE] at 11:25 am, during a second interview, the Case Manager/RN confirmed that she received the documents from the AC. Case Manager/RN stated that she gave a copy of the e-mail to the Administrator. The Case Manager/RN confirmed that the hospital documentation should have been scanned into R #121's electronic record. The Case Manager/RN confirmed that the SSD was aware of the concerns from the [MEDICAL TREATMENT] Social Worker that R #121 was not competent to make his own medical decisions. Case Manager/RN stated she was informed by the Administrator that there needs to be two physician evaluations for a resident to be deemed incompetent. When asked if the facility had completed a psychologist evaluation of their own before R #121's discharge, she stated, I wish I would have done that now. It didn't occur to me to do it and I didn't think of doing it. Case Manager/RN stated that she has been doing case management for two months and she wasn't properly trained on how to do the job. O. On [DATE] at 11:42 am, during a second interview with the SSD, she verified speaking to the [MEDICAL TREATMENT] Social Worker. The SSD stated the [MEDICAL TREATMENT] Social Worker was concerned about R #121 not being able to go home safely due to his medical condition and need for [MEDICAL TREATMENT]. The SSD stated she wasn't informed by the [MEDICAL TREATMENT] Social Worker about any psychological evaluations for R #121. The SSD stated that she did not receive any paperwork from the Case Manager/RN. The SSD was asked if she followed up with R #121 after discharge, she stated, I did not follow up with (name of R #121). I'm supposed to follow up within 24 hours, but in his case I don't believe he had a working phone number, that I believe is why I didn't follow up. The SSD stated that the [MEDICAL TREATMENT] Social Worker informed her that R #121 was deceased . P. On [DATE] at 12:15 pm, during the third interview with the Administrator, when asked why wasn't a psychological evaluation done for R #121, she stated, I don't know. We probably just didn't think. I remember discussion about the evaluation. They said there was a psych evaluation done. I don't know why I didn't say let's do our own evaluation. I was aware that he had a psych eval for whether or not he could make decisions. When asked if the evaluation factored into R #121's AMA discharge planning, she stated, I think that the way I interpreted it was that he didn't make good decisions. I think sometimes people don't make good decisions. When asked if signing a discharge AMA form is a complex medical decision, she stated, I don't know. The Administrator further stated, I think that I would of honestly preferred to do our own evaluation, in hindsight, yes. Q. On [DATE] at 1:54 pm, during a second interview with the Medical Director, he stated that if he had been aware of a psychological evaluation done at the hospital, he would have questioned R #121's ability to sign out AMA. The Medical Director stated that if he had known he would have asked for a follow up to see if R #121's decisional capacity had changed. R. Record review of R #121's Nursing Progress Notes dated [DATE] through [DATE] revealed no documentation that his attending physician was notified of his discharge. S. Record review of the Discharge/Transfer Policy and Procedure revised ,[DATE], revealed Purpose: To provide the resident and family with a safe and orderly discharge. Discharge against Medical Advice: 1. Charge nurse or designated individual will: a. complete the PN (progress note)- Discharge Against Medical Advice. b. Inform physician of the situation. e. Complete the discharge summary. 2. The social worker or designated individual will: b. If the resident is at risk to be neglected by self or others, contact Adult Protective Services and/or the local ombudsman. Note: If an AMA discharge occurs during the evening or night hours, the social worker will contact the resident the next day in an attempt to offer and arrange needed community resources.

The facility failed to ensure that intravenous (IV) [MEDICATION NAME] (antibiotic) was infused safely through an IV pump (intravenous infusion pump, which allows precise control over the flow rate and total amount delivered) into a PICC (peripherally inserted central catheter) line instead of through a dial-a-flow tubing (used to regulate the flow of fluid), which could cause kidney damage and hearing loss if the IV medication was infused too fast for 1 (R #217) of 1 (R #217) resident reviewed for intravenous therapy. Infusing [MEDICATION NAME] through a dial-a-flow device on a regular basis, instead of an IV pump resulted in an Immediate Jeopardy (IJ) at a scope and severity of level J being identified on 05/05/17 at 11:00 am. The facility administrator was notified at that time. The facility took corrective action by providing an acceptable Plan of Removal on 05/05/17 at 1:20 pm. Based on the Plan of Removal, interventions included: 1. The facility will only use Zyno IV pumps and Zyno IV tubing as of this afternoon. 2. All nursing staff will receive one-on-one training with a member of nurse management on the correct use of Zyno IV pumps and Zyno IV tubing and on IV administration. Based on observation, record review and interviews, the facility failed to ensure that 1 (R #217) of 7 (R #s 13, 15, 29, 102, 204, 214, and 217) residents observed during the medication administration observation was free of any significant medication error. This deficient practice of infusing [MEDICATION NAME] (antibiotic) through a dial-a-flow device rather than an intravenous (IV) pump has the potential to cause kidney damage (nephrotoxicity- a toxic substance that can damage the kidneys) and hearing (ototoxicity- a toxic substance that can damage the eighth cranial nerve that affects hearing) problems in the elderly if not monitored safely and infused too fast. The findings are: A. Record review of R #217's Order Summary Report dated 04/24/17, indicated the following Diagnoses: [REDACTED]. B. On 05/04/17 at 11:30 pm, during interview, Registered Nurse (RN) #2 stated that she was late giving R #217 her 10:00 pm dose of IV [MEDICATION NAME] due to not having the correct IV tubing for the IV pump (which was an Abbott Acclaim [MEDICATION NAME] pump). She stated that the pharmacy has been sending Zyno Med IV tubing, and that tubing does not work with the Abbott Acclaim [MEDICATION NAME] pump machine. C. Record review of R #217's physician orders [REDACTED]. D. On 05/04/17 at 11:45 pm, during interview, R #217 stated that since she has been at the facility (admitted on [DATE]), the nurses have not been using the IV pump due to not having the correct IV tubing. She stated that the nurses have been running the [MEDICATION NAME] through the IV tubing with the dial-a-flow regulator. E. On 05/05/17 at 12:00 am, during observation of the clean utility room, there was a Zyno Med IV pump on the shelf. This was taken to R #217's room and attached to the IV pole. F. On 05/05/17 at 12:50 am, during interview, RN #2 stated that since 6:30 pm, she has talked with 5 (five) different people at (name of the contracted pharmacy) and so far has not received the IV tubing for the Abbott Acclaim [MEDICATION NAME] pump to administer the [MEDICATION NAME]. G. Record review of R #217's Location of Administration Report dated 05/05/17, the [MEDICATION NAME] was scheduled at 19:00 (7:00 pm) and was administered at 1:19 am, approximately 6 (six) hours late. In order to keep a therapeutic range in the blood stream, [MEDICATION NAME] should be administered at approximately the same time every day. H. On 05/05/17 at 9:45 am, during interview, the (name of the contracted pharmacy) pharmacist, stated that when the pharmacy dispenses the [MEDICATION NAME] to the facility, they also dispense the IV tubing. When asked if a dial-a-flow regulator can be used to infuse the [MEDICATION NAME], he stated that the dial-a-flow can be used only in an emergency situation but it is not recommended. He stated that the [MEDICATION NAME] should be infused through an IV pump. When asked what was the type of IV pump that the facility should be using, he stated, a Zyno Med IV pump. He was informed that the facility had been using an Abbott Acclaim [MEDICATION NAME] pump, and that the facility did not have the correct IV tubing for that machine. He stated that he was not aware that the facility had been using that machine and that they should be using the Zyno Med IV pump. The pharmacy had been sending the Zyno Med IV tubing to infuse the [MEDICATION NAME]. The pharmacist stated that the Abbott Acclaim [MEDICATION NAME] pump should not have been used at the facility well over a year, the pharmacy does not dispense that IV tubing for that machine, nor is the Acclaim [MEDICATION NAME] tubing stocked in the facility's emergency kit. I. On 05/07/17 at 12:30 pm, during interview, R #217 stated that she has felt so much safer knowing that the [MEDICATION NAME] was now being infused through the IV pump. J. Record review of the medication administration records (MARs) for the months of April and May 2017, revealed that there was a total of 6 (six) different nurses that administered the scheduled [MEDICATION NAME] IV. During 04/25/17 to 05/04/17, [MEDICATION NAME] was administered through the dial-a-flow regulator and not the Zyno Med IV pump, which was a total of 10 (ten) doses. K. Record review of the facility's policy titled Intravenous Administration, revised 05/2016 revealed the following: .For specific infusion therapy procedures and guidelines, refer to Mosby's Intravenous Therapy - Pocket Guide Series, most recent edition or use the policies and procedures of the location's contracted IV pharmacy .

