Every finding on record at Marysville Post-Acute

Based on interview and record review the facility failed to follow their wound prevention, maintenance, and wound care policies and procedures (P&P) for three out of three sampled residents (Residents 1, 2, and 3) when: 1A. Resident 1 was provided wound care without a physician's order; and 1B. Skin assessments did not consistently reflect the condition of the skin or wound, and the discharge skin assessment was not completed; and 1C. A change of condition was not documented; and 2. Residents 1, 2, and 3 were not provided with repositioning every two hours. These failures contributed to Resident 1's wound development and placed residents at an increased risk for a delay in wound healing, decline in health status, and could negatively impact their psychosocial well-being. Findings: 1A. A review of the facility's P&P titled, Wound Care, indicated, a physician's order was required prior to wound care being provided. A review of the admission Record, dated 6/1/25, indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses of quadriplegia C5-C7 incomplete (messages from the brain to the nerves that made arms and legs move did not always work, which caused a total loss of arm and leg movement at times. C5-C7 was the cervical spinal area in the neck), type 2 diabetes mellitus with diabetic neuropathy (inability to control blood sugar that caused nerve damage), muscle weakness, and anemia (decreased amount of red blood cells resulting in a lack of oxygen being carried to the body's tissues.) Resident 1 was his own RP (responsible party, made own decisions). During a concurrent interview and record review on 6/20/25 at 3:00 pm, with Registered Nurse (RN), Resident 1's Nursing Admission/readmission Evaluation/Assessment (admission assessment), dated 6/1/25 was reviewed. RN confirmed performing the admission assessment and stated, the admission assessment indicated, there was no open areas to Resident 1's skin. RN reviewed a progress note, titled Alert Note, dated 6/1/25, and confirmed, the Alert Note, indicated, RN changed dressing (a material that was applied over skin or a wound) on Resident 1's coccyx (also known as the tailbone, located between the buttocks). RN stated, Resident 1 came to the facility with a foam dressing (a padded dressing) on, I applied a new foam dressing for an intervention of safety and skin integrity. There is no order needed. During a concurrent interview and record review on 6/20/25 at 3:27 pm, with Director of Nursing (DON), Resident 1's Physician's orders were reviewed. DON confirmed, a Physician's order was required for nursing to perform dressing changed and confirmed there was no physician order for a dressing change present on 6/1/25. 1B. A review of the facility's (P&P) titled, Prevention of Pressure Injuries, revised 4/1/20, indicated, facility staff would perform skin assessments upon admission, daily, and at discharge. The P&P indicated, Identify any signs of developing pressure injuries (i.e. non-blanchable [discolored skin that did not turn white when pressed] erythema (reddening of the skin]). A review of the P&P titled, Pressure Ulcer Management, revised 7/1/23, indicated, the assessment of a pressure sore included a description of the wound, the stage classification [staging a wound was how the wound was classified, based on the appearance, size, and weather it was an open or closed wound], and appearance of drainage or necrotic [dead] tissue. A review of the Job Description: Treatment Nurse [TN] RN/LPN [Registered Nurse/Licensed Nurse], dated 10/1/16, indicated the TN was responsible for documenting informative and descriptive nursing notes (progress notes), as well as the resident's response to the care. A review of the Job Description: Registered Nurse/RN, dated 2/1/24, indicated the RN was responsible for documenting informative and descriptive nursing notes (progress notes), as well as the resident's response to the care. During a concurrent interview and record review on 6/20/25 at 3:00 pm, with RN, Resident 1's admission assessment, dated 6/1/25 was reviewed. RN confirmed, the section titled, L. Skin Evaluation, indicated, Resident 1 had excoriation (red, raw, or superficial scratches to the skin) near the peri area (skin that surrounded your private parts), discoloration between both buttocks (butt cheeks), and the right buttock had an old pressure scar (thick skin that remained after an open wound had closed) and the skin was discolored. RN confirmed, the section of the admission assessment labeled 1c. Resident has wounds or skin integrity concerns present on admission, was marked as no. RN confirmed, selecting no was inaccurate, and RN should have selected yes due to skin integrity concerns. RN reviewed a progress note titled, Alert Note, dated 6/1/25 and confirmed, the Alert Note, contained additional skin assessment documentation that included Resident 1 arriving to the facility with a coccyx dressing in place and that RN had replaced the old dressing with a new one. RN confirmed, the assessment did not include a description of the coccyx area. During a concurrent interview and record review on 6/25/25 at 10:16 am, with Unit Manager/Licensed Nurse (UN/LN), Resident 1's progress note, titled, Nurses Note, dated 6/2/25 and time stamped at 9:49 am, was reviewed. UM/LN confirmed that the Nurses Note indicated, UN/LN assessed a 3.1 centimeter (cm) in length, opened area to Resident 1's skin, next to the coccyx area on the right buttock that contained slough (dead tissue). UN/LN confirmed the open wound was not staged and stated, if there was a RN here, I would have asked the RN to assess and stage the wound. I don't recall if there was an RN here or not. UM/LN confirmed, when the treatment nurse was not working, UM/LN would perform wound care treatments and stated, I can't stage [wounds], the RN has to. (Resident 1's assigned nurse on 6/2/25 was a RN) A review of the Nursing-Weekly Summary, dated 6/2/25 and time stamped at 10:01 am, indicated, Wound Certified Registered Nurse (WCRN) performed an assessment on Resident 1. The skin assessment section indicated that Resident 1 had excoriation near the peri area, discoloration between both buttocks, and the right buttock had an old pressure scar and the skin was discolored. The documentation was identically written to RN's admission skin assessment. The skin assessment section indicated that there were no new skin issues. The Nursing-Weekly Summary included an area for additional notes. The additional note section indicated that Resident 1 declined having a skin assessment performed. A review of the Nursing-Daily Skilled Charting Form, dated 6/2/25 and time stamped 10:12 am, indicated WCRN documented a second skin assessment, indicating Resident 1 had excoriation near the peri area, discoloration between both buttocks, and the right buttock had an old pressure scar and the skin was discolored. The documentation was identically written to RN's admission skin assessment and the Nursing-Weekly Summary (what WCRN had documented at 10:01 am). There was no additional note that indicated Resident 1 had declined a skin assessment. A review of the Nursing-Daily Skilled Charting Form, dated 6/3/25, indicated Resident 1 did not have any wounds, the skin color was normal, and interventions were in place to aid in wound healing. A review of the Nursing-Daily Skilled Charting Form, dated 6/4/25, indicated, Resident 1 did not have any wounds, the skin color was normal, interventions were in place to aide in wound healing, and teaching was provided regarding treatment for a linear (in the shape of a straight line) open area to the coccyx. A review of the Skin & Wound Evaluation, dated 6/4/25, indicated that TN B had performed a wound assessment. TN B documented her wound assessment as an unstageable deep tissue injury (DTI, deep tissue injuries are not open wounds) to the right gluteus (the big muscle inside the butt cheek), and it was present upon admission. The Skin & Wound Evaluation, indicated, Resident 1's wound measured 7.6 cm in length and 4.2 cm in width. The wound bed contained slough. TN B did not indicate on the Skin & Wound Evaluation that Resident 1's wound was on the coccyx or had increased in size. A review of the Initial Wound Evaluation and Management Summary, dated 6/5/25, indicated that the wound doctor performed a surgical debridement (removal of dead tissue) of the right coccyx and removed dead tissue and muscle. The Initial Wound Evaluation and Management Summary, indicated a new diagnosis of stage 4 pressure wound of the right coccyx, full thickness (extended beyond the first two layers of skin and extended into muscle, fat, or bones and was considered a severe wound). The Initial Wound Evaluation and Management Summary, indicated the wound doctor's plan for treatment was to apply a primary dressing (applied directly onto the wound) calcium alginate with silver (a sterile antimicrobial dressing that absorbed drainage) once a day and as needed if the dressing became soiled or damaged. The Initial Wound Evaluation and Management Summary, indicated, the wound doctor's plan for treatment was to apply gauze island dressing (a padded dressing) as a secondary dressing (applied over the primary dressing). A review of the Physician's Orders, dated 6/5/25, indicated, Treatment: unstageable DTI to right gluteus extending to coccyx: Cleanse with normal saline [sterile, salty water], pat dry and apply zinc oxide [medicated cream to promote wound healing] to peri wound [intact skin that surrounded the wound], silver alginate to wound bed and cover with foam dressing. The directions were to change the dressing every day and as needed. A review of the Discharge Summary, dated 6/5/25, signed and dated 6/6/25 by WCRN, indicated, Resident 1 was being discharged home (per Resident 1's request). The section titled, Skin Condition Upon Discharge, indicated Resident 1 had a deep tissue injury to the right gluteus extending to the coccyx and Resident 1 was to monitor for .increase in size, shape, skin breakdown, and/or signs and symptoms of infection until resolved. There was no review or assessment of the stage 4 pressure ulcer to the coccyx or information regarding the treatment plan that the wound doctor initiated. During a concurrent interview and record review on 6/25/25, at 10:37 am, with Director of Nursing (DON), admission assessment, dated 6/1/25, progress note, titled, Nurses Note, dated 6/2/25 and time stamped at 9:49 am, Nursing-Weekly Summary, dated 6/2/25 and time stamped at 10:01 am, Nursing-Daily Skilled Charting Form, dated 6/2/25 and time stamped 10:12 am, Nursing-Daily Skilled Charting Form, dated 6/3/25, Nursing-Daily Skilled Charting Form, dated 6/3/25, Skin & Wound Evaluation, dated 6/4/25, Initial Wound Evaluation and Management Summary, dated 6/5/25, and Discharge Summary, dated 6/5/25 was reviewed. DON confirmed wound care assessments and documentation did not consistently reflect the condition of the skin, the location of the wound, or appearance of the wound, and confirmed the discharge skin assessment was not completed. DON confirmed, none of the skin assessments included the stage of the wound and stated, the nurse assessing the wound is responsible for staging it. During the interview, WCRN joined and confirmed being Resident 1's assigned nurse on 6/2/25 and stated, I don't remember if I was notified that Resident 1's wound had changed. WCRN confirmed, both skin assessments that WCRN had documented on 6/2/25 were identically typed when compared to RN's admission skin assessment on 6/1/25, appeared to be copied and pasted, and was not able to recall if WCRN documented or copied and pasted the assessment. WCRN confirmed that there were two separate assessments documented on 6/2/25, one daily and one weekly. WCRN confirmed both documents contained a skin assessment and stated, I didn't assess his skin, he refused. 1C. A review of the facility's P&P titled, Prevention of Pressure Injuries, revised 4/1/25, indicated, facility staff would Evaluate, report, and document potential changes in the skin. A review of Resident 1's admission MDS, dated [DATE], indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was performed. Resident 1 scored 15 out of 15, which indicated intact memory. The admission MDS indicated Resident 1 required substantial assistance to roll in bed from left to right and both arms and legs were impaired (limited ability to use). During a concurrent interview and record review on 6/20/25 at 3:00 pm, with RN, Resident 1's admission assessment, dated 6/1/25 was reviewed. RN confirmed, the section titled, L. Skin Evaluation (the assessment of the skin), indicated Resident 1 did not have any open wounds upon admission. During a concurrent interview and record review on 6/25/25 at 10:16 am, with UN/LN, Resident 1's admission assessment, dated 6/1/25 was reviewed. UN/LN confirmed, the admission assessment did not indicate Resident 1 had an open wound. Resident 1's progress note, titled, Nurses Note, dated 6/2/25, was reviewed. UM/LN confirmed that the Nurses Note indicated, UN/LN assessed a 3.1 cm in length, opened area to Resident 1's skin, next to the coccyx area on the right buttock that contained slough. UN/LN confirmed, prior to performing a skin assessment, UN/LN should review the previous skin assessment and could not recall if she had. UN/LN stated, it would be considered a change of condition and confirmed, the required change of condition documentation was not completed. During an interview on 6/25/25 at 10:37 am, with DON, Resident 1's admission assessment and progress note, titled, Nurses Note, dated 6/2/25 was reviewed. DON confirmed, the assessments indicated a change of condition and there was no change of condition present in the chart. 2. A review of the facility's P&P titled, Pressure Ulcer Management, revised 7/1/23, indicated, CNAs will attestate [prove, usually through documentation] for their shift that their residents were repositioned at lease every two hours. During a concurrent interview and record review on 6/20/25, with Certified Nurse Assistant (CNA) C, Resident 1's task schedule (POC, the area of the electronic medical record where the CNAs documented care provided to residents), dated 6/1/25 through 6/6/25 was reviewed. CNA C confirmed the POC indicated Resident 1 was to be repositioned every shift, not every two hours. CNA C stated, residents are repositioned every two hours and we only chart once a day. Director of Staff Development (DSD) joined the interview and was asked how the CNAs documented that residents were provided with repositioning every two hours. DSD stated, if your resident required repositioning every two hours, then it should be documented every two hours. DSD confirmed, residents with wounds required to be repositioned every two hours and the POC indicated, Resident 1 was repositioned once a shift. A review of the admission Record, dated 4/29/25, indicated that Resident 2 was admitted to the facility on [DATE] with the diagnoses of severe protein-calorie malnutrition (unintended weight loss caused by disease processes or inadequate food consumption), generalized muscle weakness, and difficulty in walking. A review of Resident 2's admission/ 5-day MDS assessment, dated 5/5/25 indicated, a BIMS score of 12 out of 15 (moderately impaired) and required partial/moderate assistance with rolling from side to side in bed. A review of the Wound Evaluation & Management Summary, dated 5/29/25, indicated, Resident 2 had a stage 4 pressure wound of the left coccyx, full thickness. A review of the Physician's Order indicated, facility staff would encourage repositioning every two hours and as needed. A review of the POC, dated 6/1/25 through 6/25/25, indicated CNAs would turn and reposition Resident 1 every shift, not every two hours. A review of admission Record, dated 3/25/25, indicated Resident 3 was admitted to the facility on [DATE] with the diagnosis of muscle weakness and difficulty with walking. A review of Resident 3's admission/ 5-day MDS assessment, indicated that Resident 3 was dependent upon staff to roll from side to side in bed. A review of the Wound Evaluation & Management Summary, dated 4/29/25, indicated Resident 2 had a stage 4 pressure wound of the coccyx, full thickness and required to be repositioned per the facility's protocol. A review of the POC, dated 6/1/25 through 6/25/25, indicated CNAs would turn and reposition Resident 3 every shift, not every two hours. During an interview on 6/25/25 at 9:41 am, Resident 1 stated, they [facility staff] didn't turn me every two hours and confirmed, Resident 1 required assistance with repositioning. During a concurrent interview and record review on 6/25/25 at 2:00 pm, with DON, Resident 2 and 3's POC, dated 6/1/25 through 6/25/25 was reviewed. DON confirmed the POC did not indicate that Residents 2 and 3 were being repositioned every two hours and the POC indicated they were being repositioned every shift. During an interview on 6/25/25 at 2:29 pm, Resident 3 stated, they don't offer to reposition me, I have to ask, and I only get repositioned, maybe three to four times a day.