This is a repeat deficiency from the recertification survey on [DATE]. Based on interview and record review, the facility failed to ensure residents were free from neglect for 1 (R #121) of 3 (R #s 121, 230, and 231) residents reviewed for discharge. The facility allowed R #121 to discharge from the facility against medical advice (AMA), knowing he was evaluated and determined to lack the decisional capacity to make complex medical decisions and to refuse placement and failed to have the resident's mental status re-evaluated. This deficient practice resulted in R #121 going home alone where he was unable to take care of himself and as a result died . The findings are: A. Record review of the Admission Record indicated R #121 was admitted to the facility on [DATE] and discharged on [DATE] to private home/apartment with no home health services. R #121's medical [DIAGNOSES REDACTED].), [MEDICAL CONDITION] (abnormal fast heartbeat), essential hypertension (high blood pressure), pain, and [DIAGNOSES REDACTED] (low potassium level). B. On [DATE] at 9:33 am and 11:53am, during interviews with the Social Services Director (SSD), she stated she was involved with the discharge planning of R #121. The SSD stated she called Adult Protective Services (APS) on [DATE] before the R #121 left the building to let them know about his unsafe discharge and that he was signing himself out AMA (against medical advice). The SSD stated that R #121 had a nephew however, he refused to answer or return the facility's phone calls and refused to work with staff during the discharge planning. The SSD confirmed that facility staff drove R #121 to his house after he was discharged and called a locksmith to have his locks changed because R #121's nephew had his key. The SSD stated that for difficult or unsafe discharges she typically follows up with the resident or representative with a phone call to ensure their wellbeing. The SSD stated that she did not follow up with R #121 after his discharge. The SSD stated that the Case Manager and the Administrator were involved with R #121's discharge. She stated R #121 was not able to discharge safely, but he refused to stay at the facility. C. On [DATE] at 10:39 am, during an interview with the Adult Protective Services (APS) Supervisor, she confirmed that there were two reports made on behalf of R #121. One report was from R #121's nephew dated [DATE] and the other was made by the [MEDICAL TREATMENT] Social Worker (from the [MEDICAL TREATMENT] clinic where R #121 received [MEDICAL TREATMENT]) dated [DATE]. The APS Supervisor stated that she did a search in their database of R #121's name and the day he was discharged ([DATE]) and verified there were no reports made by the facility on [DATE]. The APS Supervisor stated that every call or report that comes in through the intake hotline is recorded. D. On [DATE] at 10:47 am and at 2:20 pm, during interviews with the Administrator, she stated that the facility staff contacts APS anytime they have a resident discharge AMA or an unsafe discharge. The Administrator stated she informed her staff to contact APS regarding R #121's discharge and her staff informed her that they did. The Administrator confirmed that R #121's attending physician should have been notified of his AMA discharge. The Administrator stated that R #121 had a nephew who they were trying to contact to help find placement for R #121, but he stated he didn't want to be involved in his uncle's care anymore. The Administrator stated they generally do not provide transportation for discharged residents however they made an exception for R #121. She also stated that when R #121 left the building he was no longer considered a resident of the facility and the facility drove him home to honor his choice to go home. The Administrator stated they don't usually change the locks on resident homes, but on this occasion, she approved it. The Administrator was asked if R #121 was competent to make his own decisions, she stated, My understanding is that to declare someone incompetent it would need a psych eval (psychological evaluation). We didn't have documentation that he wasn't able to make his own decisions. The Administrator confirmed that social services should have made an attempt to contact R #121 according to their policy, but she does not know if anyone did. When asked if she felt this was a safe discharge, she stated, I think, it was a place he was comfortable with, where he wanted to be. I don't know if I would necessarily say safe, it wasn't my ideal. E. Record review of the Release from Responsibility for Discharge form signed by R #121 on [DATE] with Case Manager/Registered Nurse (Case Manager/RN) signing as a witness. The form stated, This is to certify that I, (R #121) am leaving (Name of Facility and Address of Facility) against the advice of the attending physician and the center administration. F. On [DATE] at 11:24 am, during interview the Medical Director and also R #121's attending physician confirmed he was not notified before R #121 discharged AMA on [DATE]. G. On [DATE] at 1:55 pm, during interview the Case Manager/RN, stated that she worked very closely with R #121 to get a safe placement for him. The Case Manager/RN stated that R #121 was his own Power of Attorney (POA) and refused any transfers to any long-term care facilities. The Case Manager/RN stated I think he had some confusion. At times, he was competent, but if he truly understood his medical situation, I don't think he understood. Was it necessarily a safe discharge, of course not, but that's out of my control. H. On [DATE] at 1:43 pm, during interview with RN #1, she stated that R #121's nephew didn't want him to go home, because he felt R #121 was unsafe at his home. RN #1 also stated that R #121 could not transfer himself to the toilet, he could only dress himself from the waist up, and he could not stand or walk at all. RN #1 confirmed that he was going to [MEDICAL TREATMENT] and was a diabetic. I. On [DATE] at 10:10 am, during an interview with the Maintenance Technician, he confirmed he followed the facility van driving R #121 to his house. He stated that he waited with the van driver and R #121 for about 25 minutes for the lock smith to change the locks. The Maintenance Technician stated that after the locks were changed, he helped R #121 into his home. The Maintenance Technician stated they helped R #121 walk up the stairs into his home and placed him on the couch. J. On [DATE] at 10:13 am, during interview, the Maintenance Director confirmed the locks were changed at R #121's home. The Maintenance Director confirmed that at the directive of the Administrator, he was told to call and hire locksmith to have the lock changed because his nephew had his key. K. On [DATE] at 10:54 am, during interview, the [MEDICAL TREATMENT] Social Worker from the [MEDICAL TREATMENT] clinic where R #121 received [MEDICAL TREATMENT] stated that R #121 was in a wheelchair, he was not able to walk, he could not transfer into a chair, could not take his own medications, and could not get to his [MEDICAL TREATMENT] appointments. The [MEDICAL TREATMENT] Social Worker stated, He was nursing home material. Over the past year he has declined, the thing that changed was that he was in total kidney failure. Every time he went home from the hospital he would end up back at the hospital. The [MEDICAL TREATMENT] Social Worker stated that during his most recent hospital stay, a psychological evaluation was done on [DATE] and it found that R #121 did not have the decisional capacity to make complex medical decisions and that he could not refuse placement. The [MEDICAL TREATMENT] Social Worker confirmed that she e-mailed the findings from this psychological evaluation to the Admissions Coordinator (AC) at the facility on [DATE]. The [MEDICAL TREATMENT] Social Worker verified that she talked to the AC by phone on the day she e-mailed the information and verified that he received it. She stated, I was very clear and had multiple conversations (with AC) about not discharging him (R #121) because there was nobody there to help him. I couldn't have been more clear. The [MEDICAL TREATMENT] Social Worker stated that she was trying to get R #121 a guardian and suggested to his family that they should get a guardian as well as a POA to make medical decisions. The [MEDICAL TREATMENT] Social Worker stated the facility allowed R#121 to go home and less than 72 hours later, he was deceased . She also stated the facility staff said they were respecting his rights, but he didn't have the ability to make decisions. L. Record review of the e-mail sent to the AC from the [MEDICAL TREATMENT] Social Worker on [DATE] and then forwarded to the Case Manager/RN on [DATE] revealed an attachment containing two documents: a psychiatric consult note completed on [DATE] and another psychiatric consult note completed on [DATE]. The body of the e-mail stated Hi (Name of AC), I appreciate your assistance with this. This attachment is a psychiatric consult note performed by (Name of Psychologist from Hospital's Psychiatry Department) dated [DATE]. Record review of the psychiatric consult note dated [DATE] stated, He has had multiple hospitalization s for related issues over the past month, after being discharged home each time. Psychiatry asked to evaluate patient's decisional capacity to participate in discharge planning or to participate in complex medical decisions. Last week we determined that patient lacks decisional capacity to make complex medical decisions and further lacks capacity to refuse placement. Patient has failed less restrictive measures multiple times in the past month and with PT/OT (physical/occupational therapy) currently recommending SNF (skilled nursing facility) placement. Record review of the psychiatric consult note dated [DATE] stated, Final report: We were asked to evaluate patient's decisional capacity on 2 occasions during this hospitalization , and he was found to lack decisional capacity on both occasions. M. On [DATE] at 11:09 am, during an interview with the AC, he confirmed that he received the documentation from the [MEDICAL TREATMENT] Social Worker's e-mail and forwarded it to the Case Manager/RN. He stated that he did not read the whole document, but was aware it related to R #121 not being able to make good decisions for himself. The AC verified speaking with the [MEDICAL TREATMENT] Social Worker over the phone about her concerns which included R #121 not being able to get to his [MEDICAL TREATMENT] appointments and not being able to make his own medical decisions. N. On [DATE] at 11:25 am, during a second interview, the Case Manager/RN confirmed that she received the documents from the AC. Case Manager/RN stated that she gave a copy of the e-mail to the Administrator. The Case Manager/RN confirmed that the hospital documentation should have been scanned into R #121's electronic record. The Case Manager/RN confirmed that the SSD was aware of the concerns from the [MEDICAL TREATMENT] Social Worker that R #121 was not competent to make his own medical decisions. Case Manager/RN stated she was informed by the Administrator that there needs to be two physician evaluations for a resident to be deemed incompetent. When asked if the facility had completed a psychologist evaluation of their own before R #121's discharge, she stated, I wish I would have done that now. It didn't occur to me to do it and I didn't think of doing it. Case Manager/RN stated that she has been doing case management for two months and she wasn't properly trained on how to do the job. O. On [DATE] at 11:42 am, during a second interview with the SSD, she verified speaking to the [MEDICAL TREATMENT] Social Worker. The SSD stated the [MEDICAL TREATMENT] Social Worker was concerned about R #121 not being able to go home safely due to his medical condition and need for [MEDICAL TREATMENT]. The SSD stated she wasn't informed by the [MEDICAL TREATMENT] Social Worker about any psychological evaluations for R #121. The SSD stated that she did not receive any paperwork from the Case Manager/RN. The SSD was asked if she followed up with R #121 after discharge, she stated, I did not follow up with (name of R #121). I'm supposed to follow up within 24 hours, but in his case I don't believe he had a working phone number, that I believe is why I didn't follow up. The SSD stated that the [MEDICAL TREATMENT] Social Worker informed her that R #121 was deceased . P. On [DATE] at 12:15 pm, during the third interview with the Administrator, when asked why wasn't a psychological evaluation done for R #121, she stated, I don't know. We probably just didn't think. I remember discussion about the evaluation. They said there was a psych evaluation done. I don't know why I didn't say let's do our own evaluation. I was aware that he had a psych eval for whether or not he could make decisions. When asked if the evaluation factored into R #121's AMA discharge planning, she stated, I think that the way I interpreted it was that he didn't make good decisions. I think sometimes people don't make good decisions. When asked if signing a discharge AMA form is a complex medical decision, she stated, I don't know. The Administrator further stated, I think that I would of honestly preferred to do our own evaluation, in hindsight, yes. Q. On [DATE] at 1:54 pm, during a second interview with the Medical Director, he stated that if he had been aware of a psychological evaluation done at the hospital, he would have questioned R #121's ability to sign out AMA. The Medical Director stated that if he had known he would have asked for a follow up to see if R #121's decisional capacity had changed. R. Record review of R #121's Nursing Progress Notes dated [DATE] through [DATE] revealed no documentation that his attending physician was notified of his discharge. S. Record review of the Discharge/Transfer Policy and Procedure revised ,[DATE], revealed Purpose: To provide the resident and family with a safe and orderly discharge. Discharge against Medical Advice: 1. Charge nurse or designated individual will: a. complete the PN (progress note)- Discharge Against Medical Advice. b. Inform physician of the situation. e. Complete the discharge summary. 2. The social worker or designated individual will: b. If the resident is at risk to be neglected by self or others, contact Adult Protective Services and/or the local ombudsman. Note: If an AMA discharge occurs during the evening or night hours, the social worker will contact the resident the next day in an attempt to offer and arrange needed community resources.

Based on interview and record review, the facility failed to implement policies and procedures to prevent neglect for 1 (R #121) of 3 (R #s 121, 230, and 231) resident reviewed for discharge. The facility allowed R #121 to discharge from the facility against medical advice (AMA), knowing he was evaluated and determined to lack the decisional capacity to make complex medical decisions and to refuse placement, failed to have the resident's mental status re-evaluated, and failed to follow up with R #121after discharge. This deficient practice resulted in R #121 going home alone where he was unable to take care of himself and as a result died . The findings are: A. Record review of the Admission Record indicated R #121 was admitted to the facility on [DATE] and discharged on [DATE] to private home/apartment with no home health services. R #121's medical [DIAGNOSES REDACTED].), [MEDICAL CONDITION] (abnormal fast heartbeat), essential hypertension (high blood pressure), pain, and [DIAGNOSES REDACTED] (low potassium level). B. On [DATE] at 9:33 am and 11:53am, during interviews with the Social Services Director (SSD), she stated she was involved with the discharge planning of R #121. The SSD stated she called Adult Protective Services (APS) on [DATE] before the R #121 left the building to let them know about his unsafe discharge and that he was signing himself out AMA (against medical advice). The SSD stated that R #121 had a nephew however, he refused to answer or return the facility's phone calls and refused to work with staff during the discharge planning. The SSD confirmed that facility staff drove R #121 to his house after he was discharged and called a locksmith to have his locks changed because R #121's nephew had his key. The SSD stated that for difficult or unsafe discharges she typically follows up with the resident or representative with a phone call to ensure their wellbeing. The SSD stated that she did not follow up with R #121 after his discharge. The SSD stated that the Case Manager and the Administrator were involved with R #121's discharge. She stated R #121 was not able to discharge safely, but he refused to stay at the facility. C. On [DATE] at 10:39 am, during an interview with the Adult Protective Services (APS) Supervisor, she confirmed that there were two reports made on behalf of R #121. One report was from R #121's nephew dated [DATE] and the other was made by the [MEDICAL TREATMENT] Social Worker (from the [MEDICAL TREATMENT] clinic where R #121 received [MEDICAL TREATMENT]) dated [DATE]. The APS Supervisor stated that she did a search in their database of R #121's name and the day he was discharged ([DATE]) and verified there were no reports made by the facility on [DATE]. The APS Supervisor stated that every call or report that comes in through the intake hotline is recorded. D. On [DATE] at 10:47 am and at 2:20 pm, during interviews with the Administrator, she stated that the facility staff contacts APS anytime they have a resident discharge AMA or an unsafe discharge. The Administrator stated she informed her staff to contact APS regarding R #121's discharge and her staff informed her that they did. The Administrator confirmed that R #121's attending physician should have been notified of his AMA discharge. The Administrator stated that R #121 had a nephew who they were trying to contact to help find placement for R #121, but he stated he didn't want to be involved in his uncle's care anymore. The Administrator stated they generally do not provide transportation for discharged residents however they made an exception for R #121. She also stated that when R #121 left the building he was no longer considered a resident of the facility and the facility drove him home to honor his choice to go home. The Administrator stated they don't usually change the locks on resident homes, but on this occasion, she approved it. The Administrator was asked if R #121 was competent to make his own decisions, she stated, My understanding is that to declare someone incompetent it would need a psych eval (psychological evaluation). We didn't have documentation that he wasn't able to make his own decisions. The Administrator confirmed that social services should have made an attempt to contact R #121 according to their policy, but she does not know if anyone did. When asked if she felt this was a safe discharge, she stated, I think, it was a place he was comfortable with, where he wanted to be. I don't know if I would necessarily say safe, it wasn't my ideal. E. Record review of the Release from Responsibility for Discharge form signed by R #121 on [DATE] with Case Manager/Registered Nurse (Case Manager/RN) signing as a witness. The form stated, This is to certify that I, (R #121) am leaving (Name of Facility and Address of Facility) against the advice of the attending physician and the center administration. F. On [DATE] at 11:24 am, during interview the Medical Director and also R #121's attending physician confirmed he was not notified before R #121 discharged AMA on [DATE]. G. On [DATE] at 1:55 pm, during interview the Case Manager/RN, stated that she worked very closely with R #121 to get a safe placement for him. The Case Manager/RN stated that R #121 was his own Power of Attorney (POA) and refused any transfers to any long-term care facilities. The Case Manager/RN stated I think he had some confusion. At times, he was competent, but if he truly understood his medical situation, I don't think he understood. Was it necessarily a safe discharge, of course not, but that's out of my control. H. On [DATE] at 1:43 pm, during interview with RN #1, she stated that R #121's nephew didn't want him to go home, because he felt R #121 was unsafe at his home. RN #1 also stated that R #121 could not transfer himself to the toilet, he could only dress himself from the waist up, and he could not stand or walk at all. RN #1 confirmed that he was going to [MEDICAL TREATMENT] and was a diabetic. I. On [DATE] at 10:10 am, during an interview with the Maintenance Technician, he confirmed he followed the facility van driving R #121 to his house. He stated that he waited with the van driver and R #121 for about 25 minutes for the lock smith to change the locks. The Maintenance Technician stated that after the locks were changed, he helped R #121 into his home. The Maintenance Technician stated they helped R #121 walk up the stairs into his home and placed him on the couch. J. On [DATE] at 10:13 am, during interview, the Maintenance Director confirmed the locks were changed at R #121's home. The Maintenance Director confirmed that at the directive of the Administrator, he was told to call and hire locksmith to have the lock changed because his nephew had his key. K. On [DATE] at 10:54 am, during interview, the [MEDICAL TREATMENT] Social Worker from the [MEDICAL TREATMENT] clinic where R #121 received [MEDICAL TREATMENT] stated that R #121 was in a wheelchair, he was not able to walk, he could not transfer into a chair, could not take his own medications, and could not get to his [MEDICAL TREATMENT] appointments. The [MEDICAL TREATMENT] Social Worker stated, He was nursing home material. Over the past year he has declined, the thing that changed was that he was in total kidney failure. Every time he went home from the hospital he would end up back at the hospital. The [MEDICAL TREATMENT] Social Worker stated that during his most recent hospital stay, a psychological evaluation was done on [DATE] and it found that R #121 did not have the decisional capacity to make complex medical decisions and that he could not refuse placement. The [MEDICAL TREATMENT] Social Worker confirmed that she e-mailed the findings from this psychological evaluation to the Admissions Coordinator (AC) at the facility on [DATE]. The [MEDICAL TREATMENT] Social Worker verified that she talked to the AC by phone on the day she e-mailed the information and verified that he received it. She stated, I was very clear and had multiple conversations (with AC) about not discharging him (R #121) because there was nobody there to help him. I couldn't have been more clear. The [MEDICAL TREATMENT] Social Worker stated that she was trying to get R #121 a guardian and suggested to his family that they should get a guardian as well as a POA to make medical decisions. The [MEDICAL TREATMENT] Social Worker stated the facility allowed R#121 to go home and less than 72 hours later, he was deceased . She also stated the facility staff said they were respecting his rights, but he didn't have the ability to make decisions. L. Record review of the e-mail sent to the AC from the [MEDICAL TREATMENT] Social Worker on [DATE] and then forwarded to the Case Manager/RN on [DATE] revealed an attachment containing two documents: a psychiatric consult note completed on [DATE] and another psychiatric consult note completed on [DATE]. The body of the e-mail stated Hi (Name of AC), I appreciate your assistance with this. This attachment is a psychiatric consult note performed by (Name of Psychologist from Hospital's Psychiatry Department) dated [DATE]. Record review of the psychiatric consult note dated [DATE] stated, He has had multiple hospitalization s for related issues over the past month, after being discharged home each time. Psychiatry asked to evaluate patient's decisional capacity to participate in discharge planning or to participate in complex medical decisions. Last week we determined that patient lacks decisional capacity to make complex medical decisions and further lacks capacity to refuse placement. Patient has failed less restrictive measures multiple times in the past month and with PT/OT (physical/occupational therapy) currently recommending SNF (skilled nursing facility) placement. Record review of the psychiatric consult note dated [DATE] stated, Final report: We were asked to evaluate patient's decisional capacity on 2 occasions during this hospitalization , and he was found to lack decisional capacity on both occasions. M. On [DATE] at 11:09 am, during an interview with the AC, he confirmed that he received the documentation from the [MEDICAL TREATMENT] Social Worker's e-mail and forwarded it to the Case Manager/RN. He stated that he did not read the whole document, but was aware it related to R #121 not being able to make good decisions for himself. The AC verified speaking with the [MEDICAL TREATMENT] Social Worker over the phone about her concerns which included R #121 not being able to get to his [MEDICAL TREATMENT] appointments and not being able to make his own medical decisions. N. On [DATE] at 11:25 am, during a second interview, the Case Manager/RN confirmed that she received the documents from the AC. Case Manager/RN stated that she gave a copy of the e-mail to the Administrator. The Case Manager/RN confirmed that the hospital documentation should have been scanned into R #121's electronic record. The Case Manager/RN confirmed that the SSD was aware of the concerns from the [MEDICAL TREATMENT] Social Worker that R #121 was not competent to make his own medical decisions. Case Manager/RN stated she was informed by the Administrator that there needs to be two physician evaluations for a resident to be deemed incompetent. When asked if the facility had completed a psychologist evaluation of their own before R #121's discharge, she stated, I wish I would have done that now. It didn't occur to me to do it and I didn't think of doing it. Case Manager/RN stated that she has been doing case management for two months and she wasn't properly trained on how to do the job. O. On [DATE] at 11:42 am, during a second interview with the SSD, she verified speaking to the [MEDICAL TREATMENT] Social Worker. The SSD stated the [MEDICAL TREATMENT] Social Worker was concerned about R #121 not being able to go home safely due to his medical condition and need for [MEDICAL TREATMENT]. The SSD stated she wasn't informed by the [MEDICAL TREATMENT] Social Worker about any psychological evaluations for R #121. The SSD stated that she did not receive any paperwork from the Case Manager/RN. The SSD was asked if she followed up with R #121 after discharge, she stated, I did not follow up with (name of R #121). I'm supposed to follow up within 24 hours, but in his case I don't believe he had a working phone number, that I believe is why I didn't follow up. The SSD stated that the [MEDICAL TREATMENT] Social Worker informed her that R #121 was deceased . P. On [DATE] at 12:15 pm, during the third interview with the Administrator, when asked why wasn't a psychological evaluation done for R #121, she stated, I don't know. We probably just didn't think. I remember discussion about the evaluation. They said there was a psych evaluation done. I don't know why I didn't say let's do our own evaluation. I was aware that he had a psych eval for whether or not he could make decisions. When asked if the evaluation factored into R #121's AMA discharge planning, she stated, I think that the way I interpreted it was that he didn't make good decisions. I think sometimes people don't make good decisions. When asked if signing a discharge AMA form is a complex medical decision, she stated, I don't know. The Administrator further stated, I think that I would of honestly preferred to do our own evaluation, in hindsight, yes. Q. On [DATE] at 1:54 pm, during a second interview with the Medical Director, he stated that if he had been aware of a psychological evaluation done at the hospital, he would have questioned R #121's ability to sign out AMA. The Medical Director stated that if he had known he would have asked for a follow up to see if R #121's decisional capacity had changed. R. Record review of R #121's Nursing Progress Notes dated [DATE] through [DATE] revealed no documentation that his attending physician was notified of his discharge. S. Record review of the Discharge/Transfer Policy and Procedure revised ,[DATE], revealed Purpose: To provide the resident and family with a safe and orderly discharge. Discharge against Medical Advice: 1. Charge nurse or designated individual will: a. complete the PN (progress note)- Discharge Against Medical Advice. b. Inform physician of the situation. e. Complete the discharge summary. 2. The social worker or designated individual will: b. If the resident is at risk to be neglected by self or others, contact Adult Protective Services and/or the local ombudsman. Note: If an AMA discharge occurs during the evening or night hours, the social worker will contact the resident the next day in an attempt to offer and arrange needed community resources.