Based on interview and record review the facility failed to ensure discharge planning needs were met for one out of two sampled residents (Resident 1) when: 1. Resident 1 and his wife (CG, caregiver) were not provided required instructions or education on how to properly care for a wound; and 2. Resident 1 was not discharged from the facility with home health services (care provided in the home to include a nurse who would perform wound care, assessments, and education on wound care and dressing changes). This failure had the potential for the wound to worsen and become infected. Findings: 1. A review of the facility's policies and procedures (P&P) titled, Discharging the Resident, dated 9/1/24, indicated, the resident and/or responsible party would receive discharge instructions. A review of the undated document titled, Resident-Based Competencies (demonstrated skills that ensured an individual had the ability to provide adequate care), indicated, when a resident was discharged from the facility, the discharge would be safe and effective (successful). A review of the admission Record, dated 6/1/25, indicated resident 1 was admitted to the facility on [DATE] with the diagnoses of quadriplegia C5-C7, incomplete (messages from the brain to the nerves that made arms and legs move did not always work, which caused a total loss of arm and leg movement at times. C5-C7 was the cervical spinal area in the neck), fusion of the spine cervical region (a surgical procedure that permanently joined two or more moving pieces of the spine together), and bacteremia (bacteria in the blood stream). Resident 1 was his own RP (responsible party, made own decisions). A review of the admission MDS, dated [DATE], indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was performed. Resident 1 scored 15 out of 15, which indicated intact memory. The admission MDS indicated, Resident 1 required substantial assistance to dress his lower body, rolling in bed from left to right, and both arms and legs were impaired (limited ability to use). A review of the Admission/readmission Evaluation/Assessment (admission assessment), dated 6/1/25, indicated, Resident 1 did not have any open wounds upon admission to the facility. The admission assessment indicated Resident 1 had discoloration between both buttocks (butt cheeks). The admission assessment indicated, Resident 1 had an old pressure scar (the color and thickness of a pressure scar could indicate the stage of healing after a pressure ulcer was no longer open) and skin discoloration to the right buttock. A review of the Initial Wound Evaluation and Management Summary, dated 6/5/25, indicated, Resident 1 had a wound to the coccyx (also known as the tailbone, located between the buttocks) and the wound doctor performed a surgical debridement (removal of dead tissue) that resulted in dead muscle being removed from the coccyx wound. The Initial Wound Evaluation and Management Summary, indicated, there was a new diagnosis of stage 4 pressure wound of the right coccyx, and a new wound care treatment was required to manage and heal the wound. A review of the Physician's Orders, dated 6/5/25, indicated, a new wound care treatment to Resident 1's coccyx area included: cleaning the wound with normal saline (sterile salty water), pat dry and apply zinc oxide (a medicated cream that promoted wound healing) to the peri-wound (the intact skin that surrounded a wound), apply silver alginate (a medicated dressing) to the wound bed and cover with a foam dressing. During an interview on 6/25/25 at 9:41 am, Resident 1 stated, I did not have any open wounds when I was admitted to the facility. No one taught me or CG how to care for my wound before and I've been to the emergency room three times since I was discharged [from the facility] due to my wound worsening. Resident 1 stated, the emergency room sent me home with wound care supplies and set me up with home health. CG joined the phone call with Resident 1's permission and stated, I was not present during the discharge instructions, we were not given any [wound care] supplies, and I was not given any instruction or education on caring for the wound. CG confirmed that Resident 1 would not be able to perform his own wound care and required CG to perform wound care and dressing changes the coccyx. During a concurrent interview and record review on 6/25/25 at 10:01 am, with Wound Certified Registered Nurse (WCRN) Resident 1's Progress Note, dated 6/6/25 was reviewed. WCRN confirmed, the Progress Note, indicated, Resident 1 was discharged from the facility on 6/6/25, WCRN was the nurse that performed the discharge, and WCRN had provided wound care education. WCRN confirmed Resident 1's wound was located on the coccyx and Resident 1 would not be able to perform his own wound care. WCRN stated, education provided included education on treatments and signs and symptoms of infection. WCRN stated an inability to recall if Resident 1's care giver had been provided with education and instruction on how to perform wound care per the physician's order. WCRN confirmed, the Progress Note, did not indicate who the wound care education was provided to, the supplies needed for wound care, or that a return demonstration (showing someone how to perform wound care and observing them perform the wound care) had been performed with Resident 1's caregiver (CG). During a concurrent interview and record review on 6/25/25 at 10:37 am, with Director of Nursing, (DON) Progress Note, dated 6/6/25 and written by WCRN was reviewed. DON stated, if the patient is alert and oriented [their own responsible party], and able to perform a return demonstration, the wound care education is provided to them. DON confirmed, Resident 1's wound was located on his coccyx and Resident 1 would not be able to perform his own wound care. DON stated, if Resident 1's CG would perform wound care, the CG should have been provided the education. DON confirmed, the Progress Note did not indicate that CG was instructed on wound care or performing dressing changes. During a review of Resident 1's Discharge Summary, dated 6/5/25, indicated, Resident 1 would be discharged home on 6/6/25 and WCRN completed the Nursing Services section. The section labeled Skin Condition Upon Discharge (where the nurse documented any skin concerns, including wounds, and the physician ordered wound care was described) did not include the stage 4 pressure wound of the coccyx and there was no instruction on how to care for it. 2. A review of the facility's P&P titled, Discharging the Resident, dated 9/1/24, indicated, the facility would assist the resident with coordinating care that was required after discharging from the facility such as home health or needed equipment. A review of the Discharge Planning care plan (a document that described resident goals and care required to reach goals), dated 6/6/25, indicated, Resident 1 preferred to be discharged home, would be assessed for discharge needs and would be provided education related to discharge needs. During an interview on 6/20/25 at 3:00 pm, Registered Nurse (RN) confirmed, RN was the nurse who performed Resident 1's admission to the facility on 6/1/25. RN stated, Resident 1 did not want to be in the facility, wanted to go home, and I had to convince him to stay and complete his antibiotic therapy. During an interview on 6/25/25 at 9:41 am, Resident 1 stated, I don't remember anyone offering me home health. No one taught me or CG how to care for my wound and I've been to the emergency room three times since I was discharged [from the facility] due to my wound worsening. Resident 1 stated, the emergency room sent me home with wound care supplies and set me up with home health. Resident 1 confirmed he did not want to be in the facility and RN had convinced him to stay and complete his antibiotic therapy. During a review of Resident 1's Discharge Summary, dated 6/5/25, indicated, the Social Services Director (SSD) completed the section titled, Social Services. The SSD's section indicated that Resident 1 would be discharged home on 6/6/25. The section labeled discharge services and referrals, indicated Resident 1 was not ordered home health services and would need to be seen by his primary care physician within seven days after discharge. During a telephone interview on 6/25/25, at 3:33 pm, SSD stated, There was a case conference note that indicated Resident 1's understanding of leaving the facility unplanned, education was provided, and Resident 1 was notified that he would be required to make a follow up appointment with the doctor after discharge. SSD confirmed, the note would be provided via secured email. SSD confirmed that Resident 1 did not want to be in the facility and wanted to be discharged after the antibiotic therapy was completed on 6/6/25. On 6/27/25 at 7:00 am, Resident 1's provided an IDT Conference Note,, dated 6/5/25 and locked (after a note was written the writer locked it, indicating the note was complete) on 6/19/25, was reviewed. The IDT Conference Note indicated that SSD completed the form, this was an admission conference, and an active discharge plan was being developed for Resident 1 to discharge from the facility the next day (6/6/25). The IDT Conference Note,' indicated, SSD would follow up with any needed appointments and home health. The note indicated, Resident 1 declined home health and understood the risks of leaving unplanned. The IDT Conference Note did not include education provided regarding the dangers associated with declining home health for wound care, that wound care supplies would be needed, or where the wound care supplies could be obtained.