This is a repeat deficiency from the recertification survey completed on 05/10/16. Based on record review and interview, the facility failed to notify the physician of changes to resident status for 1 (R #121) of 3 (R #'s 121, 230 and 231) residents reviewed for unsafe discharge, when they failed to notify the physician R #121 was discharging AMA (against medical advice). This deficient practice prevented the physician from making an informed decision regarding R #121's safety to leave the facility AMA, resulting in R #121 leaving and dying after three days. The findings are: A. On 05/04/17 at 10:47 am, during interview with the Administrator, she confirmed that R #121 was discharged from the facility AMA. When asked if the physician would be notified of residents leaving AMA, she stated, I would think he would of been. B. On 05/04/17 at 11:24 am, during interview, the Medical Director confirmed he was not notified before R #121 discharged AMA. C. On 05/05/17 at 1:54 pm, during interview the Medical Director, stated that if he was aware of the psychological evaluation done at the hospital, he would have questioned R #121's ability to sign out AMA. The Medical Director stated that if he had known he would have asked for a follow up to see if his decisional capacity had changed. D. Record review of Nursing Progress Notes dated 03/17/17 to 04/03/17, do not reveal any documentation indicating that the Physician was notified of R #121 discharging from facility AMA. E. Record review of the Discharge/Transfer Policy and Procedure revised 11/16, revealed Charge nurse or designated individual will: Inform physician of the situation.

Based on interview and record review, the facility failed to provide sufficient and appropriate social services for 1 (R #121) of 3 (R #s 121, 230, and 231) residents reviewed for unsafe discharge, by failing to ensure R #121 was discharged to a safe environment and failing to follow up with R #121 after he left the facility Against Medical Advice (AMA). This deficient practice resulted in R #121's death due to being discharged to his home, where he lived alone with no medical support, assistance, or follow up. The findings are: A. On [DATE] at 9:33 am, during interview, the Social Services Director (SSD) stated, For difficult cases we will follow up with them (residents) for sure. If we didn't get a good feeling or if their plan was difficult or they are found in the home alone, it is an APS referral. The SSD stated that she made a referral to APS for R #121 before he walked out the door on the day he discharged because he could not go home alone and he refused long term care. The SSD stated, I did not follow up with (name of R #121) after AMA discharge. The SSD stated that the Case Manager and the Administrator were involved with R #121's discharge. She stated that it was determined R #121 was not able to safely discharge, but he refused to stay at the facility. B. On [DATE] at 11:53 am, during interview, the SSD stated that she called APS on [DATE] and made a report. When asked what number she called, the SSD stated that she did a internet search for the number for APS and called the referral line. The SSD doesn't remember who she talked to, but she answered questions and told them it was an unsafe discharge. C. On [DATE] at 10:39 am, during interview the Adult Protective Services Supervisor, confirmed that there were two reports made on behalf of R #121. One was from R #121's nephew dated [DATE] and the other was made by the Social Worker from the dialysis clinic dated [DATE]. The APS Supervisor stated that she did a search of R #121's name and the day he discharged on [DATE] and verified there was not a report made by the facility regarding R #121's AMA discharge. The APS Supervisor stated that every call or report that comes in through the intake hotline is recorded. D. On [DATE] at 11:42 am, during a second interview with the SSD, she stated that she did talk to the Social Worker at the dialysis clinic. The SSD stated, Her (Social Worker at the dialysis clinic) concerns were that he (R #121) wouldn't be safe to go home based on his condition and need for dialysis. I didn't hear anything from her about a psych eval. I don't remember any discussion about a psych eval, it could of happened. I should be made aware (of an evaluation) yes. I let her know that he went AMA and we were respecting his self determination. The SSD stated that she did not receive any paperwork from the Case Manager/RN. The SSD was asked if she followed up with R #121 after discharge, she stated I did not follow up with (name of R #121). I'm supposed to follow up within 24 hours, but in his case I don't believe he had a working phone number, that I believe is why I didn't follow up. The SSD stated that the Social Worker informed her that R #121 was deceased . E. On [DATE] at 2:20 pm, during interview the Administrator, was asked if Social Services should have followed up with R #121 after discharge, she stated, I see from the policy that they should have and I agree that we should have. F. Record review of Nursing Progress Notes dated [DATE], indicates, This social worker (SSD) contacted Adult Protective Services and made a report, as (Name of R #121) discharged home without being safe to do so. This occurred as a result of (Name of R #121) stating that he did not want ALF (assisted living facility) options, and continuously verbalizing wanting to return home. The progress notes do not reveal any documentation before [DATE] that R #121 is stating he wanted to go home and no discharge against medical advice note was completed. G. Record review of the Discharge/Transfer Policy and Procedure revised ,[DATE], revealed Purpose: To provide the resident and family with a safe and orderly discharge. Discharge against Medical Advice: The social worker or designated individual will: If the resident is at risk to be neglected by self or others, contact Adult Protective Services and/or the local ombudsman. Note: If an AMA discharge occurs during the evening or night hours, the social worker will contact the resident the next day in an attempt to offer and arrange needed community resources.

Based on observation, record review and interview, the facility failed to implement the plan of care for 1 (R #136) of 1 (R #136) resident reviewed for accidents by failing to ensure the resident was wearing non-skid socks to prevent avoidable falls. This deficient practice resulted in R #136's fall, subsequent pain and signs of depression. The findings are: A. On 05/02/17 at 9:36 am, during observation of and interview with R #136, she was seen grimacing and grabbing her left hip area with her hand. R #136 stated that she was in a lot of pain. R #136 was observed with regular tube socks on her feet. B. On 05/03/17 at 1:23 pm, R #136 was observed in her room resting in bed with regular tube socks on her feet. C. On 05/03/17 at 4:04 pm, R #136 was observed in her room resting in bed with regular tube socks on her feet. D. Record review of R #136's care plan dated 08/16/16 indicated the resident was at risk for falls and one of the interventions listed was to ensure that the resident is wearing appropriate footwear including non-skid socks. E. Record review of a nurse's note dated 04/11/17 at 3:13 am, indicated the following: I was called to resident's (R #136) room because she was found on the floor beside her bed next to her wheelchair. She (R #136) stated that she had had a bad dream and was getting up to look for the boy. She stated that she had stood up to try and walk and fell . She was wearing regular tube socks. F. Record review of the incident report pertaining to R #136's fall on 04/11/17 dated 4/21/17 stated the resident was found sitting on the floor bedside next to her wheelchair. The report stated R #136 said that she had a bad dream and got out of bed to look for a boy. The report stated the resident was assessed for injuries which included a 9 cm (centimeter) long by 1/2 cm wide abrasion on her left forearm, a 1 cm by 1 cm skin tear on her right wrist, a 2 cm long by 2 cm wide by 2 cm high bump on head and a large bruise forming on her left hip. G. Record review of R #136's History and Physical completed by a physician's assistant dated 05/02/17 stated, The patient sustained a fall next to her bed. She describes sitting on a chair and falling off landing on her left hip. She has been in pain ever since. She is unable to qualify or quantify the pain due to limited mobility and speaking English. H. Record review of R #136's Psychological/Behavioral Health Progress Notes and Consultation Record completed by the resident's psychologist dated 04/27/17 stated, She fell recently and is still in bed complaining of pain. Her outlook is somewhat more depressed, in that this current fall is slowing down her aspirations of going home. She holds onto that hope as a way of making her days bearable. I. Record review of R #136's physician order [REDACTED]. J. Record review of R #136's nurse's notes and Medication Administration Record (MAR) for the month of April 2017 revealed a lack of consistent documentation of the resident's pain level, especially during the period after her fall on 04/11/17. The MAR and nurse's notes revealed R #136's pain level was not documented on the following days: 04/11/17, 04/12/17, 04/14/17, 04/15/17, 04/16/17, 04/17/17, 04/19/17, 04/20/17, 04/21/17, 04/23/17, and 04/25/17. K. On 05/05/17 at 3:09 pm, during an interview with the Director of Nursing (DON), she stated she expects her staff to document a resident's pain level every shift after the resident sustained [REDACTED]. The DON could not say whether R #136 had her pain level checked every shift on the days after her fall on 04/11/17 however she verified that the documentation indicated it was not done. The DON acknowledged R #136's order dated 04/18/17 for an x-ray of her left hip due to pain/bruising as evidence that the resident was in pain during the period after her fall however the DON could not speak to the intensity or frequency of that pain. L. On 05/04/17 at 9:22 am, during an interview with the Assistant Director of Nursing (ADON), she stated the nurse on duty is responsible to complete an incident report when a resident sustains a fall. The report is then reviewed by a team who determine the root cause of the fall and develop new interventions to avoid future falls. The team also updates the care plan to indicate the resident has fallen and to reflect the new interventions. The ADON verified that no new interventions were developed or implemented after R #136's falls on 04/11/17. She also verified that R #136's care plan was not updated to indicate the resident had fallen and no new interventions were added. The ADON verified that R #136 was not wearing non-skid socks at the time of the fall and she should have been. She also stated not wearing the appropriate socks could have contributed to her fall.