Based on interview and record review the facility failed to ensure the discharge Minimum Data Set (MDS, a resident assessment tool) was accurate for one out of two sampled residents (Resident 1) when the discharge MDS did not reflect Resident 1's stage 4 (a deep wound that could expose muscle, tendon, or bone) coccyx (also known as the tailbone, located between the buttocks) wound at discharge. This caused an inaccurate reflection of Resident 1's health status and skin condition at discharge and had the potential to impact the discharge planning process. Findings: A review of the Long-Term Care facility Resident Assessment Instrument 3.0 User's Manual (RAI, a manual that provided clear guidance about how to complete the MDS), dated [DATE], indicated, when a resident was discharged from the facility, an assessment was required. The RAI indicated the intent of Section M: Skin Conditions, was to document the presence of wounds. A review of the admission Record, dated 6/1/25, indicated resident 1 was admitted to the facility on [DATE] with the diagnoses of quadriplegia C5-C7, incomplete (messages from the brain to the nerves that made arms and legs work did not always reach the nerves, which caused a total loss of arm and leg movement sometimes. C5-C7 was the spinal area in the neck), fusion of the spine cervical region (a surgical procedure that permanently joined two or more moving pieces of the spine together, cervical region was in the neck area), and bacteremia (bacteria in the blood stream). Resident 1 was his own RP (responsible party, made own decisions). During a concurrent interview and record review on 6/20/25 at 12:30 pm, with MDS Coordinator, Resident 1's admission MDS, Section M: Skin Conditions was reviewed. MDS Coordinator confirmed, the admission MDS indicated, Resident 1 was admitted with two unstageable pressure injuries (a wound that cannot be fully seen) that presented as deep tissue injuries (intact skin that appeared to be discolored due to damage of underlying soft tissue pressure). A review of the Admission/readmission Evaluation/Assessment (admission assessment), dated 6/1/25, indicated, upon the admission assessment, Resident 1 did not have any open wounds. The admission assessment indicated Resident 1 had discoloration between both buttocks (butt cheeks). The admission assessment indicated Resident 1 had an old pressure scar (the color and thickness of a pressure scar indicated the stage of healing after a pressure ulcer was no longer open) and skin discoloration to the right buttock. A review of the Progress Note, dated 6/2/25, indicated, Resident 1 had an open area to the coccyx. A review of the Initial Wound Evaluation and Management Summary, dated 6/5/25, indicated that the wound doctor performed a surgical debridement (removal of dead tissue) of the right coccyx and removed dead tissue and muscle. The Initial Wound Evaluation and Management Summary, indicated a new diagnosis of stage 4 pressure wound of the right coccyx. During a concurrent interview and record review on 6/24/25 at 11:35 am, with MDS Coordinator, Resident 1's discharge MDS, dated [DATE], was reviewed. MDS Coordinator confirmed, the discharge MDS, Section M: Skin Conditions, indicated, Resident 1 was discharged with two unstageable pressure injuries that were present upon admission and did not include the physician diagnosed stage 4 pressure ulcer to the coccyx. During an interview on 6/24/25 at 3:04 pm, the MDS Coordinator confirmed the discharge MDS, dated [DATE], should have reflected Resident 1's stage 4 pressure ulcer to the coccyx and it did not.

Based on interview, record review, and facility policy review, the facility failed to provide a bed-hold notice upon transfer to the hospital or within 24 hours following an emergency transfer, which affected 2 (Resident #7 and Resident #47) of 3 residents reviewed for hospitalizations. Findings included: An undated facility document titled, Bed Hold Policy and Notification revealed, It is the policy of this facility to provide any resident that is transferred to a general acute care hospital the right to exercise the bed hold provision. 1. Resident #7's admission Record indicated the facility admitted the resident on 05/20/2023. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, and type two diabetes mellitus. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #7's Care Plan Report included a focus area, revised on 05/06/2024, that indicated the resident required long-term care related to increased activities of daily living (ADL) care needs, medical needs, and clinical needs. The Care Plan Report also included a focus area, revised on 05/01/2024, that indicated the resident had impaired cognitive function/impaired thought process. Interventions directed staff to administer medications as ordered and to monitor/document for side effects and effectiveness (initiated 05/01/2024). Resident #7's Progress Notes revealed a Nurse's Note, dated 01/06/2025 at 10:44 AM, that revealed Resident #7 had increased confusion and increased lethargy. The note indicated orders were received from the physician to send the resident to the emergency room. Resident #7's medical record revealed no evidence that the resident or a representative had been notified of the bed-hold policy within 24 hours of the transfer. Resident #7's Progress Notes revealed an Admission/re-admission Summary Note, dated 01/12/2025 at 1:58 PM, that revealed Resident #7 was readmitted to the facility after being hospitalized for a diagnosis of sepsis. Resident #7's Progress Notes revealed an Alert Note, dated 01/20/2025 at 3:14 AM, that revealed Resident #7 complained of not feeling right and became anxious about possibly having a stroke. The note indicated orders were received to send the resident to the emergency room. Resident #7's medical record revealed no evidence that the resident or a representative had been notified of the bed-hold policy within 24 hours of the transfer. Resident #7's Progress Notes revealed an Admission/re-admission Summary Note, dated 01/27/2025 at 4:00 PM, that revealed Resident #7 was readmitted to the facility after being hospitalized for a diagnosis of metabolic encephalopathy. Resident #7's Progress Notes revealed a Nurse's Note, dated 03/21/2025 at 3:30 PM, that revealed the physician gave an order for Resident #7 to be sent to the emergency room for further evaluation related to the abnormal laboratory results. Resident #7's medical record revealed no evidence that the resident or a representative had been notified of the bed-hold policy within 24 hours of the transfer. 2. Resident #47's admission Record indicated the facility admitted the resident on 07/05/2021. According to the admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus, essential hypertension (high blood pressure), and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/2025, revealed Resident #47 had short- and long-term memory problems and severely impaired cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS). Resident #47's Care Plan Report included a focus area, initiated 01/08/2023 and revised on 06/27/2023, that indicated the resident had impaired cognition due to having had a stroke with cognitive changes and aphasia. Resident #47's Progress Notes revealed a Nurse's Note, dated 01/24/2025 at 7:10 PM, that indicated Resident #47 had a fever of 101.6, a cough, and was fatigued and drowsy. The note indicated an order was received to send the resident to the hospital for further evaluation. Resident #47's medical record revealed no evidence that the resident or a representative had been notified of the bed-hold policy within 24 hours of the transfer. During an interview on 04/03/2025 at 9:18 AM, the Director of Nursing (DON) stated that going forward, the nurses would be the process holders for the bed-holds. She stated they were to call the family and notify them of the resident being transferred to the hospital, and then, while the nurse had the family on the phone, they were to ask the family if they wanted the resident's bed held. She stated that the nurse would then initiate and complete the bed-hold/transfer form and enter progress notes in the electronic health record. The DON stated the Admissions Coordinator would follow up with the resident/representative afterward to ensure the bed-hold stayed in place for seven days, and the Business Office Manager was responsible, going forward, to ensure there was a signature from the resident/representative on the bed-hold form as soon as possible, in addition to the verbal acceptance or refusal of the bed-hold. The DON stated the facility was not following the process of notifying a resident of the bed-hold policy upon transfer until it was brought to their attention, during the survey. The DON stated her expectation was for the process of obtaining permission for a bed-hold to be done timely. During an interview on 04/03/2025 at 9:40 AM, the Administrator stated his expectation of the bed-hold process was that staff completed the notifications and paperwork within the timeframes designated in the regulations.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that 1 (Resident #38) of 4 residents reviewed for medication administration was assessed for their ability to self-administer medications. Specifically, Resident #38 expressed a desire to self-administer their medications, and without first assessing the resident to determine if they were clinically appropriate and safe to do so, the facility allowed the resident to self-administer a nebulizer treatment while unsupervised by staff and denied the resident the right to self-administer their inhaler. Findings included: A facility policy titled, Self-Administration of Medications, reviewed 10/2024, indicated, Residents have the right to self-administer medications when it is clinically appropriate and safe for the resident to do so. The policy specified, 1. As part of their overall evaluation, resident's mental and physical abilities will be considered to determine whether self-administering medications is clinically appropriate for the resident. Resident #38's Admission Record indicated the facility admitted the resident on 05/21/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, acute and chronic respiratory failure with hypoxia (low oxygen level), and muscle weakness. Resident #38's Care Plan Report included a focus area, initiated 05/21/2024 and revised 02/23/2025, that indicated the resident had an alteration in their respiratory system with acute symptoms and had a high risk for the development of cardio-pulmonary symptoms, respiratory distress, and functional decline related to a diagnosis of COPD. Interventions dated 05/21/2024 directed staff to administer medications and nebulizer treatments as ordered. Resident #38's Care Plan Report did not include any focus areas addressing the resident's ability to self-administer medications. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/24/2025, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated Resident #38 did not have a functional limitation in range of motion in their upper or lower extremities. Resident #38's Order Summary Report revealed the following orders: - an order dated 02/11/2025 for ipratropium-albuterol solution 0.5-2.5 milligrams per 3 milliliters (mg/3mL) to be inhaled via a nebulizer every 6 hours as needed for shortness of breath or wheezing; -an order dated 02/04/2025 for Xopenex nebulization solution 0.63 mg/3mL to be inhaled via a nebulizer every 6 hours for COPD or wheezing; - an order dated 02/04/2025 for Spiriva HandiHaler inhalation capsule 18 micrograms (mcg) inhaled orally one time a day for COPD; and - an order dated 03/24/2025 for Breo Ellipta inhalation aerosol powder 100-25 micrograms per actuation (mcg/act) inhaled orally one time a day for COPD. The Order Summary Report did not contain orders addressing the resident's ability to self-administer medications. An observation on 03/31/2025 at 10:28 AM revealed Resident #38 had a nebulizer treatment in progress. No staff member was present in Resident #38's room. During an interview on 03/31/2025 at 1:45 PM, Resident #38 stated that they had an inhaler ordered, and they wanted to be able to keep it with them so they could administer it when needed, but the facility would not allow them to keep the medication and administer it themselves. Resident #38 stated when staff provided their nebulizer treatment, staff handed the treatment to the resident and left the room. During an interview on 04/02/2025 at 1:44 PM, Licensed Vocational Nurse (LVN) #1 stated that if a resident requested to self-administer medications, he would tell them that per the facility's policy, medications had to be administered by a nurse and that it was not possible for the resident to keep their medications themselves. LVN #1 stated that no resident in the facility self-administered medications. During an interview on 04/02/2025 at 3:40 PM, LVN #2 stated that if a resident wanted to self-administer medications, the nurse still gave the medications and stayed with the resident to supervise the resident while they administered the medications. LVN #2 stated residents could not keep medications in their room and take the medications themselves. LVN #2 further stated there were no residents in the facility that had orders for self-administration of their medications. During an interview on 04/02/2025 at 3:53 PM, the Respiratory Therapist (RT) stated the nurses administered inhalers and nebulizers. The RT stated a nurse was supposed to stay in the room with a resident while administering a nebulizer treatment to monitor for any adverse reactions. The RT stated she would not be surprised to hear that Resident #38 was administering their own nebulizer treatment, but had not seen the resident self-administer their nebulizer very often. The RT stated Resident #38 had requested to self-administer medications, but it was not allowed. The RT further stated they did not make the rules, they just followed them. During an interview on 04/03/2025 at 9:05 AM, the Director of Nursing (DON) stated that due to having residents who were confused and wandered, the facility tried not to have any residents self-administer medications. The DON stated that there were currently no residents in the facility that self-administered their medications. During an interview on 04/03/25 at 9:24 AM, the Administrator stated self-administration of medications was a clinical issue that he expected nursing staff to manage.

Based on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurately coded for pressure ulcers and restraints for 1 (Resident #62) of 21 sampled residents. Findings included: A facility policy titled, Resident Assessments, revised 10/2024, revealed, A comprehensive assessment of each resident is completed at intervals designated by OBRA [Omnibus Budget Reconciliation Act] regulations and PPS [Perspective Payment Plan] requirements. The section of the policy titled, Policy Interpretation and Implementation included 6. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated 10/2024, revealed, M0210: Unhealed Pressure Ulcers/Injuries, specified Coding Instructions Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days. - Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back period. Then skip to M1030, Number of Venous and Arterial Ulcers. Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. The manual further revealed Section P: Restraints and Alarms, defined Physical Restraints as Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body (State Operations Manual, Appendix PP). The manual revealed the Coding Instructions, directed staff to After determining whether or not an item listed in (P0100) is a physical restraint and was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the 7-day look-back period or it was used but did not meet the definition. Code 1, used less than daily: if the item met the definition and was used less than daily during the observation period. Code 2, used daily: if the item met the definition and was used on a daily basis during the look-back period. Resident #62's Admission Record indicated the facility admitted the resident on 10/10/2023. According to the Admission Record, the resident had a medical history that included diagnoses of dementia, essential hypertension (high blood pressure), depression, and anxiety. A quarterly MDS, with an Assessment Reference Date (ARD) of 02/20/2025, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident required partial/moderate assistance with rolling left and right while in bed. The MDS revealed M0210 was coded to indicate the resident had one or more unhealed pressure ulcers/injuries, however, M0300 A through M0300 G indicated the resident did not have any pressure ulcers/injuries. The MDS indicated that the resident used bed rails as a restraint daily. Resident #62's Care Plan Report included a focus area initiated on 10/11/2023, that indicated the resident was at risk for activity of daily living (ADL)/mobility decline and required assistance related to cognitive impairment. Interventions indicated the resident used one-quarter length bilateral bed rails (initiated 10/11/2023 and revised 06/20/2024). The Care Plan Report revealed a focus area initiated on 02/21/2025, which was after the MDS ARD, that indicated Resident #62 had a pressure ulcer to their left heel and was at risk for further breakdown and/or slow, delayed healing. During an interview on 04/02/2025 at 1:47 PM, the MDS Coordinator stated she had been working at the facility for eight years. She stated the MDS should be accurate and stated that it was her responsibility to ensure the MDS was accurate. She stated Resident #62's side rails were used for mobility and should not have been marked as a restraint on the MDS; it was an error . The MDS Coordinator stated she could see on the resident's MDS that it had been coded to indicate Resident #62 had existing pressure ulcers, but each type of pressure ulcer had been marked to indicate the resident did not have any. The MDS Coordinator stated the resident's MDS was not correct. During an interview on 04/03/2025 at 9:21 AM, the Director of Nursing (DON) stated her expectation was for the MDS assessments to be accurate. She stated the nurse who was completing the MDS needed to go section by section to ensure the assessment was correct before it was transmitted. During an interview on 04/03/2025 at 9:45 AM, the Administrator stated his expectation for the MDS process going forward was for the MDS Coordinator to review each MDS section by section to ensure the accuracy prior to transmitting them to Center for Medicare and Medicaid Services (CMS).

Based on interview and record review the facility failed to ensure one of three residents sampled for patient rights (Resident 1) was treated with dignity and respect when the Marketing Director (MD) had spoken with Resident 1 on the phone with the hospice nurse (HN) available and stated, What the hell are you doing. We would've never brought you back if we knew you weren't going on hospice. Nobody wants you here, This resulted in Resident 1 becoming tearful and had the potential to result in psychosocial harm. Findings: A review of a facility policy titled, Resident Rights, with a revised date of [DATE], indicated, Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. A review of the facility's records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), obstructive sleep apnea (sleep disorder with recurrent episodes of complete or partial blockage of the upper airway during sleep, leading to reduced or absent breathing), other abnormalities of gait and mobility, generalized muscle weakness, acquired absence of right leg above knee, chronic pain syndrome, and unspecified depression (symptoms of depression). During an interview on [DATE] at 2:45 PM with Resident 1's power of attorney (POA), she stated the Marketing Director (MD) had spoken with Resident 1 on the phone with the hospice nurse (HN) available and stated, What the hell are you doing. We would've never brought you back if we knew you weren't going on hospice. Nobody wants you here, which caused Resident 1 to cry. POA stated that after speaking to Resident 1 he stated he did not have a POLST filled out but did not want to die, but did not want full Cardiopulmonary Resuscitation (CPR), so he had picked selective treatment. She stated that she requested for a POLST form and was met with comments that stated Resident 1 is supposed to go onto hospice, and he would not need a POLST. POA stated that once Resident 1 was sent to the hospital on [DATE] at 5:50 AM, the facility informed POA that Resident 1 had his POLST sent to the hospital with him; however, upon arrival to the hospital she found Resident 1 intubated and being transferred to the ICU. POA stated, How is it that days later they didn't have that signature on the POLST. During an interview on [DATE] at 2:30 PM with the hospice liaison (HL), she stated the MD was on the phone with Resident 1 and stated, The only reason I brought you back was because you said you were going to go on hospice, and further stated that the hospice staff took the phone away from Resident 1 because it was not okay to speak with him that way. HL stated after she spoke with Resident 1 he did agree to hospice after a consult, but did not want to start hospice at the facility because he did not feel safe, we then updated his POLST. HL stated the POLST was never signed by his provider, and he had a medical emergency that resulted in CPR and being intubated. HL stated that the staff was not helpful and unprofessional and initially refused to give him a POLST to fill out and stated he needs to go on hospice and not deal with a POLST. During an interview on [DATE] at 11:45 AM with Licensed Vocational Nurse (LVN) 1, she stated the, POLST was not signed, by the medical provider, but it was signed by the resident as DNR selective. It wasn't signed on the 20th, and stated how she has expressed her concerns to the medical provider. LVN 1 stated the EMT's that arrived said Resident 1 will be considered full code (full resuscitation attempt) due to the POLST not being signed by the medical provider. LVN 1 stated, Yes, they should, sign the POLST immediately in some form, especially since Resident 1 had been declining. LVN 1 stated there was a lack in the quality of care for Resident 1. During an interview on [DATE] at 12:15 PM with MD, stated Resident 1 was supposed to be admitted to hospice; however, according to them (the hospice nurse) determined that he was alert and oriented (of sound mind) and he refused hospice at that time. MD, who confirmed she was a marketer with no medical background, stated when she talked to him he seemed confused and not oriented. MD stated she felt that Resident 1 needed hospice even though he was of sound mind at the time he refused hospice care. MD stated she was talking to the hospice nurse over the phone on speaker with Resident 1 present and stated that he was supposed to be on hospice as it was the plan and she did not want hospice to leave without him signing up for hospice. MD stated she was upset that hospice left and didn't follow through with Resident 1 and she did not feel that hospice offered all that they were supposed to offer him. During an interview on [DATE] at 1:25 PM with Director of Nursing (DON), she stated that the resident had a right to determine he did not want to go on hospice as he was oriented, which she had also verified. DON stated that someone without a medical background should not be able to determine if a resident was confused and not oriented.