This is a repeat deficiency from a recertification survey conducted on 05/10/16. Based on record review and interviews, the facility failed to provide necessary care and services needed to address a resident' s specialized needs for 2 (R # 41 and 103) of 2 (R #41 and 103) residents who had nutritional needs and a pessary (a device that is inserted into the vagina to treat a fallen uterus) in place. This deficient practice resulted in R #41 having weight loss and R #103 having a difficult removal of the pessary and extensive vaginal/cervix erosion due to pessary being in place since December 2015. The pessary should have been removed and cleaned every 3 (three) months. The findings are: Findings for R # 103: A. Record review of R #103's medical document titled Clinic Referral from (name of provider) dated 12/03/15, revealed the following: Progress notes: pessary check, no problems, pessary fits well and working well. Continues [MEDICATION NAME] vaginal cream - use 3x/wk (3 times a week) at hs (hour of sleep) (same dose), date of next appt (appointment) in 3 months. This appointment was followed with a physician order [REDACTED]. B. Record review of R #103's medical records revealed no other documentation to indicate that R #103 had been seen by another physician regarding the checking of the pessary placement. C. On 05/01/17 at 1:20 pm, during interview, R #103's daughter shared many concerns regarding her mothers' care at the facility. She stated that during the beginning of March of this year (2017), she had discussed with the facility's physician about her mother's pessary. The physician at the time of this discussion was not aware that her mother even had a pessary inserted. D. Record review of R #103's medical document titled Clinic Referral dated 03/30/17, revealed that R #103 was seen by a physician who specializes in women's health. The progress notes from that visit indicated that the pessary was removed with difficulty. There was extensive erosion to the vagina/cervix area due to the pessary being in place since 12/2015, which should have been removed and cleaned every 3 (three) months. There was a comment which indicated, pt has also not being (sic) using vaginal [MEDICATION NAME] cream regularly, should have been 2 (two) x (times) a week at hs. E. On 05/05/17 at 1:25 pm, during interview, the ward clerk/Nursing Unit Secretary on second floor stated that when residents return from an office visit that it is her responsibility to arrange the follow-up physician appointment. She stated that, usually, for R #103, her daughter had been scheduling the physician appointments. She stated that for some unknown reason either due to R #103's daughter or herself, the appointment following the pessary check in December of 2015 had not been scheduled. Findings for R # 41: F. Record review of the MAR (Medication Administration Record) dated 05/01 through 05/11/17 revealed that there was no nutritional supplement listed. G. Record review of the April 2017's MAR revealed that there was no nutritional supplement listed on it. H. Record review of the Medication Review Report dated 05/01/17, revealed a physician order [REDACTED]. I. Record review of the Nutritional assessment dated [DATE] revealed R #41 was, .appropriately receiving Regular diet .Poor dentition noted. Intakes have been meeting estimated needs. Significant weight loss over 90 days noted, part of weight loss possibly r/t new wheelchair and improper measurement data. However, continued, though less significant amount, of weight loss has since continued. Per observation, resident visually appears to have lost weight. Has begun receiving (name of nutritional supplement) to provide additional Calories and resident and weight gain noted since. Is being monitored weekly .(name of R #41) Unable to make needs known. No pressure ulcers . J. Record review of the Nutrition note dated 04/20/17 revealed the following: 1. Weight loss has been confirmed. Re-weighed and new weight continues to show a loss, though continues to be shy of significant weight gain. Resident weighed on standing scale so new wheelchair likely not a factor in weight discrepancy. 2. BMI (body mass index) remains WNL (within normal limits), which was 24.1. 3. (Meal) Intakes remain > 75% and meeting estimated needs. Will recommend House Supplement with HS (hours of sleep) Snack to provide additional Calories and protein. 4. Resident is being monitored weekly .until weight documented as stable x (times) 6 (six) weeks. K. Record review of the Physician order [REDACTED]. L. Record review of weights revealed the following: 1. 01/04/17 128.2 lbs (pounds) 2. 02/01/17 129.6 lbs 3. 03/01/17 128.6 lbs 4. 04/05/17 114.8 lbs 5. 04/12/17 122.6 lbs 6. 04/19/17 123.6 lbs 7. 04/25/17 118.0 lbs 8. 05/04/17 119.6 lbs 9. 05/04/17 119.6 lbs M. On 05/05/17 at 12:04 pm, during interview, the Registered Dietitian (RD) stated that R #41 was on a nutritional supplement and has gained weight of 1 pound. R #41 received a new wheelchair and this might have led to the weight loss. He stated that R #41's meal intakes were adequate. R #41 had been receiving a nutritional supplement once a day, that was ordered on [DATE]. R #41 does sit at the table with residents needing assistance with their meals and was receiving chopped meats, canned fruits and vegetables. The snack was the (name of nutritional supplement). The RD stated that if R #41 wanted other snacks she could have them 24/7. He also stated that at this time R #41 was going in the right direction (being her weight). He will be watching her weight for the next 5 (five) weeks and if there was a decline in her weight then he would look and increase the nutritional supplement or medications. N. On 05/08/17 at 10:50 am, during interview, Registered Nurse (RN) #2 stated that the Certified Nursing Assistant's (CNAs) are the ones making notes about R #41 intake of the nutritional supplement . O. On 05/08/17 at 11:02 am, during interview, CNA #2 stated that nutritional supplement drinks are to be documented on the fluid intake system. P. On 05/08/17 at 12:22 pm, during interview, the DON and Interim DON stated there was no documentation to indicate that R #41 was receiving her (name of nutritional supplement). The DON also stated that it should be the nursing staff documenting (the nutritional supplement). The Interim DON stated that it should be documented on the MAR and it was not. She stated that (the physician order) did not make it to the MAR. Q. On 05/08/17 at 1:53 pm, during interview, when the RD was asked if he was aware that R #41 was not receiving the nutritional supplement since 04/20/17 when it was ordered, and He stated No. R. On 05/08/17 at 11:57 am, during observation of the noon meal, there was no nutritional supplement on the table.

Based on record review and interview, the facility failed to consistently provide care and services to prevent the development of an avoidable pressure ulcer, for 1 (R #227) of 6 (R #1, 208, 226, 227, 228 and 229) residents reviewed for pressure ulcer wounds. This deficient practice resulted in R #227 developing an avoidable pressure ulcer that ultimately lead to R #227 being transferred to the hospital for treatment. The findings are: A. Record review of R #227 medical records revealed that she was admitted on [DATE] from an outside hospital after undergoing hip surgery, due to a fall sustained at home. Further review revealed a medical history that included [MEDICAL CONDITION] (abnormal fast heart rate),[MEDICAL CONDITION](hypertension- high blood pressure) and DM (diabetes mellitus-abnormal blood sugar levels). B. Record review of the hospital progress notes dated 04/08/17 revealed no documentation that would indicate R #227 had any signs of skin breakdown. C. Record review of the initial Nursing assessment dated [DATE] indicated there were no alterations in skin integrity except for her surgical wound site to the right hip. No signs of reddened areas or rashes noted on admission. The assessment also indicated that R #227 was incontinent of both urine and stool and required the assistance of one (1) staff member for toileting and transfers (meaning moving from bed to wheel chair and wheel chair to toilet). D. Record review of the Admission Pressure Sore Risk assessment indicated; a risk score of 14- indicating R #227 was a 'Moderate Risk' for developing a pressure sore. The intervention guide includes: Frequent Turning with a planned schedule, Use foam wedges for 30 degrees lateral positioning, pressure reduction support surfaces, protect heels .manage moisture .manage nutrition and manage friction and shear. E. Record review of the Kardex dated 04/13/17 for R #227 indicated that she required a one person assist with transfers and bed mobility (positioning in bed). F. Record review of the MDS (minimum data set) dated 04/30/17 confirmed R #227 required a one person assist with transfers and bed mobility. G. Record review of the Nursing Progress notes dated 04/23/17 revealed, during skin check R #227 was found to have developed a Stage II (partial skin loss presenting like an abrasion, blister or shallow crater) pressure wound to her coccyx (lower spine) area. H. Record review of the Wound Data Collection sheets revealed; 1. Data collection sheet dated 04/23/17 revealed R #227 had a stage II pressure ulcer to the coccyx measuring 2 cm (centimeter) by (X) 1 cm and having no depth. 2. Data collection sheet dated 04/30/17 measured 4.5 cm X 5 cm X 1 cm depth - eschar (dark colored dead skin tissue) noted to the entire wound bed and a bruise to the right side of wound measuring 4 cm X 5 cm with redness noted to the left side of the wound .also documented: bruise to right side looks like it is going to open and there is presence of possible complications, increasing area of ulceration, or soft tissue infection .no odor noted. 3. Data collection sheet dated 05/01/17 measured 8 cm X 8.5 cm X 1 cm depth, described as unstageable (unable to stage due to eschar tissue covering wound), possible complications remain as stated above now with odor present - described as foul smelling. 4. Data Collection sheet dated 05/02/17 measured 9 cm X 8.5 cm and no depth recorded. Description: red, bruised with moderate drainage and foul smelling, no purulent drainage. I. Record review of the Care Plan for R #227, dated 04/20/17 revealed the Care plan had been updated on 05/03/17 to include: provide air mattress, cushion on w/c (wheel chair) which was initiated on 05/01/17 per documentation. Note: resident was transferred to the hospital on [DATE]. J. Record review of the physician orders [REDACTED]. K. Record review of the Treatment Administration Record (TAR) dated 04/01/17 to 04/30/17 and TAR dated 05/01/17 to 05/11/17 confirmed the above physicians order as written with a starting date of 04/24/17. L. Record review of the 'Daily Skilled Notes' (nursing notes) dated 04/13/17 through 05/02/17 revealed the following: 1. Notes dated 04/24/17 indicated Stage II pressure wound was cleaned and a foam dressing applied (no mention of Santyl being used as ordered). 2. Notes dated 04/26/17 indicated Stage II pressure ulcer noted, barrier cream (skin protection) applied to area (no mention or indication prescribed Santly was used). 3. Notes dated 04/27/17 indicated Stage II pressure ulcer with moderate amount of serosanguineous (light blood color) drainage and foul odor noted coming from wound. Wound cleaned and calcium alginate (absorbs wound drainage but which is not Santyl) placed on wound bed. Again, the prescribed Santyl was not used as ordered on [DATE]. 4. Notes dated 04/28/17 to 05/02/17 described wound as getting larger, foul odor and no documentation that the prescribed treatment with Santyl was being used until 04/30/17. 5. There were also several notations of notifying the Physician or Physicians Assistant however, there was no documentation found that would indicate a physician saw R #227 until 05/02/17 when the resident was transferred to the hospital due to her wound status. M. On 05/03/17 at 12:50 pm, during interview, R #227's Family member #1 and her POA (Power of Attorney) stated, her aunt (referring to R #227) was in the hospital and not doing very well . she [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus- a multi drug resistant bacterial infection) in her wound, heart failure and pneumonia . and the wound was down to the bone. This would indicate the pressure wound upon arrival to the hospital was now a Stage IV wound (full thickness skin loss with extensive destruction down to bone structures). Family member #1 then stated, The doctor at the hospital said she would need surgery but given her age and present health condition she (R #227) would not be a good candidate for surgery and may have a poor outcome . she also added that she (family member #1) would visit her (R #227) while she was here (meaning the facility) .she (R #227) came here for rehabilitation after having hip surgery . she was doing pretty well then she started to decline .her appetite was very poor. Family member #1 then stated her aunt (R #227) started to decline about the same time she developed the pressure wound . and they put the special mattress (referring to an air mattress- used to help prevent pressure ulcers from developing) which was new and had only been on her bed for a day or two. Family member #1 then added, when she (Family member #1) was visiting no one came into the room to check on her aunt ( R #227) . she would spend 4 hours visiting and there were times when she had to go to the nurses station and tell them that her aunt needed to be changed .and when she wasn't there her brother was. N. On 05/03/17 at 1:03 pm, during interview with Family Member #2 he stated , when he was visiting a couple of days ago there was an odor. Family member #2 then added that his aunt (R #227) pressed the button and it took 30 to 45 minutes for them (meaning staff) to come and put her ( R#227) to bed and no one answered the call light. He waited another 20 -25 minutes before he went to the nurses station for help. O. On 05/11/17 at 10:08 am, during interview with Certified Nursing Assistant (CNA) #1, he stated he remembered R #227 and had worked with her several times .she was able to reposition herself in bed and was able to turn self side to side but some times needed some assistance. CNA #1 then added that when he worked with R #227 he would turn her side to side because of the sore on her backside but she would roll on to her back .she would remove support pillows .she preferred to stay on her back even though he would explain she needed to be on her side. CNA #1 also stated that R #227 told him that she was more comfortable on her back . and thought the regular mattress was changed to the special air mattress after her wound was getting worse. P. On 05/11/17 10:35 am, during an interview with the Assistant Director of Nursing (ADON), she stated they ( facility staff) would have discussed R #227's pressure ulcer in their wound meetings. When asked where the minutes from these wound meetings were documented, the ADON stated, the meetings have not been documented in the electronic medical records (EMR) and was unable to provide any documentation that would have indicated these meetings were taking place.