Based on interview, and record review, the facility failed to implement resident-directed care consistent preferences and rights for one of three residents sampled for patient rights (Resident 1) when the facility did not maintain a valid copy of Physician Orders for Life-Sustaining Treatment (POLST- a voluntary option for people to use to communicate their end-of-life decisions) in Resident 1's medical record when transfer from the facility via ambulance was made. This failure resulted in Resident 1's right to decline specific treatment in the event of a medical emergency to not be followed. Findings: A review of a facility policy titled Advance Directives, with a revised date of [DATE], indicated, The director of nursing services or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care . The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive . The nurse supervisor is required to inform emergency medical personnel of a residents advance directive regarding treatment options and provide such personnel with a copy of the advance directive or Physician orders for life-sustaining treatment (POLST) when transfer from the facility via ambulance or other means is made. A review of a facility policy titled, Resident Rights, with a revised date of [DATE], indicated, Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. A review of a facility policy titled, Do Not Resuscitate Order, with a revised date of [DATE], indicated, Do not resuscitate (DNR, allow natural death) orders must be signed by the resident's attending physician . State specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include: POLST . A review of the facility's records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), obstructive sleep apnea (sleep disorder with recurrent episodes of complete or partial blockage of the upper airway during sleep, leading to reduced or absent breathing), other abnormalities of gait and mobility, generalized muscle weakness, acquired absence of right leg above knee, chronic pain syndrome, and unspecified depression (symptoms of depression). A review of the facility's record POLST for Resident 1 indicated selective treatment (do not intubate, avoid intensive care (ICU), comfort-focused care) was selected for Resident 1 with a DNR. The date the form was prepared was on [DATE], and it was signed by Resident 1 on [DATE]. This form indicated that the Physician (DR) signed the POLST on [DATE]. A review of the facility's progress note dated [DATE] at 7:51 AM, indicated, Resident was sent with face sheet, medication summary, and POLST of DNR selective however it had pending provider's signature of DNR elective. Emergency Medical Technician (EMT) stated, provider's signature is required, therefore resident is considered full code. He left the facility . at 0550. POA was notified at 5:54 AM. A review of the facility's calendar for the physician and nurse practitioner schedule for [DATE], indicated, the nurse practitioner and physician did not enter the clinic to see residents [DATE]th, 18th, 19th of 2025. The nurse practitioner did enter the clinic to see residents on [DATE] and the physician did not enter the clinic until [DATE]. During an interview on [DATE] at 2:45 PM with Resident 1's power of attorney (POA), she stated the Marketing Director (MD) had spoke with Resident 1 on the phone with the hospice nurse (HN) available and stated, What the hell are you doing. We would've never brought you back if we knew you weren't going on hospice. Nobody wants you here, which caused Resident 1 to cry. POA stated that after speaking to Resident 1 he stated he did not have a POLST filled out but did not want to die, but did not want full Cardiopulmonary Resuscitation (CPR), so he had picked selective treatment. She stated that she requested for a POLST form and was met with comments that stated Resident 1 is supposed to go onto hospice, and he would not need a POLST. POA stated that once Resident 1 was sent to the hospital on [DATE] at 5:50 AM, the facility informed POA that Resident 1 had his POLST sent to the hospital with him; however, upon arrival to the hospital she found Resident 1 intubated and being transferred to the ICU. POA stated, How is it that days later they didn't have that signature on the POLST. During an interview on [DATE] at 11:45 AM with Licensed Vocational Nurse (LVN) 1, she stated the, POLST was not signed, by the medical provider, but it was signed by the resident as DNR selective. It wasn't signed on the 20th, and stated how she has expressed her concerns to the medical provider. LVN 1 stated the EMT's that arrived said Resident 1 will be considered full code (full resuscitation attempt) due to the POLST not being signed by the medical provider. LVN 1 stated, Yes, they should, sign the POLST immediately in some form, especially since Resident 1 had been declining. LVN 1 stated there was a lack in the quality of care for Resident 1. During an interview on [DATE] at 1:25 PM with Director of Nursing (DON), she stated, No, it wasn't appropriate, for the physician to sign the POLST with a date of [DATE] when they were not there to sign it that day and stated that nobody should be backdating documentation. DON stated it is not fair that the resident had to be intubated (to insert a tube for breathing) if he did not want to be intubated.

Based on interview and record review, the facility failed to ensure residents received supervision to prevent falls for one of four residents sampled for falls (Resident 1). Resident 1 was assessed as high risk for falls and the Interdisciplinary team (IDT) (a facility group composed of a physician, a registered nurse, a social worker and additional appointed facility staff) did not revise Resident 1's fall care plan interventions based on Resident 1's fall risk factors and resident-centered needs to include increased supervision following 14 falls between 8/7/24 and 9/13/24. These failures resulted in Resident 1 having avoidable falls which resulted in hospitalization on [DATE] for bleeding in her brain, and caused bruising to the bridge of her nose, left eye, a laceration (a cut or tear in the skin and underlying tissues that can be caused by blunt force trauma), a raised lump to the left temporal region (behind the ear), and a chipped front tooth on 9/13/24. Findings: A review of the facility policy, Managing Falls and Fall Risk, dated 3/2018, indicated fall risk factors included lower extremity (legs) weakness, medication side effects, and neurological disorders. The policy indicated the staff will implement a resident-centered fall prevention plan to reduce the risk factors of falls for each resident with a history of falls. During a review of Resident 1's face sheet (a document with demographic, personal and medical information) dated 9/19/24, the record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1's diagnoses included Huntington's disease (a chronic, inherited, and incurable brain disorder that causes the gradual breakdown of nerve cells in the brain. Symptoms include clumsiness, balance issues, and involuntary movements), traumatic subdural hemorrhage (a brain injury that occurs when a blood vessel tears and leaks blood into the space between layers of the brains lining, usually caused by a severe head injury, such as a blow to the head or a fall), muscle weakness and unsteadiness on feet. During a review of the clinical record for Resident 1, the Minimum Data Set (MDS) (assessment of healthcare and functional needs) dated 6/4/24, indicated Resident 1 had short- and long-term memory impairment. The MDS document indicated Resident 1 was severely impaired in decision making during activities of daily living and required supervision with mobility and transfers. The MDS document indicated Resident 1 was taking medications in two high-risk drug classes, antipsychotic and antidepressant medications. A review of the facility's Incidents by Type log for falls, indicated Resident 1 sustained 14 falls in the 50-day period from 8/1/24 through 9/19/24. Six of the falls were unwitnessed. A review of the facility policy, Care Planning-Interdisciplinary Team, dated 3/2022, indicated the Interdisciplinary Team (IDT) included the resident's physician, a registered nurse, a certified nurse's assistant, food and nutrition services staff, the resident or their representative as practicable, and other staff as necessary. The IDT is responsible for the development of comprehensive (all inclusive), resident-centered (a practice in which patients actively participate in their own medical treatment in close cooperation with their health professionals) care plans based on resident assessments. During a review of the clinical record for Resident 1, the Progress Notes dated 8/1/24 through 8/16/24, indicated the following. An IDT fall note dated 8/7/24 at 9:30 am, indicated Resident 1 had a witnessed fall onto her bottom and then fell back and hit her head on the floor at 5:50 am. After further investigation the IDT determined Resident 1 did not hit her head. The IDT noted fall risk factors including Huntington's disease, a history of falling with traumatic brain injuries, muscle weakness, and high-risk medications. The IDT recommended interventions to prevent further falls were to Reach out to family for more visits more frequently, therapy to do post-fall evaluation. Continue to educate staff for frequent checks. A review of the Therapy Post-Fall Evaluation dated 8/7/24 at 4:24 pm, indicated Patient has had multiple falls, may benefit from one-on-one supervision An IDT fall note dated 8/9/24 at 9:30 am, indicated CNA (Certified Nurse Assistant) reported to nurse that Resident 1 had an unwitnessed fall on 8/8/24 at 1:30 pm. Resident 1 was sitting in an upright position on the floor. The CNA told the nurse After assisting [Resident 1] back to bed, when I came out from room, I immediately heard sound and turned back around. I found [Resident 1] sitting on the floor. IDT recommended interventions to prevent further falls were medication adjustments. An IDT noted dated 8/13/24 at 10:14 am, indicated staff heard a noise at 6:05 am and went to Resident 1's room. Resident 1 was found sitting on the floor at the side of her bed. Resident 1 had a 1.5 cm (centimeter, a unit of measure) abrasion (a partial thickness wound caused by friction to the skin) with bruising to the left knee, a 3.2 cm by 1 cm abrasion with bruising to the right knee, a 3 cm abrasion to the left elbow, and a 1.7 cm laceration to the left eyebrow. The root cause analysis (a method for identifying the underlying causes of problems and developing corrective actions) indicated that due to Resident 1's medical condition, she does not remember to ask for assistance, got up on her own, lost balance and was found on the floor. IDT recommended interventions to prevent further falls were therapy to do a post-fall evaluation and soft/soothing music. A review of the Therapy Post-Fall Evaluation dated 8/13/24 at 11:12 am, indicated Patient may benefit from one-on-one supervision at all times, frequent visual checks An IDT note dated 8/14/24 at 9:33 am, indicated Resident 1 was found on the floor in the hallway outside her room by nursing staff at 8:03 pm. IDT recommended interventions to prevent further falls were to attempt to obtain insurance authorization for sensory integration techniques (therapies such as deep pressure, weighted vests, and swinging). An IDT note dated 8/16/24 at 10:12 am, indicated a CNA informed the nurse about Resident 1's fall. Per CNA Resident 1 was walking and lost her balance and sat on the floor. IDT recommended interventions to prevent further falls were therapy to do a post-fall evaluation, hip protectors (a specialized form of pants or underwear with pads designed to prevent hip fractures following a fall) and encourage one-on-one activities. A review of the Therapy Post-Fall Evaluation dated 8/16/24 at 7:31 am, indicated the above fall occurred on 8/15/24 at 10:30 am. The recommendations from therapy were Patient would benefit from one-on-one supervision. An IDT note dated 8/19/24 at 7:55 am, indicated Resident 1 was at the Nurse's Station in a wheelchair 8/16/24 at 6:05 am. The nurse turned her back to Resident 1 and Resident 1 got out of her wheelchair. The nurse turned around and saw Resident 1 lose her balance and fall onto her bottom. IDT recommended interventions to prevent further falls were therapy to do a post-fall evaluation and a urinalysis (a medical test that examines urine to check for a variety of conditions, including urinary tract infections). A review of the Therapy Post-Fall Evaluation dated 8/19/24 at 8:50 am, indicated Patient would benefit from one-on-one supervision. An IDT note dated 8/19/24 at 8:13 am, indicated Resident 1 was assisted to the floor on 8/18/24 at 8:06 am. The nurse saw Resident 1 walking in the hallway and assisted her to walk. The nurse turned to ask someone to grab her a pair of socks. When the nurse looked away, Resident 1 started falling backwards and was lowered to the floor. As Resident 1 was being lowered to the floor, her jerking movements caused her to hit the back of her head against the wall. The ambulance arrived at 8:36 am and Resident 1 was taken to the emergency room . A review of the Therapy Post-Fall Evaluation dated 8/19/24 at 9:03 am, indicated Patient could benefit from one-on-one supervision. An IDT note undated, indicated that the IDT met to review a fall on 8/19/24 at 2:20 pm. Resident 1 got up from bed, started walking, lost her balance, stepped backwards and hit her head. MD ordered Resident 1 to be sent to the emergency room for further evaluation. The ambulance arrived at 2:37 pm. At 6:30 pm the acute hospital notified the facility that Resident 1 was being admitted to the hospital due to a hemorrhage (bleeding) in her brain. During a review of acute care hospital records for Resident 1, the Emergency Department progress notes dated 8/19/24, at 8:56 p.m., indicated Resident 1 was brought in by ambulance from the facility following a fall and striking her head on the ground. The note indicated that Resident 1 has had multiple falls recently as the care home she is in has been unable to provide one on one watch over the patient and the patient is left alone and tries to get out of bed and falls. Resident 1 was transferred to a higher level of care for treatment of her injuries. During a review of the clinical record for Resident 1, the Progress Notes dated 9/4/24 through 9/13/24, indicated the following. An IDT note dated 9/4/24 at 9:26 am, indicated Resident 1 was found on her back with her feet pointing toward the bed and her head toward the door on 9/4/24 at 6:15 am. IDT recommended interventions to prevent further falls were therapy to do a post-fall evaluation and to have a physician evaluate Resident 1's medications. An IDT note dated 9/6/24 at 9:50 am, indicated on 9/5/24 at 8:45 am Resident 1's roommate shouted for help. A CNA went into the room and found Resident 1 on the floor. Resident 1 was lying on her back on the floor next to her bed. IDT recommended interventions to prevent further falls were Continue current plan of care. An IDT note dated 9/13/24 at 8:19 am, indicated Resident 1's roommate shouted for help on 9/13/24 at 6:10 am. Resident 1 was found lying on her stomach with her face against the oxygen concentrator (a machine used to provide supplemental oxygen from the environment) with blood on the floor. Resident 1 had a 1 cm by 0.3 cm laceration with bruising to the bridge of her nose, a 1 cm by 0.2 cm laceration to the left cheek, a raised lump to the left temporal region, bruising to the left eye and a chipped front tooth. IDT recommended interventions to prevent further falls were therapy to do a post-fall evaluation, physician to reevaluate Resident 1's medications, and keep the television on for a diversion. During an interview on 9/19/24 at 1:15 pm, Resident 2 stated she witnessed Resident 1 fall on 9/13/24. Resident 1 got out of bed and fell to the floor. Resident 1's head and nose were bleeding and there was too much blood on the floor. Resident 2 stated that she frequently takes care of Resident 1 because the staff don't watch her. Resident 2 stated, There was nobody on the floor (unit). I had to look around for someone to tell that she fell . During an interview on 9/19/24 at 1:18 pm, CNA A stated [Resident 1] gets up out of nowhere. We try to supervise her as much as possible, but she is unpredictable. [Resident 1] has had numerous falls. Anytime [Resident 1] would start to dangle her feet off the side of the bed, [Resident 2] would alert us. During an interview on 9/19/24 at 1:20 pm, Licensed Vocational Nurse (LVN) B stated that Resident 2 would alert staff if she thought Resident 1 was going to fall. During an interview on 9/19/24 at 1:47 pm, family member (Fam) C stated [Resident] 1 has had many, many falls, they don't supervise her She had repeated falls and got a massive brain bleed from one of them. Recently she fell and hit her face. They didn't tell me her face and nose were bruised I told [the facility] if you don't want her to fall the only way to stop it is to get a sitter (one-on-one supervision). The Social Services Director told me I was free to hire a sitter. The clinic that [Resident 1] goes to for Huntington's disease offered to come to the facility to help give them recommendations to stop these falls, but the facility didn't take them up on the offer. During an interview on 9/26/24 at 12:30pm, the Huntington's disease clinic Social Worker (SW) stated it is usual for Huntington's disease patients to have falls, but there are ways we know to mitigate that. SW stated that her concern was the number of falls that were unobserved. SW stated that showed that Resident 1 needed more supervision. SW stated that the facility kept changing Resident 1's care plan and then changing it back without evaluating the effectiveness of what they were doing. Every fall seemed to be met with a medication review. Resident 1 should have been moved to a room within eyesight of staff at all times due to her uncontrolled movements and urge to get up. Resident 1 should have had a scheduled toileting program (help the resident ambulate to the bathroom every three to four hours, or according to the individualized program) so she didn't fall in the morning, for instance. SW stated that she tried to give the facility advice and offered to come there in person to do an in-service for free, but the facility never followed through. During an interview on 9/19/24 at 2:30 pm, the Social Services Director (SSD) reviewed Resident 1's care plan. SSD confirmed that the current interventions were not enough. SSD stated that she was trying to get the family to help get a sitter. The CNAs can't help her, they have to go to other rooms. It seems to be a financial issue that we don't hire sitters. During an interview on 9/19/24 at 2:15 pm, the Director of Nursing (DON) reviewed Resident 1's care plans. DON stated We don't have one-on-one sitters in this building We don't have the staff to do that. DON stated Resident 1 was not appropriate for the facility due to her need for supervision. During an email conversation on 10/10/24, at 11:19 am the administrator stated We will hire a specific position for a sitter for residents like this. We've also assigned an extra CNA to that resident hall to make sure we have an extra set of eyes. At 12:03 pm, the administrator stated, The one-on-one sitter was a suggestion from rehab, and we discussed in IDT we wouldn't be able to provide a sitter 24/7.

Based on interviews, observations and record review, the facility did not meet this requirement when it failed to provide evidence of incontinent (no ability to control one's bowels or bladder and requires staff to clean), care for two of 17 sampled residents (Resident 1 and 2). This resulted in the potential for skin breakdown and a loss of dignity for both residents, who were dependent on staff for care. Findings: Resident 1 was admitted to the facility on [DATE] for conditions that included rhabdomyolysis (a breakdown of muscle), spondylosis (abnormal wear of the spinal cartilage), history of stroke and difficulty walking. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment tool that measures health and mental status in nursing home patients), dated 6/4/24 indicated that her ability to use the restroom, Toilet Hygiene, was rated at 2 or Substantial/Maximal Assist. During an interview and observation on 7/24/24 at 11:20 AM, Resident 1 ' s room smelled strongly of stale urine. Resident 1 was observed seated at the edge of her bed and in an interview, concurrently stated that she was waiting for assistance because she was wet. Resident 1 stated that she had pressed the call light at 11:00 AM and had been at the edge of the bed waiting for an unidentified CNA (Certified Nursing Assistant) who said they would return, I ' ve been waiting 20 minutes here, I looked at the clock. Resident 1 stated that she had also been left wet the night before: a CNA changed her at 10:10 PM, the next shift took over, and Resident 1 stated that the CNA from registry (a temporary help agency) who did not check on her the entire shift until it was time for the next shift to come on and changed her at 5:25 AM. She stated this happens all the time, and that it also happened on 7/15/24 when she was left wet for at least six hours. Resident 1 stated that on 7/22/24 and 7/23/24, her sheets were wet and she was not changed which made her uncomfortable. Resident 2 was admitted to the facility on [DATE] for conditions that included leg cellulitis (inflammation of the leg), diabetes, congestive heart failure, legal blindness, muscle weakness and unsteadiness on her feet. A review of Resident 2 ' s MDS dated [DATE], indicated that her ability to use the restroom, Toilet Hygiene, was rated at 1 or Dependent, Helper does all the work. In an interview and observation on 7/24/24 at 11:42 AM, Resident 2 stated, I'm getting left wet all night long. I can't tell you which CNA was here because I never saw her. I get changed before the evening shift leaves, and I don't see anyone until morning. Resident 2 had a large cast on her right foot and stated that she previously had a boot with bolts in it that seemed to intimidate the newer or registry CNAs who were not sure how to handle her. She stated, I think they avoided changing me because they didn't know how to handle me at night. In an interview on 7/24/24 at 11:48 AM, CNA C acknowledged that CNA D was a registry staff member and that her shift followed CNA D ' s coming off of the night shift of 7/23/24 and she had been assigned to Residents 1 and 2 and began doing resident care at 6:45 AM. CNA C stated that she arrived on shift to find Resident 1's bed saturated by urine. CNA C stated that she had arrived at 6:15 am and began her shift at 6:45 following report. CNA C stated that CNA D reported to her that she had taken Resident 1 to the restroom at 5:30 AM, and that CNA D, was supposed to do a time stamp on her work if she had done it. CNA C stated that residents are to be rounded on every two hours or more frequently as needed, per policy. In an interview on 7/24/24 at 11:50 AM, Licensed Vocational Nurse (LVN) A stated that she had been assigned as Unit Manager on the night shift. LVN A stated, I can tell if a CNA is rounding every two hours. If they're not, the bed will soak through, that ' s how I can tell if they ' re changing residents. Residents don't usually urinate enough every two hours to soak the bed. LVN A stated that she was familiar with Resident 1, whom she stated was alert, oriented, and credible. She keeps track of things. If she said it happened, it happened. LVN A stated that CNAs are trained to round every two hours, standard care, and that CNAs are also supposed to do walking rounds to check on residents being taken over by next shift, when a wet resident would be evident. In an interview and record review on 7/24/24 at 12:15 PM, Director of Staff Development (DSD) B confirmed that registry CNA D had been assigned to Resident 1 on 7/23/24, and that had been CNA D ' s first assignment at the facility. DSD B further stated that she received a text at 6:52 AM from unit manager LVN A on the morning of 7/24/24 regarding CNA D, Came in early, left at 6:50 [am], didn't give report and Nothing's done. In a concurrent record review of the facility ' s document titled, Point of Care Audit Report dated 7/24/24, reflected that CNA D had not charted that she gave any care to residents or indicated in any way that care had been done. DSD B also stated that she had received a report from staff on 7/15/24, the night that Resident 1 stated she had been left wet. DSD B provided the text for review, Whoever worked last night didn't give me a report. Some residents weren't changed. DSD B stated that registry CNAs come and go, they don't have a boss so it's hard to supervise them. They work for themselves. A review of the facility ' s policy titled, Activities of Daily Living, Supporting, (undated), provided by DSD B, indicated as follows: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including support and assistance with Elimination (toileting) q 2 hours and prn. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Total Dependence requires full staff performance of an activity with no participation of the resident for any aspect of the ADL activity. Finally, the policy indicated, The resident's response to interventions will be monitored, evaluated, and revised as appropriate.