Based on observation, record review and interview, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent avoidable falls for 1 (R #136) of 3 (R #s 66, 79 and 136) residents reviewed for accidents. R #136 was not wearing non-skid socks at the time of her fall and her subsequent injuries caused her to be in constant pain and exhibit signs of depression. This deficient practice caused R #136's injuries, and could jeopardize other residents at risk for falls. The findings are: A. On 05/02/17 at 9:36 am, during observation of and interview with R #136, she was seen grimacing and grabbing her left hip area with her hand. R #136 stated that she was in a lot of pain. R #136 was observed with regular tube socks on her feet. B. On 05/03/17 at 1:23 pm, R #136 was observed in her room resting in bed with regular tube socks on her feet. C. On 05/03/17 at 4:04 pm, R #136 was observed in her room resting in bed with regular tube socks on her feet. D. Record review of R #136's care plan dated 08/16/16 indicated the resident was at risk for falls and one of the interventions listed was to ensure that the resident is wearing appropriate footwear including non-skid socks. E. Record review of a nurse's note dated 3:13 am on 04/11/17 stated, I was called to resident's (R #136) room because she was found on the floor beside her bed next to her wheelchair. She (R #136) stated that she had had a bad dream and was getting up to look for the boy. She stated that she had stood up to try and walk and fell . She was wearing regular tube socks. F. Record review of the incident report pertaining to R #136's fall on 04/11/17 dated 4/21/17 stated the resident was found sitting on the floor bedside next to her wheelchair. The report stated R #136 said that she had a bad dream and got out of bed to look for a boy. The report stated the resident was assessed for injuries which included a 9 cm (centimeter) long by 1/2 cm wide abrasion on her left forearm, a 1 cm by 1 cm skin tear on her right wrist, a 2 cm long by 2 cm wide by 2 cm high bump on head and a large bruise forming on her left hip. G. Record review of R #136's History and Physical completed by a physician's assistant dated 05/02/17 stated The patient sustained a fall next to her bed. She describes sitting on a chair and falling off landing on her left hip. She has been in pain ever since. She is unable to qualify or quantify the pain due to limited mobility and speaking English. H. Record review of R #136's Psychological/Behavioral Health Progress Notes and Consultation Record completed by the resident's psychologist dated 04/27/17 stated, She fell recently and is still in bed complaining of pain. Her outlook is somewhat more depressed, in that this current fall is slowing down her aspirations of going home. She holds onto that hope as a way of making her days bearable. I. Record review of R #136's physician order [REDACTED]. J. Record review of R #136's nurse's notes and Medication Administration Record (MAR) for the month of April 2017 revealed a lack of consistent documentation of the resident's pain level, especially during the period after her fall on 04/11/17. The MAR and nurse's notes revealed R #136's pain level was not documented on the following days: 04/11/17, 04/12/17, 04/14/17, 04/15/17, 04/16/17, 04/17/17, 04/19/17, 04/20/17, 04/21/17, 04/23/17, and 04/25/17. K. On 05/05/17 at 3:09 pm, during an interview with the Director of Nursing (DON), she stated she expects her staff to document a resident's pain level every shift after the resident sustained [REDACTED]. The DON could not say whether R #136 had her pain level checked every shift on the days after her fall on 04/11/17 however she verified that the documentation indicated it was not done. The DON acknowledged R #136's order dated 04/18/17 for an x-ray of her left hip due to pain/bruising as evidence that the resident was in pain during the period after her fall however the DON could not speak to the intensity or frequency of that pain. L. On 05/04/17 at 9:22 am, during an interview with the Assistant Director of Nursing (ADON), she stated the nurse on duty is responsible to complete an incident report when a resident sustains a fall. The report is then reviewed by a team who determine the root cause of the fall and develop new interventions to avoid future falls. The team also updates the care plan to indicate the resident has fallen and to reflect the new interventions. The ADON verified that no new interventions were developed or implemented after R #136's falls on 04/11/17. She also verified that R #136's care plan was not updated to indicate the resident had fallen and no new interventions were added. The ADON verified that R #136 was not wearing non-skid socks at the time of the fall and she should have been. She also stated not wearing the appropriate socks could have contributed to her fall.

Based on observation, interview and record review, the administration of the facility failed to manage and coordinate resident care in a manner that would enable each resident to attain or maintain his or her highest practicable physical, mental, and psychosocial well being, for 98 residents listed on the alphabetical census list provided by the Administrator on 05/01/17. These deficient practices likely contributed to poor resident outcomes with respect to quality-of-life, quality-of-care, health, safety and comfort. The findings include: A. The facility failed to notify the physician of changes to the resident's status prior to a discharge against medical advice for Resident #121. This prevented the physician from making an informed decision regarding the Resident's safety to leave the facility AMA, resulting in R #121 leaving and dying after three days. (Refer to F157) B. The facility failed to ensure residents were discharged appropriately and to a safe environment knowing that the resident lacked the decisional capacity to refuse placement for Resident #121. (Refer to F201) C. The facility failed to ensure that residents were free from neglect by allowing R #121 to discharge from the facility against medical advice (AMA), knowing he was evaluated and determined to lack the decisional capacity to make complex medical decisions and to refuse placement and failed to have the resident's mental status re-evaluated. (Refer to F224) D. The facility failed to implement their policies and procedures to prevent neglect by allowing R #121 to discharge from the facility against medical advice (AMA), knowing he was evaluated and determined to lack the decisional capacity to make complex medical decisions and to refuse placement and failed to have the resident's mental status re-evaluated and failed to follow up with the resident after discharge. (Refer to F226) E. The facility failed to provide sufficient and appropriate social services by failing to ensure Resident #121 was discharged to a safe environment and failing to follow up after he left against medical advice (AMA). The resident was found dead in his home after being discharged to his home where he lived alone with no medical support, assistance or follow up. (Refer to F250) F. The facility failed to consistently provide care and services to prevent the development of an avoidable pressure ulcer and failed to ensure treatments to prevent the worsening of pressure ulcers. This ultimately lead to Resident #227 being transferred to the hospital for treatment. (Refer to F314) G. The facility failed to provide sufficient nursing staff to answer call lights in a timely manner, provide assistance to residents in getting them up in the morning before breakfast, and attend to other resident needs. (Refer to F353) H. The facility failed to ensure that intravenous (IV) [MEDICATION NAME] (antibiotic) was infused safely through an IV pump (intravenous infusion pump, which allows precise control over the flow rate and total amount delivered) into a PICC (peripherally inserted central catheter) line instead of through a dial-a-flow tubing (used to regulate the flow of fluid), which could cause kidney damage and hearing loss if the medication was infused too fast. (Refer to F425) I. The facility failed to establish an effective infection control program by failing to address monthly infection control data, develop an action plan and initiate a follow up analysis; failed to perform rounds in ancillary department area; failed to maintain a clean, sanitary environment for storage of stock medications, supplies and health care equipment; failing to ensure beard covers were being worn during food preparation and handling of food. (Refer to F441)

Based on record review and interview, the facility failed to consistently provide care and services to promote the healing of a pressure ulcer (bed sore), or prevent the development of an avoidable pressure ulcer, for 2 (R #s 1 & 2) of 6 (R #s 1, 2, 3, 4, 5 & 6) residents reviewed during a complaint investigation survey. Documentation of the staging (severity), size and progress of R #1's wound was inconsistent, routine monitoring of wound status by a designated wound specialist was absent, and interventions specified by a physician in her plan for the resident were not put in place. These deficient practices resulted in the facility's failure to recognize the deterioration in the resident's wound, ultimately leading to her suffering septic shock (a life-threatening illness resulting from infection throughout the bloodstream) and needing multiple surgeries, including removal of a portion of her spine. R #2 developed an avoidable pressure ulcer while a resident at the facility. The findings are: Findings for Resident #1: A. Record review of R #1's hospital record from her admission on 11/25/16 found: 1. R #1 was noted to be a [AGE] year-old woman admitted from the facility due to a blood test result showing an elevated white blood cell count (a sign of systemic infection) and changes to her coccyx (lower spine) wound which suggested local infection. 2. that the resident was found to be in septic shock in the emergency department, evidenced by increased respiration rate, increased body temperature, and decreased level-of-consciousness. 3. that she was admitted to the Medical Intensive Care Unit (MICU), sedated, and intubated (installation of a breathing tube to sustain life). 4. that surgeries on 11/26/16, 11/28/16 and 11/30/16 were performed to debride (remove dead tissue from) the wound and also to remove her coccyx and a portion of her sacrum (bones of the lower spine), due to the infected wound having deepened to involve the spine. 5. that both the resident and her family had reported to hospital staff that they felt she had been neglected while a resident of the facility. B. On 01/31/17 at 2:00 pm, during interview with R #1's daughter and second power-of-attorney, she verified the information that she had detailed in her complaint to the Department of Health on 12/08/16. She stated that the facility did not provide updates to the family about the resident's progress, and when the family asked about R #1's wound, they were told that the wound was improving. She stated that when the family visited on 11/24/16, they found the resident to be very lethargic and with a strong odor coming from her wound, and described these changes to the nursing staff. Later that evening, she said, the facility called to advise the family that the resident was being sent out to an emergency room . The resident's daughter stated that, since her episode of septic shock and her surgeries, R #1's health has been severely compromised, including a [MEDICAL CONDITION] and respiratory arrest (failure to breathe) resulting in an emergency [MEDICAL CONDITION] (creation of an opening in the throat to facilitate breathing). She stated that the resident still had her pressure ulcer, as her health hasn't been stable enough to allow her to have a planned skin graft surgery. C. Record review of R #1's facility electronic medical record did not reveal a pressure ulcer listed on the [DIAGNOSES REDACTED]. D. Record review of a physician's History & Physical document for R #1, dated 11/03/16, indicated that her only skin issue was a 3-4 cm (centimeter) decubitus (bed sore) ulcer that is just adjacent to the rectum and it appears to have dated cellular material (old tissue) in the center with irregular pink borders around. The depth is approximately 1 1/2 cm. The Plan section of the History & Physical indicated the resident would have dressing changes every 24 hours, and that a pressure-relieving air mattress would be used. It also stated The patient is extremely complicated with a magnitude of life-threatening chronic medical conditions. So any (name of medical practice) provider will be seeing this patient every 1-2 days to check on her progress and to check on her labs which will be a CBC (Complete Blood Count a type of blood test) and a BMP (Basic Metabolic Panel, a type of blood test) drawn every 2-3 days. E. Record review of physician's progress notes for R #1 dated 11/04/16 and 11/14/16 found that notes indicated that the resident was seen by the medical team twice during the remaining 21 days of her stay at the facility, by a physician's assistant on 11/04/16 and by a physician on 11/14/16. The physician's note on 11/14/16 used identical language for her assessment of the wound to the description in the History and Physical document of 11/03/16, and the wound dimensions did not reflect the larger wound size documented elsewhere, likely indicating that the physician did not reassess the wound on 11/14/16. F. Record review of physician's orders [REDACTED]. Blood work was ordered twice, on 11/02/16 and 11/24/16. G. Attempts to reach R #1's facility physician on 02/16/17 were unsuccessful, as she is no longer with the practice that oversaw the resident's care. H. Record review of Wound RN (Registered Nurse) Assessment documents for R #1 found that they did not include wound measurements. Notations indicated: 1. On 11/03/16, the wound was assessed as Stage 4 (the most severe stage, indicating muscle or bone involvement). 2. On 11/07/16 and 11/14/16, the wound was assessed as Stage 2 (a shallow wound involving a break of the skin). 3. On 11/17/16, the wound was assessed as being unstageable (unable to visualize wound depth, due to the presence of dead tissue). 4. On 11/24/16, the wound was again assessed as Stage 4. I. Record review of Wound Data Collection documents for R #1 found that: 1. the initial documentation of the wound, on 11/03/16, did not include a stage, and stated that the wound measured 5.5 x 5.7 x 0.1 cm. 2. that later documentation variously showed the wound as Stage 2 or Stage 4, or did not indicate the stage. Size of the wound showed fluctuation between 6-9 cm x 6-7 cm. Depth was not always recorded, but on 11/23/16 and 11/24/16 was recorded as 1 cm and 1.5 cm, respectively, indicating that the wound depth had increased by 10 or 15 times during the resident's stay at the facility. 3. that on 11/24/16, the wound exhibited a strong odor and purulent (pus-like) drainage, indicators of infection. J. Record review of Minimum Data Set (MDS) assessments for R #1 indicated that on 11/09/16, the wound was recorded as being unstageable, with the dimensions 6 x 8 x 1 cm. Her discharge MDS assessment, dated 11/24/16, indicated the wound was unstageable and 6 cm x 6 cm. No depth was noted. K. On 02/16/17 at 11:40 am, during interview with the facility's wound nurse, she stated that the wound was a Stage 4 pressure ulcer upon admission. She confirmed that the assessments indicating that the wound was a Stage 2 or unstageable wound did not make sense, as a Stage 4 wound is never reduced in stage as it heals. She stated that documentation of a wound should tell the story of a wound's progression, but that it didn't in this case due to variations in documentation by different nurses. She stated that she does not routinely assess every wound in the facility; that it is the responsibility of the residents' assigned nurses to do dressing changes and alert her, the resident's physician, and the resident's family if they should see a deterioration in the wound's condition. While different assigned nurses were assessing the wounds, she indicated that they should be able to know if changes to the wound were occurring, by looking back at the documentation of previous nurses' dressing changes. The wound nurse confirmed that, in this case, the resident might have benefited from a consult with a wound care specialist, but that one had not been done. L. On 02/16/17 at noon, during an interview with the Director of Nursing (DON) Services, he confirmed that the individual assigned nurses are responsible for wound care. He indicated that the assigned nurses complete the Wound RN Assessment and Wound Data Collection documents, and that the wound nurse does not routinely assess residents' wounds. He stated that it is the responsibility of the individual assigned nurses to alert the wound care nurse if a wound is deteriorating. On checking the medical record, he verified that the frequent medical visits and frequent laboratory work that the physician included in her plan for the resident did not appear to have happened. He confirmed that the physician assessment of the wound on her 11/14/17 progress note was likely copied from the History & Physical on 11/03/17, and did not indicate that the physician had viewed the wound on 11/14/17. He verified that, had regular blood tests been done, as mentioned in the physician's plan of care, the facility might have had an earlier indication of a systemic infection, and transported the resident to the hospital sooner. Findings for Resident #2: M. Record review of the Admission Record revealed R #2 was admitted to the facility on [DATE] with a Trochanteric fracture ([MEDICAL CONDITION]) and Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). N. Record review of the Braden Scale for Predicting Pressure Sore risk dated 01/31/17, indicated R #2 was at a mild risk for developing a pressure ulcer, with a score of 18. O. Record review of R #2's Care Plan dated 01/31/17, revealed The resident has potential for pressure ulcer development r/t (related to) braden scale score of 18 upon admission. Goal: Resident will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions: monitor/remind/assist to turn/reposition at least every 2 hours, inform resident/family of any new area of skin breakdown, notify nurse immediately of any new areas of skin breakdown. P. Record review of the Nursing Admission Data Collection dated 01/31/17, indicated that R #2 did not have a pressure ulcer at time of admission. Q. Record review of the Wound RN assessment dated [DATE], indicated R #2 had a pressure ulcer on his left heel that was not present on admission/re-admission. R #2's pressure ulcer was identified two days after admission. R. Record review of R #2's Wound Data Collection assessment dated [DATE], indicated an initial wound for a left heel Intact water blister measuring 2.5 cm long and 2.5 cm wide. S. On 02/16/17 at 8:54 am, during interview, the DON confirmed that R #2 developed an unstageable pressure ulcer to his left heel after admission on 01/31/17. When asked if the pressure ulcer was avoidable or unavoidable, the DON stated, When you look at all the rules it would be avoidable. The DON further verified that the care plan was not implemented, stating The nurse didn't follow policy and procedure. T. On 02/16/17 at 11:30 am, during an interview with the Wound Nurse, she stated that blisters related to pressure or friction are always considered Stage 2 pressure ulcers (partial thickness skin loss, presents as an abrasion, blister, or shallow crater). The Wound Nurse verified that R #2's pressure ulcer to his left heel was developed in the facility, likely due to lack of circulation. The Wound Nurse also stated that R #2's pressure ulcer might have developed because he had a left hip replacement and it caused him pain when he moved his leg. The Wound Nurse, stated that staff should be floating residents heels if they are immobile. U. Record review of the facility Pressure Ulcers Policy dated 01/17, indicated Based on the resident's comprehensive assessment, the location will use prevention and assessment interventions to unsure that a resident entering the location without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable.