Based on observation, interview, and record review, the facility failed to ensure one of 13 sampled residents (Resident 2) was treated with dignity and respect during direct patient care. This deficient practice had the potential to negatively affect Resident 2's psychosocial well-being and did cause Resident 2 to become angry. Findings: During a review of the facility's policy revised 2/2021, titled, Dignity, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of wellbeing, level of satisfaction with life, and feelings of self-worth and self-esteem. This policy also indicated residents are treated with respect and dignity at all times. During a review of the facility's policy revised 2/2021, titled, Resident Rights, indicated each resident is to be treated with respect, kindness, and dignity; and to be supported by the facility in exercising his or her rights. A review of Resident 2's clinical record indicated she was admitted to the facility on [DATE] with diagnoses that included injury of lower spine and pelvis, sequela (an after effect of a disease, condition, or injury), Chronic Obstructive Pulmonary Disease (COPD, a progressive lung disease), difficulty walking, chronic pain, heart disease, and a history of falls. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 4/10/24, indicated that Resident 2 was cognitively intact (able to think and reason) and made her own decisions, and is her own responsible party (RP). A review of a care plan dated 4/8/24, indicated Resident 2 is dependent on staff for activities for daily living (ADLs-hygiene, toileting, grooming, dressing, and bathing) related to limited physical mobility and a history of falls with injury. This care plan indicated Resident 2 needed assistance of one staff member with transfers and ambulation related to pelvis fracture, pain, and weakness. During an interview on 5/3/24 at 2:30 pm, Resident 2 stated, I get tired of waiting on the Certified Nursing Assistants, (CNA)s. [CNA F] made me wait for 30 minutes to get help to the bathroom and I wet myself. [CNA F] was not supposed to come back in here. They promised me I would not have to see [CNA F] again. I am angry, I do not want an apology, I don't ever want to see her again. During an interview on 5/3/24 at 3:10 pm, Licensed Nurse (LN) A confirmed CNA F was not supposed to go back in Resident's 2 room after she discussed a complaint made by Resident 2. LN A stated, I think there might be a language barrier, and CNA F has received corrective action. I will also be providing more education to CNA F; she has only been a nurse assistant for less than 90 days. During an interview on 5/3/24 at 3:15 pm, Assistant Director Of Nursing stated, Yes, I agree CNA F did cause Resident 2 to become angry and this is a dignity issue for the resident, she needs to be monitored and put on alert charting. Even though she is her own RP, we will call the family. During an interview on 5/3/24 at 3:20 pm, the Director of Nursing (DON) confirmed she was aware of the complaint by Resident 2 about CNA F and this CNA was not supposed to have the assignment to help Resident 2 per request. DON stated, I will follow up with [CNA F] and tell her even if she is scheduled in error, she is not allowed to go into the room of Resident 2. We will monitor Resident 2 for any new behaviors since this mistake happened today.

Based on observation, interview, and record review the facility failed to have or follow policies and procedures for Quality Assurance and Performance Improvement (QA/PI) nor any formalized QAPI projects as required. This failure demonstrated a lack of quality and performance improvement that could lead to a decrease in Resident quality of life, enjoyment and happiness, causing adverse clinical outcomes. Findings: On 11/16/23 at 10:30 AM during a concurrent interview and record review the Facility Administrator (Admin) was interviewed regarding facility administration functions. The Admin was not able to provide regulation required policies and procedures on Quality Assurance and Performance Improvement (QA/PI). The QA/PI processes assist a facility in recognizing issues potentially affecting residents adversely, guiding the facility in monitoring and improving issues to reduce or prevent adverse outcomes. The Admin stated he did not have a policy for QA/PI processes available. The Admin did not have any documented formalized regulatory required QA/PI projects with planning, review, data analysis and outcome progress. The Admin verbalized understanding of the process and need for ongoing QA/PI initiatives stating he would be sure these will be done in the future.

Based on observation, interview and record review, the facility failed to ensure infection control program was properly maintained or implemented to reduce the spread of infection when: 1. Personal protective equipment (PPE, gloves, gowns, eye protection, and masks) was not consistently and correctly used by staff when providing care for Coronavirus disease (COVID-19: an infectious disease caused by the SARS-CoV-2 virus) positive residents; and 2. Tuberculosis (TB-a bacterial infection that mainly attacks the lung. A tuberculosis screening test checks to see if a person has the bacteria (germs) that cause TB in the body) screen was not done per the facility's policy for one out of six sampled employees. 3. Hospitality Aide (HA) did not perform hand hygiene (wash hands or use hand sanitizer) before or after direct resident contact with five out of five residents (Resident 41, 66, 52, 62, and 15) including contact with self. These failures had the potential to result in the development and transmission of infectious diseases that could lead to significant adverse consequences to residents, staff, and visitors. Findings: A review of Centers for Disease Control and Prevention (CDC)'s guideline titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/2023, the guideline indicated, Healthcare Personnel (HCP) who enter the room of a patient with suspected or confirmed COVID infection should adhere to Standard Precautions and use a The National Institute for Occupational Safety (NIOSH)-approved particulate respirator (a type of air-purifying respirators protects by filtering particles out of the air the user is breathing) with N95 filters (N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). During a concurrent observation and interviewed on 11//13/2023, at 8:30 am, at Hall 100, observed an unidentified staff (Staff C) coming out of room [ROOM NUMBER] without wearing a face shield. Staff 1 stated we don't need to wear an eye shield . During a concurrent observation and interviewed on 11/13/23 at 12:08 pm outside room [ROOM NUMBER], a sign of airborne precautions (for patients known or suspected to be infected with pathogens transmitted by the airborne route) was posted at the door of room [ROOM NUMBER], a 3-drawer plastic storage for PPE was placed outside the room. Observed a Certified Nursing Assistant (CNA) B providing care to Resident 29 without wearing gloves and a face shield. Observed CNA B coming out of room [ROOM NUMBER], opening the top drawer of the PPE storage without sanitizing her hands. CNA B stated, You don't need gloves if you don't contact the resident . CNA B stated that she just attended an infection control in-service couple weeks ago and she was taught that she didn't need gloves. During a concurrent observation and interviewed on 11/14/2023 at 8:31 am, outside room [ROOM NUMBER], CNA D was observed coming out of room [ROOM NUMBER] without wearing N 95 mask and a face shield. CNA stated Yeah, we do need to wear N 95, I just did not do it . During an interview on 11/14/2023 at 9:02 am at the Infection Preventionist (IP)'s office, the IP consultant stated that the facility followed CDC guideline which indicated that the staff should wear gown, gloves, eye protection, and mask while taking care of COVID-19 positive residents. The IP consultant said, The staff were expected to wear gloves and face shield. 2. A review of the facility policy, titled Employee Health Records, revised 11/2019, the policy indicated that A health record for each employee will contain associate TB screening Record. During a concurrent interview and record review on 11/15/2023 at 4:31 pm at the Director of Staff Development's (DSD) office. The DSD stated that the facility followed CDC guidelines for employee TB screen which was two-step skin test for new hire. Staff E's Health record was reviewed, indicated that Staff E was hired on 6/17/2023, and Staff E's TB screening record was missing. The DSD stated that she could not find Staff E's TB screening record and that's why she asked Staff E to do TB skin test on 11/8/2023. 45315 3. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised 8/1/19, indicated This facility considers hand hygiene the primary means to prevent the spread of infection. The P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures . and hand hygiene would be performed, Before and after direct contact with residents. During an observation on 11/13/23 at 12:12 pm, in the social dining room, located on hall 4, Hospitality Aide (HA) was observed touching Resident 41's head with bare hands. HA touched HA's face, eyeglasses, hair, and while readjusting the N95 mask (a mask that filtered 95 percent of airborne particles) HA placed uncleansed fingers into the N95. HA was observed placing a kiss on top of Resident 66's head while touching Resident 66's shoulders. HA walked over to Resident 52 and touched the arm rest and handles of Resident 52's wheelchair. HA placed hands on Resident 62's shoulders and was rubbing HA hands back and forth. HA walked across the social dining room and hugged Resident 15. HA was observed readjusting N95 mask, placing fingers on the inside of the N95. HA had not performed hand hygiene before or after coming into direct contact of each resident with bare hands or touching self. During an interview on 11/14/23 at 12:01 pm, HA confirmed not performing hand hygiene during 11/13/23's observations in the dining hall, confirmed touching five residents and self without performing hand hygiene, and stated importance of hand hygiene in between direct resident contact was to protect self and residents from getting sick. HA stated being an employee of the facility since May 2023 and received training about hand hygiene upon hire and had not attended any in-services provided by the facility. HA stated the in-services were for the Certified Nursing Assistants and not the HA. During a concurrent interview and record review on 11/14/23 at 4:15 pm, with Director of Staff Development (DSD), Inservice-Sign in Sheet and Education Program Lesson Plan, dated 11/6/23 was reviewed. DSD stated the Education Program Lesson Plan indicated, hand hygiene was required Before and after direct contact with residents. DSD stated the In-Service Sign in Sheet indicated, HA wad been present for the in-service.

Based on observation, interview and record review the facility failed to have records of Quality Assurance and Performance Improvement (QA/PI) meetings to obtain feedback, use data, and take action in conducting structured, systematic investigations and analysis of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility failing to have a structured, functional QA/PI process addressing potentially harmful and preventable issues creates the potential for resident harm and adverse clinical outcomes. Findings: During a concurrent record review and interview on 11/16/23 at 9:56 AM, with the Facility Administrator (Admin) when questioned about monthly and quarterly Quality Assurance and Performance Improvement (QA/PI) meetings the Admin stated the facility has, Daily quality meetings with department by department issues the managers select. The Admin was not able to print a report. Observed the form and it appears to be a day by day (not a formal monthly or quarterly) account of departmental quality assessments and improvement but not in the format of a QA/PI meeting. The Admin provided Quality Assurance (QA) sign in sheets for the months of June, July, August, September, October and November 2023. The Admin reviewed and acknowledged the Medical Director did not attend nor sign the attendance sheets on a quarterly basis (as required). The Admin provided a document set titled, Welcome November 13, 2023 Quality assurance monthly meeting consisting of six double sided pages containing a list format of usual Quality Assurance/Performance Improvement (QA/PI) functions. From the documents there are no discussions seen as would be expected resulting from a QA/PI meeting. The Admin acknowledged the list format provided does not include discussions of the items present; meeting minutes do not include meaningful information upon which an improvement plan or process can be monitored and assessed. The Admin stated, We do work on issues like falls and they are improving. The document provided does not have any feedback for results as would be an expected result from a QA/PI meeting such as improving the current status of items present. There is no discussion of adverse events, whether or not they occurred. In addition, there were no prioritization, development or action plans of any QA/PI activities discussed. When asked the Admin was not able to produce a copy of a policy/procedure on QA/PI program activities. At 11/16/23 12:41 PM, the Admissions Coordinator (AC) member was interviewed. When asked if the AC attended monthly QA/PI meetings the AC replied, Yes, daily in stand-up (a daily status meeting) I go. The AC identified her names and signatures on the QA/PI meeting attendance sign in sheets. The AC was not able to elaborate on any discussion of quality or performance issues discussed in the QA/PI meetings. At 11/16/23 12:52 PM, The Assistant Director of Nursing (ADON) was interviewed regarding attendance at QA/PI meetings. The ADON was not familiar with the meeting frequency and stated, We talk about it in the daily stand-up. When asked specifically regarding when the QA/PI meeting is held the ADON replied, I think Quarterly. It has been some time. I'm thinking October? The ADON did not state any QA/PI projects when asked though he offered, We go over things in stand-up. The ADON signature appears on the October QA/PI attendance sheet. At 11/16/23 12:56 PM, the Director of Nursing (DON) was interviewed regarding the QA/PI meeting. The DON replied, Quarterly when asked how often the QA/PI meeting was held. The DON's signature appears on monthly sign in sheets for June, July, August, October and November 2023. The DON has signed he attends the QA/PI meetings consistently on a monthly basis (with exception of September 2023) but states the meetings are only held quarterly. The DON offered that a QA/PI project is fall reduction and that the falls have decreased. The ADON and AO were not aware of falls being a QA/PI project. At 11/16/23 01:49 PM, The Medical Records Director (MRD) member was interviewed as the MR's name appears on the sign in sheets. We have meetings monthly. We work on falls, yes we go over the numbers. Every manager attends. Yes, the Medical Director attends monthly. The Medical Director signature does not appear on the monthly sign in sheets.