The facility failed to ensure food in the facility kitchen was properly stored, prepared and served under sanitary conditions by: 1) having cockroaches and flies, 2) moldy food stored in direct contact with fresh food, 3) food being stored in boxes on the floor and piled up passed the appropriate storage line, 4) two wire storage racks (one in dry storage and one in walk-in fridge) were being held up with canned goods, 5) a dirty heater vent covered with black soot and dust directly over food that was uncovered and being prepared, 6) a broken thermometer on the outside of a warmer where cooked food is kept, 7) a large industrial sized steamer was plugged into an outlet with a piece of duct tape holding it together. The facility also failed to ensure dishes were being properly washed and sanitized in the facility dishwasher, as well as ensuring the correct parts per million (ppm) were being maintained per manufacture guidelines. Cutting boards used to cut poultry, were being properly washed and sanitized in order to prevent food borne illness. This deficient practice has the potnetial to affect all 84 residents as identified on the Resident Census List provided by the Director of Nursing (DON) on 05/18/15. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 05/18/15 at 4:11 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included: 1) Sanitizing Sink-all dietary staff were trained on sanitation procedures for the three compartment sink, and training for the staff on the correct PPM to use/proper temperature for the dishwasher 2) Sanitizer product was available to ensure enough sanitizer was used in three compartment sink, 3) Wire storage racks having cans used as support were emptied and repaired, 4) Undated food was removed, 5) Warmer thermometer was replaced, 6) items stored on top rack in pantry moved below 18 (eighteen) inch sprinkler clearance line from ceiling, 7) exterminator was called to spray for pests. Based on the Plan of Removal and observations, the IJ was lifted on 05/18/15 at 6:22 pm. This resulted in the scope and severity being reduced from a scope and severity of L to Level 2, Scope and severity F. Based on observation, record review, and interviews, the facility failed to ensure a safe and sanitary kitchen was utilized to prepare, cook, and store food as well as properly wash and sanitize dishes for all 84 residents as identified on the Resident Census Sheet provided by the DON on 05/18/15. The finding are: A. Review of the Sanitation Dishwashing Policy and Procedure dated February 2013 indicated Purpose: To promote good practice during dishwashing regarding prevention of food-borne illness. Policy: Dietary staff will ensure that food preparation equipment, dishes, and utensils are effectively cleaned, sanitized to destroy potential disease carrying organisms and stored in protective manner. Procedure: Post a Dish Machine Temperature Log in the dish room at the beginning of each month. Each center is to compare manufacturer's guidelines and write the appropriate temperatures and chemical concentrations on the form when needed.Record temperature and/or chemical level on Dish machine Temperature Log.If temperatures/chemicals are outside acceptable parameters, staff will notify the director of dietary services. B. On 05/18/15 at 9:42 am, during observation during initial tour of the kitchen, a cockroach was observed smashed on the floor in front of the salad/sandwich counter. C. On 05/18/15 at 9:44 am, during observation of the kitchen and interview with the Dietary Manager revealed the Chemical dishwasher, and the three compartment sink, had no temperature logs indicating the daily temperature of the water/rinse cycles, or proper sanitizing solution (ppm) and water temperatures were being recorded by staff. At this time, the three compartment sink was observed to be very low on it's sanitizing solution (Multi Quat Sanitizer). During interview the Dietary Manager confirmed that there were no temperature logs being kept for the dishwasher water/rinse cycle, or the three compartment sink. D. On 05/18/15 at 9:56 am, during observation of the kitchen walk-in refrigerator and freezer revealed the refrigerator to be very cluttered with food that was outdated. The freezer was observed to have multiple boxes of food stored near the doorway, and inside from the floor to the ceiling, making it difficult to enter and exit the freezer. E. On 05/18/15 at 9:58 am, during observation in the kitchen, the Dietary Manager did not have her hair fully contained within the hairnet. F. On 05/18/15 at 10:15 am, during observation of the kitchen Hot box (which staff refer to as a large food warmer to keep cooked food warm) and interview with the Dietary Manager revealed no temperature log from 05/01/15 to 05/22/15 was being kept or documented by staff. During interview the Dietary Manager stated It (referring to the temperature log on the Hot box) should be filled out each day. G. On 05/18/15 at 10:20 am, during observation of the kitchen revealed the floors to be wet, sticky, and dirty with food. There was a large amount of brown syrup and standing water on the floor in front of the dishwasher. H. On 05/18/15 at 12:27 pm, during observation in the Dry Storage area of the kitchen revealed not all the large canned food items were dated. There were opened boxes of hot rice cereal, powdered sugar and malt-o-meal that were not dated. There were three rotten onions stored in a clear uncovered container with good purple onions. Also noted was a large red bag of brown rice opened and not dated. I. On 05/18/15 at 12:29 pm, during observation of the Dry Storage area and the walk-in refrigerator of the kitchen and interview with the Dietary Manager, observations revealed old canned foods were being used to hold up a metal rack that contained on it. There was also an old V8 (vegetable drink) can seen holding up a shelf in the refrigerator. During observation of the refrigerator revealed items to be opened, not dated, or labeled. A bottle of Dijon mustard was opened with no date. There was a container of cottage cheese that was opened and not dated. There was also a large slab of Salmon observed being stored on a stainless steel sheet. On top of the Salmon was a large cardboard box of beef chunks. During interview, the Dietary Manager was asked what the package of brown meat was. She stated, It's salmon. It's brisket, and they (staff) didn't date it. J. On 05/18/15 at 12:35 pm, during interview when (Dining Services Personnel #1) was asked if a temperature log has ever been kept for the dishwasher or the three compartment sink, Dietary Services Personnel #1 stated, Since (name of Dietary Manager) has come on, the logs have not been used. She (Dining Services Personnel #1) then was asked about the Hot Box temperature logs if those are being kept. She stated, It should be kept, but it hasn't been. It has been broken, so they (staff) put a thermometer inside to check the temperature. When Dining Services Personnel #1 was asked about outdated food, she stated, Everything should be dated if opened. Especially in the dry storage. It (refering to food/supplies) needs to be stored 18 inches below the ceiling. Nothing is to be stored that high. K. On 05/18/15 at 12:45 pm, during observation of kitchen and interview with the Dietary Manager, when the Dietary Manager was asked, how do staff check to see if the dishwasher is running properly and at the proper temperature? She stated, We don't have a paper to check the temperature since this is a chemical dishwasher. We use these test strips every shift before running the dishes through. We have never kept any temperature logs. We rely on the computer system, and that person comes out once a month. A second observation was made of the same large amount of brown syrup on the floor and water in front of the dishwasher that was identified earlier that morning. L. On 05/18/15 at 12:46 pm, during observation of the three compartment sink and interview with Cook #1, observation revealed no temperature logs to ensure water temperature/rinse sanitizer was being documented. During interview Cook #1 stated We are supposed to check the three compartment sink every day. I'm not aware of ever having any temperature logs. We are in the process of cleaning this place up, but with our high turnover with new employees, it has been rough. If the sanitizing solution is not 150 ppm, then we are supposed to change it. M. On 05/18/15 at 12:47 pm, during observation of the kitchen Hot box warmer and interview with Cook #1, observation of the Hot box warmer revealed that the door to the Hot box warmer was being held shut with a large can of Jalapeno's sitting on the floor. During interview Cook #1 stated that the Hot box is used to keep food that has already been cooked warm. Cook #1 then stated The door doesn't close all the way, so we use this canned good as a brace to keep the door shut. When observing the outside thermometer of the Hot box warmer, the thermometer was observed to be broken. During interview Cook #1 stated, We try to keep the temperature between 175-180 degrees to keep the food warm inside, but the outside gauge is not working. It has been down for about four days now that I know of. From just looking at it, (referring to the outside thermometer) you wouldn't know the food was being kept hot unless you walk or stand near the warmer to feel the heat. N. On 05/18/15 at 12:48 pm, during observation of the Dry Storage and interview with Cook #1, observation of the Dry Storage area revealed a large bag of Chocolate instant pudding and pie filling mix on the floor underneath the shelf. During interview Cook #1 stated, I wasn't aware that was even there. It shouldn't be there on the floor. O. On 05/18/15 at 1:13 pm, during observation of the freezer revealed several packages of hot dogs and raw chicken which were sitting on top of each other. Both packages were opened and not dated. There was also a small metal container with cooked meat in it which was not dated or labeled. P. On 05/18/15 at 1:30 pm, during observation of the Dishwasher and interview with Dietary Aide #2, Dietary Aide #2 was asked how do you determine what the appropriate water/rinse temperature is when washing the dishes in the dishwasher, and how do you ensure the proper (PPM) is being maintained. Dietary Aide #2 stated, There are these two knobs on the dishwasher that tell you the temperature, but I can't tell you what the temperature should be. There was a guy that just told me what the temperature should be. It (the required temperatures) used to be posted, but I don't see it posted anymore. When Dietary Aide #2 was asked about checking the appropriate (PPM) Dietary Aide #2 was observed taking the Chlorine test strip (which is used to test the presence of Chlorine) out of the vial/container, she dipped the Chlorine purple test strip into the rinse water, then compared the Chlorine purple test strip to a black and white diagram taped to the dishwasher. At this time, the Chlorine purple test strip was placed against the black and white posted diagram (and not against the plastic vial/container). During interview Dietary Aide #2 stated, It goes off the darkness for me. When I use the test strips, if it's not dark enough, then I know it's probably at 10 ppm. (According to the Chlorine Test Strips Guideline, the appropriate ppm should be 200 ppm). Q. On 05/18/15 at 2:00 pm, during interview the Dietary Manger was asked about the dishwasher and the three compartment sink. She stated that the facility uses a chemical dishwasher. When she comes in every day, she does a walk through the kitchen with her staff. She stated I ask about the temperatures and the sanitization test strips with whoever is in the dish area. When the Dietary Manager was asked why the facility was not keeping a log of the temperatures and (PPM) used, she stated, We quit using the log when (Name of Vendor) took over. When she was asked to explain the process of running the dishwasher she stated that when checking the PPM, Staff are to compare the test strip to the color on the bottle/vial to read the appropriate PPM. If its not correct, then they would have to do it again. When the Dietary Manager was asked if she was aware of any other way the kitchen staff were checking the dishwasher ppm, she stated, No they (staff) should always be looking on the diagram on the bottle/container. I even had (name of the Vendor) do a training on the dish machine a couple of months ago. When the Dietary Manager was asked about the three compartment sink sanitizer solution, she stated, When running low, staff should be looking at the bottle of chemicals to make sure they have enough. When the Dietary Manager was asked if she was aware of the Kitchen Hot Box warmer thermometer being broken, she stated, I do know it (the outside temperature gauge) has not been working since I have been here (which was about six months), but the staff have been instructed to place a thermometer inside the box. R. The following (name of Vendor) service reports (which is a computer generated system that detects any malfunctions of the equipment and/or optimal levels of dish detergent being used and/or chemicals used to ensure proper sanitization, or desired wash water is being changed out) were reviewed from January 2015 through May 2015 which indicated the following: 1. % (percentage) Racks Washed with Desired Detergent fell below 100% on 12/02/14, 12/08/14, 12/11/14, and 12/16/14 which indicated the dishes were not being properly washed with the proper amount of dish detergent. 2. % Racks Washed with Desired Sanitizer fell below 100% on 01/04/15 (where it was reading below 80%) which meant the dishes were not being properly washed with the desired sanitizer. 3. % Racks Washed with Desired Wash Tank Change Out fell below 100% on 12/05/14, 12/10/14, 12/11/14, and on 12/21/14 which indicated the dish water wasn't being changed out. 4. % Racks Washed with Desired Detergent fell below 100% on 02/02/15 (where it was reading slightly above 60%) which indicated the dishes were not being properly washed with the proper amount of dish detergent. 5. % Racks Washed with Desired Detergent fell below 100% on 03/03/15 which indicated the dishes were not being properly washed with the proper amount of dish detergent. 6. % Racks Washed with Desired Wash Tank Change Out fell below 100% on 03/16/15 (where it was reading slightly above 80%) which indicated the dish water wasn't being changed out. 7. % Racks Washed with Desired Detergent fell below 100% on 04/15/15 and on 04/18/15 (where the reading was near 60%), 04/19/15 (where the reading was below 40%), and on 04/22/15 and 05/02/15 (where the reading was near 80%). 8. % Racks Washed with Desired Wash Tank Change Out fell below 100% on 04/18/15, 04/19/15, 04/21/15, 04/22/15, 04/23/15, 05/04/15, 05/06/15 and on 05/08/15 which indicated the dish water wasn't being changed out. S. On 05/18/15 at 2:15 pm, during interview with the Dietary Manager regarding (name of Vendor) dishwasher reports for the months of January 2015 through May 2015, she indicated that she only got a portion of the vendors report. Not the full report, and was not aware of the detailed computer generated readings. She indicated that only the front page of the report is discussed with her. The Dietary Manager stated I don't know too much about the (name of Vendor) charts. I've never seen when he (referring to name of the Vendor) has actually been out to the facility. I just get a print out that he will show me on his computer. I only get the front copy of his report. I do know the staff are supposed to change the dish washer water out periodically and his print out shows if the water was not changed in the proper amount of time. When the Dietary Manager was shown the (name of Vendor) monthly reports which indicated the times in which there was not enough dish detergent used, or the water was not changed out, the Dietary Manager stated, I really don't know what this means. I do know the heater booster in the dishwasher was changed (because it was bad). It was changed out three to four weeks ago. T. On 05/18/15 at 2:55 pm, during interview when the Dietary Manager was asked how do the staff know the process of testing the dishwasher using the appropriate test strips, the Dietary Manger stated, They (staff) are shown on the test strip vial/container where it (the correct ppm) should be reading at. We do additional training's periodically. The dishwasher machine was a issue a couple of months back. We replaced the heater booster. The Dietary Manager stated We also use the three compartment sink using soapy water, a rinse and a sanitizing solution. I do not keep any logs for that. When the Dietary Manager was asked do you know how hot the water in the three compartment sink should be, the Dietary Manager stated, At least 100 degrees. U. On 05/18/15 at 3:16 pm, during observation and interview with Cook #1, observation was made of a live cockroach on the wall over the three compartment sink. During interview, Cook #1 was asked if this had been the first time he has seen roaches. He stated, No, it was not the first time. It may be time to get the exterminator here. Cook #1 was also asked about the three compartment sink and what staff do when they are low on chemical sanitizing solution. Cook #1 stated, They would then use a bleach solution. When Cook #1 was asked where are the cutting boards (which were being used to cut raw poultry on) washed, Cook #1 stated, In the three compartment sink, but they should be running through the dishwasher. V. On 05/18/15 at 3:30 pm, during observation of the walk in refrigerator revealed there to be three to four sheet pans of raw bacon stored on stop of each other. Sitting on top of the raw bacon was a large brown box of whip topping. Sitting on top of the brown box of whip topping was a large bag of raw scrambled eggs that was thawing out. The sheets of bacon were right above the canned good that was holding up the wire racks. The can had black caked dirt on it. W. On 05/18/15 at 4:31 pm, observation of the three compartment sink revealed when the rinse water was tested with a digital thermometer, the rinse water was only reading at 89 degrees. (According to the Sanitation Pots and Pans Policy and Procedure dated February 2013 indicated that the proper rinse water temperature of the three compartment sink should be 120 degrees to rinse pots and pans). When the wash water of the three compartment sink was checked, it was reading at only 90 degrees. (According to the Sanitation Pots and Pans Policy and Procedure dated February 2013 indicated that the proper wash water will be kept at a temperature of 110 degrees to 120 degrees to melt the fat and keep the detergent in suspension). X. On 05/18/15 at 4:39 pm, during observation of the three compartment sink and interview with the Dietary Manger, the Dietary Manager was observed dipping the Hydrion QT-40 Test Strip into the full compartment of Sanitizer Solution. (According to the Solid Quat Broad Range Sanitizer Manufacture Guidelines (not dated) indicated steps 1 and 2 show testing solution should be at room temperature and tested in a separate container). At this time, the Dietary Manger did not hold the test strip in the water for the (required) ten seconds also as per manufacture guidelines. She then placed the test strip directly on the package scale container and stated, that it's (referring to the reading) not good. It's not at 400. The Dietary Manager then re-dipped the same test strip back into the same sanitizing water and again placed the same test strip on the package scale container and stated that it still wasn't good. At this time, she again, re-dipped the same test strip into the Sanitizing water (for a total of three separate times). The Dietary Manger was asked how long are you supposed to hold the test strip in the water. She stated, Usually ten seconds. When she was asked if she held it in the water for ten seconds, she stated, I didn't. When the Dietary Manger was asked if you are supposed to re-dip the same test strip into the water, she stated, No. During interview, the Dietary Manager stated there was not enough chemical solution in the three compartment sink, and that the staff should be following the instructions on the wall. Y. On 05/18/15 at 4:47 pm, during observation of the kitchen, flies were observed flying around. Z. On 05/18/15 at 4:50 pm, during observation of the walk-in refrigerator, there was a large carton of Classic Cysco Shredded Cole Slaw which was opened and spoiled. The expiration date was April 18, 2015. AA. On 05/18/15 at 4:57 pm, during observation the heater vent located directly above the steam table serving line was observed to be filled with dark, thick, black dust particles on the outer perimeter of the heater and inside. BB. On 05/18/15 at 5:00 pm, during observation in the kitchen, a large industrial steam machine was plugged into the wall. The outlet had a piece of duct tape covering the plug and outlet. CC. On 05/18/15 at 5:05 pm, during observation in the kitchen, the overhead heater vent was still covered in thick black dust and soot. At this time, food was being prepared on the serving line for dinner which was uncovered and directly below the heater vent. DD. On 05/18/15 at 5:15 pm, during observation of the dishwasher and interview with Dietary Aide #3, Dietary Aide #3 stated The water temperature should be between 135-150 degrees for the rinse. The ppm is supposed to be between 100 ppm. That is what I use, going by these test strips. When Dietary Aide #3 was observed checking the ppm for the dishwasher, he was observed taking the purple test strip out of the vial/container, dipping the purple test strip into the rinse water, then comparing the purple test strip to a black and white diagram taped to the dishwasher. At this time, there was no way to determine what the appropriate ppm of the dishwasher was due to it being compared to the black and white diagram instead of the required colored test strip vial/container. During interview Dietary Aide #3 stated, When I check the test strips, I put it on this (referring to the black and white diagram). This is what I go by. I can just tell it's ok. EE. On 05/19/15 at 1:45 pm, during interview with the Administrator regarding the temperature logs and monthly dishwasher service reports from the (name of the vendor), the Administrator stated I've only seen the front of the report from (name of vendor). I haven't seen these other reports (referring to the vendors detailed reports of sanitizing solution, water change out, or amount of dish detergent being used). When reviewing the (name of vendor) monthly reports indicating that dishes were not being washed with the proper amount of dish detergent, the Administrator was asked how would you know if there was an issue. The Administrator stated, It would be my expectation for the staff to be documenting when there is a problem and when they are properly recording the temperatures. FF. On 05/19/15 at 2:55 pm, during interview the Administrator stated You are correct, it is my understanding that the staff were documenting the temperatures of the dishwasher and the three compartment sink on these sheets, (referring to a Dietary Chemical Sanitizing Log and Dish Machine Temperature Log-Chemical Sanitizing) and this has not been done. We will be doing inservicing on this. The Administrator then stated, With the dishwasher, there is the (name of vendor) computer gadget located on the wall that will alert the staff (by an exclamation point) if there is something wrong with the dishwasher. It is my understanding that the staff know what the problem is, because it will alert the staff on what the problem is. They should know how to address it. For example, if the there is something wrong with the dish washer temperature. GG. On 05/20/15 at 10:15 am, during observation of the kitchen there were crumbs of food on the floor, and standing water in front of the dishwasher, and in front of the three compartment sink. The heater vent located above the steam table serving line was again observed to be covered with thick, black dust and soot. HH. On 05/20/15 at 10:19 am, during interview the Dietary Manager stated that she was not aware of the heater vents above the steam table being dusty. Regarding the duct tape on the electrical outlet the Dietary Manager stated, I don't know why tape was over it. II. On 05/21/15 at 7:19 am, during observation of the steam table where food was being prepped under the heater vent, and interview with the Environmental Services Director, the Environmental Services Director was asked if he had received any work orders regarding maintenance of the kitchen. He stated, I would expect that the Dietary Manager would be telling us, but I have received no work orders. When the Environmental Services Director was shown the overhead heater vent (which was again covered in thick black dust and dirt) he stated, With the vents, they are cleaned as needed. It would be up to the kitchen staff to be telling us things like this so we in maintenance would know. The Environmental Services Director stated, These vents need a proper cleaning and this should have been caught by the Dietary Director through their own walk through. I was not made aware of any issues in here regarding this vent or the pooling of water in front of the dishwasher. The vent is very dirty and needs to be cleaned. I can see food is being prepped here and it would be something I would expect to be made aware of and I was not. At this time sausage, bacon, french toast, pancakes, scrambled eggs, plates and bananas were seen uncovered and being prepped for residents breakfast. JJ. On 05/21/15 at 8:05 am, during interview regarding the (name of vendor) monthly service inspection reports for the dishwasher, (Name of vendor Representative) stated I come out once a month. We would like it to be 100% but there is always a situation where staff are forgetting to put the dish detergent in the dispensers for the dishwasher. Regarding my reports, each dot you see on the grid where it drops below 100%, you will see the % (percentage) that shows that there is a day that the dish detergent in the dishwasher was not put into the dispenser. It is supposed to alarm the staff in which there will be a very loud beep and the computer system will show them (the staff) that they need to refill the dishwasher detergent. In fact, it will even show them (the staff) how to change it out. They (the staff) are supposed to be able to identify who was working that day and be able to train their specific staff then document what corrective action was done. The (name of vendor Representative) then stated Regarding the desired wash tank change out, that means that we even have it posted above the dishwasher where they (staff) are supposed to change out the water every two hours. If they (staff) don't change the water out, then it will alarm the staff that they didn't change the water as they were supposed to. It needs to be changed because if they don't change out the water in the dishwasher, then you will have dirty water. That would mean that the dishes are not being properly cleaned. If they are running low on the sanitizing solution of the three compartment sink, they (staff) should have the product in house. Regarding the correct parts per million, the standard I teach is anytime you put a plate in the dishwasher and run it through the dishwasher rack and pull it out, you are required to match the test strips up with the colored indicator listed on the vial. That is the standard. (Name of vendor Representative) then stated On the monthly service reports when you see a dip in the system, that will alert the staff there is something wrong. For example, my report for 05/13/15 where you see the % (percentage) of racks washed at desired rinse temp, when you see a dip that falls below 100%, that would mean the rinse temperature of the dishwasher was not at the proper temperature. For the percent racks washed with desired detergent, he stated you will see a lot of dips that fall below 100%. One for example that even falls below 40% which meant that the dishwasher detergent was not put into the dispenser as it should have been. Again, whenever you have a low desired dish detergent reading, that would indicate that dishes are not getting properly cleaned. KK. On 05/22/15 at 8:00 am, during observation of the kitchen, the duct tape was still covering the outlet for the large industrial steam machine. LL. On 05/22/15 at 8:06 am, observation of the refrigerator revealed there to be seven cans of sweetened condensed milk which were not dated. Also noted was large damp cardboard box that contained several rotten and moldy bell peppers stored with good bell peppers. MM. On 05/22/15 at 8:15 am, during interview when the Dietary Manager was asked when was the last time she had been in the refrigerator. She stated I hadn't been down here today. She indicated that she was not aware of the moldy bell peppers, the cucumbers being soft and squishy, or another box of moldy bell peppers, and lemons that were bad. When the cucumber box was checked by the Dietary Manager, the box was dated 05/18 and had soft squishy cucumbers in it. NN. On 05/22/15 at 8:18 am, during observation of the refrigerator there was a bag with portobello mushrooms in it that had no date on it. OO. On 05/22/15 at 8:35 am, during observation of the kitchen a live cockroach was observed above the three compartment sink. PP. On 05/22/15 at 8:38 am, during interview when Dietary Aide #1 was asked if food is supposed to be covered, she stated, I keep it covered until I' am ready to start serving. When Dietary Aide #1 was asked if she had ever noticed the vent above the serving table with dust on it, she stated, No. QQ. On 05/22/15 at 9:46 am, during interview the Dietary Manager confirmed there was an issue with cockroaches in the kitchen stating, Sometimes we see them here or there in the kitchen. It was hard to say. I don't see them all the time. You may see one today and then I won't see them for a week. RR. On 05/22/15 at 9:51 am, during interview regarding hair nets the Dietary Manager stated, Everyone should wear a hair net or hat. When she was asked if staff could have bangs sticking out, she stated, No hair should be fully covered.Staff shouldn't be coming in the door to the kitchen without a hair net. SS. On 05/22/15 at 10:14 am, during interview the Maintenance Director was asked if he knew about the duct tape on the electrical outlet. He stated that he didn't know anything about this.and This was not appropriate. TT. On 05/22/15 at 11:59 am, during observation revealed a live cockroach on the light box above the three compartment sink. UU. On 05/22/15 at 5:00 pm, during interview with the Administrator regarding the kitchen, the Administrator stated, We have talked about some issues in the kitchen about eight weeks ago. I did a walk though of all the dining and kitchen areas and pointed out different areas to the Dietary Manager. I thought there was improvement, and I emphasized the importance of now maintaining that. With the dry storage room for example, my recommendation was to have someone come in to do organization to make sure empty boxes are taken down. I know we also talked about dating all the food in the storage area. I do think there were some processes in place that weren't working. It was my expectation that all of this would have been done. VV. Record review of the Dress Code Policy and Procedure dated February 2013 indicated Hairnets (or hair and beard restraints) will be in place while in the food preparation or food st

Based on record review and interview, the facility failed to provide the necessary care and services to monitor and treat the resident's post surgical pain, for one (#220) of one sampled residents (#220) reporting pain. This deficient practice resulted in severe unrelieved pain for this resident, with a likely decline in physical well being and quality of life. The findings are: A. A review of the Nursing Admit Data Collection tool dated 06/10/14, indicated the resident was admitted from a hospital following bilateral toe amputations. B. A review of the resident's medication orders found an order for [REDACTED]. C. A review of the MAR (medication administration record) dated 06/10-27/14, indicated that the resident received between one and four doses of [MEDICATION NAME]-[MEDICATION NAME] every day. D. A review of the TAR (treatment administration record), indicated that three pain assessments, dated June 17, 19 and 26, 2014 noted pain was rated at four out of five. E. A review of Progress Notes for Resident #220 found that: 1. On 06/25/14 the resident rated his right LE (Lower Extremity) pain as 7 out of 10. 2. On 06/26/14 at 10:18 am, the resident rated his right foot pain as 8 out of 10. 3. On 06/26/14 at 5:45 pm, the resident reported 9 out of 10 pain in his feet. 4. On 06/28/14 the resident rated his bilateral foot pain as 7 out of 10. 5. On 06/29/14 at 1:53 am, the resident rated his bilateral foot pain as 7 out of 10. 6. On 06/29/14 at 1:49 pm, the resident c/o of pain to bilateral LE. 7. On 06/30/14 the resident reported bilateral foot pain at 7 out of 10. F. A review of the resident's Care Plan dated 06/10/14, revealed that "Resident has acute/chronic pain/discomfort R/T S/P bilateral partial foot amputation. Resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date." Interventions include: "Notify health care provider if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain." G. On 06/25/14 at 4:02 pm, during an interview with Resident #220 he was asked about the frequency of his pain, he stated "It goes on all day and through the night. It gets worse at night time." He was asked to describe the pain and he stated "It's a throbbing pain in both feet or on my heel part for both. It's a constant pain." He was asked about pain medication he was receiving and he stated "Every six hours I get pain medication. It doesn't help at all." The resident denied that nursing staff inquire about the effectiveness of his pain medication after administration. He was asked if he informs nursing staff that the pain medication is not effective and he stated he tells them "'I'm still in pain.' They say that's the doctors orders and they say they can't do anything about it." He denied that other methods of pain control have been attempted and reported "Sometimes the pain keeps me awake." H. A review of the Pain Assessment tool for Resident #220, dated 06/10/14, revealed that the resident is at a high risk for pain. Sections for effective non-pharmacological interventions and recommended pain management plan were found to be blank. I. On 06/27/14 at 5:02 pm, During an interview with Licensed Practical Nurse (LPN) #1 he was asked how often he assesses residents for pain and he stated "Twice in the shift, in the beginning and the end. When you give a PRN and you click on the follow up to say it's effective." Regarding this residents pain he stated "He has pain in his legs, he had his toes amputated, usually about a 7 or so, so he gets a PRN...Before he gets his pain meds is gets pretty bad." J. During an interview with the Director of Nursing on 06/30/2014 at 9:05 am, she was asked how often pain levels are assessed. She stated, "Once per 12 hour shift and PRN. If they medicate the resident, it (the computer program) will trigger and tell them to follow up on the effectiveness of the medication." She stated that pain levels are documented in the progress notes. She was asked whether she felt a [MEDICATION NAME] PRN ordered for osteo-arthritis was sufficiently aggressive pain management for a resident who was post-amputations. She stated, "Honestly that would be at the doctor's discretion. I know that the doctors review everything closely, they reach out to their outside partners." K. On 06/30/14 at 9:43 am, during an interview with the Acting Medical Director he was asked about pain management for Resident #220. He stated "All I know is what I've been told. I've never actually seen him. (The Medical Director) has been away for a week or 10 days. She saw him on the 16th. Looks like he has [MEDICATION NAME]. I've never had anyone tell me that he's having breakthrough pain or signs of distress." When asked whether he felt that a long-acting [MEDICATION NAME] would have been indicated, he stated, "If he were asking for it every 6 hours round the clock, I'd probably order something longer acting. I am extremely dependent on (nursing staff) letting me know. I'm not here every day."

Based on observation, record review and interview the facility failed to provide the necessary care and services to ensure that 2 residents (R #3 and 4) of 4 sampled residents (R #s 3, 4, 6 and 8) identified as "fall risk" were free from injuries. This failed practice likely resulted in a fractured right femur for R #3 and a laceration to the back of the head and a fractured cervical spine for R #4. The findings are: A. Record review and interview for R #3 revealed the following: 1. Daily Skilled Notes indicated: a. On 08/24/12 at 3:36 pm, "... CNA (Certified Nursing Assistant) was pushing (pushing in W/C) Pt. (patient) in hallway with feet raised. Feet dropped to ground causing 95 degree flexion (bent) to bilateral (both) knees..." b. On 08/25/12 at 6:00 pm, "Pt complains of (C/O) right leg hurting. Unable to bear rubbing or pushing up against foot..." c. On 08/26/12 at 4:00 pm, "... C/O pain in morning... (Family Member #1) present and concerned about pain to right leg..." d. On 08/27/12 at 7:00 pm to 7:00 am shift, "...Pt. C/O pain..." e. On 08/28/12 at 6:30 am, "Back Charting for 08/27/12 at 7:00 am - 7:00 pm shift, "Patient alert and oriented... C/O pain 8/10 (pain level at 8 on a scale of 1 to 10) when touched or moved to bilateral lower extremities... Right knee significantly swollen... Patient is unable to bear weight... Mobility assessment changed to total lift... Family informed of changes in POC (plan of care); (Family Member #8) spoken with at length; family very upset with decline of patient's condition..." f. On 08/28/12 at 1:45 pm, "... C/O pain... Patient complaining of pain in right knee and insisted to know what's wrong. Pt. sent to (Name of Hospital) emergency room for evaluation of right knee secondary to [MEDICAL CONDITION] and pain." 2. Physicians Progress Notes indicated: a. On 08/27/12, "Crying out to slightest touch... expresses history of hitting her knee or falling out of wheelchair or running into someone... I am able to detect pain only at right knee where there is swelling..." b. On 08/28/12, "Transfer patient to (Name of hospital) emergency room downtown for evaluation of right knee pain secondary to pain/[MEDICAL CONDITION]." 3. Resident Transfer Sheet dated 08/28/12, indicated, "Transfer to (Name of hospital) emergency room ; Complains of pain in right knee, unable to bear weight." 4. (Name of ambulance service) report dated 08/28/12, indicated that the resident was transferred to emergency room at 1:17 pm for right knee pain over last two days. "... Patient does have some bruising to the back side of her knee and swelling from the knee to her ankle. Patient appears to be in pain when the leg/knee is touched or moved..." 5. (Name of hospital) History and Physical dated 08/28/12, indicated, "This is an [AGE] year old woman here for presentation in the emergency department with a few days history of right knee pain and swelling... AP (anterior/posterior) and lateral (side) views of the right femur demonstrates supracondylar (above the knee) [MEDICAL CONDITION] (farthest from center of the body) femur..." 6. (Name of hospital) X-Ray Report dated 08/28/12, indicated, "Impaction fracture (fracture were bone is slammed into bone) of the distal femur just proximal (near) to the prosthesis (artificial knee joint)..." 7. On 01/15/13 at 11:15 am, the Director of Nursing stated, "... The Resident kept complaining about pain in her right knee... On the 28 th (08/28/12), we sent her to ER (emergency room ) for further evaluation of her right knee... she (Family Member #8) told the nurse that she (R #3) had a fracture in her pelvis or femur. The incident where her legs went under the wheelchair when she was being taken for a shower was witnessed." 8. On 01/15/13 at 12:00 pm, Staff Member #6, the Physical Therapy Assistant stated, "She had no motivation to follow through. She couldn't walk... Standing at the parallel bar, she always favored her right leg...We tried to get her on the bar and she screamed. This was unusual for her. I reported it to nursing." 9. On 01/18/13 at 9:45 am, Staff Member #7, CNA, stated, "I was taking her to the shower... there were no foot rest on the wheelchair. When I was pushing her she put her feet to the floor. I stopped and lifted the back of the wheelchair and pulled her backward to get her legs out. I immediately reported it to the nurse. The only pain she ever complained of was pain in both her knees." 10. On 01/16/13 at 10:15 am, Family Member #8, stated, "... When I went to see her (R #3) on 08/24/12 at 5:30 pm, her legs were hurting. I asked (name of nurse) what happened. I thought she had just worked hard in therapy... On the 25 th. I requested the doctor to check her... I moved her leg to sit on the bed and she screamed. She told me about a crash... The doctor came in and told one of the nurses that something was wrong... My sister took her to the hospital and she (R #3) had a fractured femur. My sister said they took x-rays in the ER. The knees were bruised; she had a fractured femur..." 11. On 01/16/13 at 2:30 pm, the Administrator stated, "I spoke with the (Family Member #8). She reported that (R #3) had a fracture. When we were notified, we immediately talked to (Name of Staff Member #7). He said that he was pushing her (R #3) in the W/C when she put her feet down..." B. Record review and interviews for R #4 revealed the following: 1. History and Physical indicated [DIAGNOSES REDACTED]. 2. Falls Data Collection Tool dated 11/07/12 and 11/12/12 indicated that the resident was a high fall risk. 3. Progress Notes indicated: a. On 11/12/12, "Found sitting on floor by side of bed. Neck bent to chest." b. On 11/13/12, "Found on floor next to bed early 11/12/12. Today complains of neck pain." c. On 11/14/12, " C/O (complaint of) neck pain. [MEDICATION NAME] to neck." d. On 11/20/12, "Frail elderly - C/O some neck pain." e. On 11/21/12, "Had CT (Computerized Tomography) of cervical spine this am (morning). CT showed C2 (second vertebrae in the neck) fracture. Transfer to hospital." f. On 11/21/12, "Radiologist did call (Name of doctor) and reported to her a discovered non displaced C2 fracture. Received orders to transport to (Name of hospital)... ." g. On 11/26/12, "(Name of resident) returned from hospital on [DATE] with special collar to neck. C2 Fracture. High risk for falls." 4. Care Plans indicated: a. On 11/12/12, "Alteration in balance/mobility related to Dementia and [MEDICATION NAME] Degeneration. Fall with injury. Laceration to posterior (back side) head. Found lying on floor with chin resting on chest and back of head against bedrail." b. On 11/22/12, "Alteration in comfort R/T (related to) neck fracture. Wear neck brace continuously." 5. Daily Skilled Notes Indicated: a. On 11/12/12, " Rsd (resident) found on floor at approximately 2455 (12:55 am), wound to R (right) posterior head... ." b. On 11/12/12, at 0900 (9:00 am) C/O neck pain after found on floor graveyard shift." c. On 11/14/12, at 10:00 am, "Review of falls committee incident that occurred 11/12/12 - When CNA (Certified Nursing Assistant) responded to call light & found resident laying on floor with her chin resting on her chest & back of her head against bedrail. Sustained laceration to back of head... C/O neck pain that was not resolved with pain meds (medication)... ." d. On 11/22/12, " Came back from (Name of hospital) has a J collar (neck brace) for C2 fracture." 6. Interdisciplinary Rehab Rounds indicated: a. On 11/19/12, "Pt (patient continues to C/O neck pain when OOB (out of bed)." b. On 11/20/12, "Increased C/O neck... ." 7. Radiology Report of CT without contrast dated 11/21/12 indicated "There is a [MEDICATION NAME] horizontal fracture through the body of the C2 vertebra with displacement of the odontoid anteriorly (bony tooth like projection of C2 vertebra) approximately 3 cm. There is anterior tilt of the odontoid. There is a second fracture through the left lateral mass (side of thick bony area) of C2." 8. Neurosurgery Consult Note dated 11/21/12 indicated, ""According to the son, the patient was found sitting by the bed about 1 week ago. At that time the patient complained of some neck pain and the son requested to have a x-ray of her cervical spine. Her x-ray was reviewed by a radiologist who recommended a CT scan of her cervical spine...she was found to have a C2 vertebrals vertebral body fracture... ." 9. On 01/15/13 at 3:45 pm, Staff #3 (Licensed Practical Nurse - LPN) stated, "When I reported to duty at 7:00 am, I received report that she had fallen. I assessed her and she complained of severe neck pain. I notified the doctor to get an ordered for a C spine x-ray. It was negative but she continued to have pain and decreased range of motion." 10. On 01/15/13 at 4:00 pm, Staff #4 (Certified Nursing Assistant - CNA) stated, "I came in one day and she had fallen. She complained of a lot of neck pain. Later I found out she had a neck fracture." 11. On 01/16/13 at 3:50 pm, Staff #1 (Registered Nurse - RN) stated, "The CNA had just put her to bed a few minutes before this happened and a few minutes we heard a loud noise. The roommate called us and she was on the floor lying flat on her back with her chin to her chest and the back of her head against the foot of the bed. Upon assessment, she had a laceration to the back of her head and complained of neck pain. The incident was unwitnessed." 12. On 01/16/13 at 4:10 pm, Staff #5 CNA stated, "I had just left the room about five minutes before this happened. The light came on and I went back in and found her on the floor with her head against the back of the metal railing. I got the nurse (Staff #1) and she assessed her. There was a cut on the back of her head and complained of pain in her head and neck." 13. On 01/18/13 at 9:30 am, the DON agreed that the resident had sustained a laceration and it was later discovered that she had a fractured C-spine.

Based on record review and interview the facility failed to provide medical justification for the use of an indwelling urinary catheter for one (# 56) of 4 (#'s 35, 56, 70, and 101) residents reviewed. This deficient practice likely caused the resident to develop urinary tract infections [MEDICAL CONDITION] and does not prevent a decline or promote improvement in bladder function. The findings are: A. Resident #56's medical record review revealed the following: 1. physician's orders [REDACTED]." There was no medical diagnosis/justification for an indwelling urinary catheter documented on the physician's orders [REDACTED]. 2. Bladder Assessments, dated 07/05/11 and 11/23/11, indicated "Recommended for a toileting Program." 3. Interdisciplinary Assessments and Summary Reviews: Entry dated 10/13/11, indicated the resident was treated for [REDACTED]." 4. physician's orders [REDACTED]. 5. physician's orders [REDACTED]. 6. Laboratory results indicated: a. Urine sample collected on 08/29/11 at 7:20 pm, was positive for a urinary infection. b. Urine sample collected on 01/09/12 at 3:35 pm, was positive for a urinary infection. B. The facility's Catheterization policy, revised 01/09, indicated "A resident will not be catheterized unless the clinical condition demonstrates that catheterization is necessary and will not be used solely for nurse/physician convenience." C. On 07/10/12 at 2:35 pm, during interview, the second floor front hall Registered Nurse/Case Manager (RN/CM) stated, "The resident has a catheter (indwelling urine catheter) due to incontinence (inability to control bladder release) of urine. Her Power of Attorney, the daughter, wanted her to have it (the catheter) and the physician agreed to write an order for [REDACTED]." D. On 07/12/12 at 11:40 am, during interview. the Physician's Assistant reviewed Resident #56's medical record then stated, "I'm not seeing any medical necessity or indication for an indwelling urinary catheter. I'm not sure why she has this catheter." E. On 07/12/12 at 1:45 pm, during interview, the second floor front hall RN/CM stated, "I asked (physician's name) why (Resident # 56) has a catheter. He told me it was for gross urinary incontinence.'' F. On 07/12/12 at 2:20 pm, during interview with the DON (Director of Nursing), she stated, "Gross urinary incontinence is not a medical justification for a Foley catheter. The catheter is being continued at the resident's daughter's request."