Based on observation, interview, and record review the facility did not post daily staffing for public viewing as required by regulation. This failure created the potential for staffing issues including, short staffing, staffing and workload misinformation leading to decreased quality of care and adverse clinical outcomes. Findings: During a concurrent Interview and record review on 11/14/23 at 3:42 PM, the Director of Nursing (DON) attempted to locate the daily staffing posting. When the document for 11/14/23 was not available and determined not to exist the DON stated, It is not here. I will check and see if I can find it and left the DON's office. The DON approached the Assistant Director of Nursing (ADON), asked if the ADON was familiar with the form and had a current copy. The ADON did not have knowledge of the form and did not have a copy. Neither the ADON nor DON had the regulation required documents for the last 18 months. At 3:50 PM on 11/14/23 during a concurrent interview and document review the Facility Administrator (Admin) was not familiar with the requirement for posting daily staffing in a public location and the 18-month retention requirement. The Admin stated, My staffing probably has that but she walked off the job last Sunday. No daily staffing posting document was provided on request. No posting was observed during the survey. The regulatory requirement was provided to the Admin via email. The Admin affirmatively responded, Obviously we haven't been posting it . and affirmed the facility would publicly post the required information for future compliance. 45315

Based on observation, interview, and record review, the facility failed to ensure the five rights of medication administration had been followed for one resident (Resident 53) when Licensed Nurse (LN) F did not know the name or dosage of a medication that LN F provided to Resident 53 and LN F did not document the medication had been given. This failure had the potential for incorrect medication administration, duplication for medication administration, and could cause Resident 53 negative clinical outcomes. Findings: During a review of the facility's policy and procedure (P&P) titled, Administrating Medications, revised 12/1/22, indicated, The individual administering the medication must check the label to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication. The P&P indicated the Individual administering the medication will record in the resident's medical record: the date, time, dose, and sign record. A review of the undated record titled Admission Record indicated Resident 53 was admitted to the facility with the diagnosis of morbid (severe) obesity (more than 80 to 100 pounds over the ideal body weight) and chronic obstructive pulmonary disease (a group of lung diseases that made it difficult to breath). The Admission Record indicated Resident 53 had good cognition (ability to think and recall information) and was her own responsible party (had the ability to make own medical decisions). During a concurrent observation and interview in 11/13/23 at 9:57 am, LN F was observed walking into Resident 53's room with a suppository. Resident 53 stated LNs did not administer the suppository and that Resident 53 would self-administer the suppository. LN F handed a suppository to Resident 53 and left the room. Resident 53 placed the suppository in a box on top of the bedside table and stated Resident 53 would administer the suppository later. During an interview on 11/14/23 at 2:47 pm, LN F stated Resident 53 requested a suppository, an unknown staff member handed LN F a suppository, and was told that Resident 53 administered her own suppositories. LN F stated not looking at the suppository prior to handing it to Resident 53. LN F stated not being aware if the suppository LN F provided to Resident 53 was the suppository that the physician ordered, if it was the right medication, or the right dose. LN F confirmed not signing the Medication Administration Record and stated LN F thought the nurse who gave LN F the suppository signed it out on the Medication Administration Record (MAR). LN F stated LN F did not review Resident 53's order to ensure a different medication was to be used prior to administering the suppository. During a concurrent interview and record review on 11/14/23 at 4:10 pm, with Director if Nurses (DON), Resident 53's MAR, dated 11/1/23 through 11/30/23 was reviewed. DON stated the MAR indicated a suppository had not been signed out by a LN on 11/13/23. DON stated the MAR indicated the physician had ordered a Dulcolax suppository 10 milligrams insert 1 suppository rectally every 24 hours as needed for constipation if milk of magnesia was ineffective. Record if taken. DON stated medication administration expectancy was for LN know the five rights of medication administration which included: LN were to not administer a medication that the LN did not prepare, LN should follow the physician order's, LN are required to know what medication and dose was being given to a resident, and LN needed to sign the MAR to indicate the medication was given to the resident. DON confirmed LN F did not follow facility expectancy or policies for medication administration. A copy of the MAR was requested. The MAR provided had been updated after the record request to include May self-administer this medication by keeping at bedside.

Based on observation, interview, and record review the facility failed to provide sufficient staffing that met the needs of the residents when: 1. Two out of 11 residents (Resident 45 and 50) stated they did not receive a shower due to the facility not having enough staff. 2. Eight out of 11 residents stated they experienced long call light wait time due to the facility not having enough staff. This failure had the potential to result in resident inability to attain or maintain their highest practicable level of physical, mental, and psycho-social well-being. Findings: During a review of the facility's policy and procedure (P&P) titled, Staffing, revised 4/1/21, indicated, Our facility provides adequate staffing to meet needed care and services for our resident population. The P&P indicated, Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. 1. During a review if the facility's P&P titled Shower, revised 5/1/18, indicated, The purposes of this procedure are to promote self-determination and facilitate resident choice regarding shower and bathing to ensure cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The P&P indicated Staff will honor shower and/or bathing preferences such as frequency of shower schedule. During an interview on 11/14/23 at 12:18 pm, CNA L stated on 11/12/23, there was only three CNAs working in the facility. CNA L stated, when the facility was short staffed, the residents did not get their assigned showers, there were long call light wait times, and stated feelings of sadness and concern due to the residents not getting the care they should. CNA L stated, documenting NA (not applicable) in the resident's medical records, when a shower was not provided to a resident due to the facility being short staffed. A review of Resident 45's record titled Bathing, dated 10/19/23 and 10/30/23, indicated, the shower response of NA was selected. During a review of Resident #50's clinical record it indicated admission was on 6/19/23, with diagnoses Unspecified Heart Failure, Diabetes Mellitus (DM), Benign Prostatic Hyperplasia (BPH, enlarged prostate blocking the flow of urine), and bipolar disorder (mental health condition causing extreme mood swings of extreme highs (mania) and lows (depression)). The facility's MDS dated [DATE], rated Resident #50's cognition 12/15, moderately impaired. During a concurrent observation and interview on 11/13/23 at 11:40 am with Resident #50 and family member (FM), Resident #50 was observed to have a full moustache and beard and was lying in bed with clothing that had food remnants noted on the front of the shirt. Resident #50 stated, they are short staffed. I may get one shower a week. I have never been shaven since I have been here, and I like to be clean shaven. FM stated the only things we have problems with are related to getting the resident's clothes changed regularly and sometimes the clothes have had evidence of being soiled with food or even feces. The same clothes have been worn for several days. The resident does wear a brief and has a foley catheter, the brief can leak onto the clothes. We think they are short on staff, across the board short staffed for days and nights. First thing I did today was go to the nurse station and told them I wanted Resident #50 to be changed into the clean clothes I have brought in, and we are still waiting. I just want Resident #50 clean. They must have shaven at some point, but they have not shaven Resident #50 very often, and the preference is clean shaven. I am here every other day, and this is a continuous issue. During a review of Resident #45's clinical record, indicated that Resident 45 was admitted to the facility on [DATE] with diagnoses which included stroke, affecting left non-dominant side, type 2 diabetes (high blood sugar) and muscle weakness. He was his own healthcare decision maker. During a review of Resident #45's MDS, dated [DATE], the MDS indicated that Resident #45 had a BIMS score of 15, at section C Cognitive Patterns indicating that his cognition was intact. During an interview on 11/13/2023 at 12:15 pm in Resident #45's room, with Resident #45, Resident # 45 stated Today is my shower day. They told me that I cannot have my shower because there were only two CNAs on the floor today . During an interview on 11/13/2023 at 12:32 pm with LN A, LN A acknowledged that she was aware that Resident #45 was told that he could not have his shower. LN A said Ya, that was earlier, we had short staff. We have registry now; we can give him shower. I'll go and tell him. During a concurrent observation and interview with HA F on 11/14/23 at 10:00 am regarding the whiteboard of roommates, Resident #34's whiteboard indicated the resident is to be shaven with hygiene and is clean shaven, Resident #50's whiteboard does not have a shaving designation and has a full beard and moustache. HA F stated, there is a shortness of CNAs that is why I am sitting for Resident #34. Typically, this would not be my job. I understand the CNA that was supposed to be here called in or something. We have a lot of call ins. I feel like we are short staffed often. I do feel like our residents suffer. I think the staffer quit last weekend. It didn't matter because staffing is bad at this building anyway. We are assigned [NAME]-nilly kind of. Some days there is a lot of CNAs and some days there's hardly any. Like the other day we only had two CNAs to cover the day. This place is very understaffed. We used to use Registry, but they stopped because we had some bad registry people that did not care for our residents adequately. But we are running so short, people are getting tired and overwhelmed. They have been offering incentives like money to pick up shifts, especially since state is here. We only had two aids on yesterday until you guys showed up then they start calling to recruit. We cannot do a really good job with the lack of staff. As a Hospitality Aid, we are directed to turn lights off and ask what the person wants and help if we can. We cannot often-times and we need to get a nurse or aid and sometimes they aren't available. The lights are timed, so when we turn them off it breaks the time. People for the most part get showered. I mean, sometimes they refuse, or we can't get to them. Shaving should be done as part of a shower, but it does not always happen unless there is a specific reminder written on the resident's white board. There are some residents that don't want a shave, but others that probably do but don't get them because they haven't been put on the list and have the shaving designation written on the white board. We just can't provide what is best for our residents. 2. During a review of the facility's P&P titled, Answering the Call Light, revised 10/2/22, indicated, The purpose of this procedure is to respond to the residents' requests and needs. The P&P indicated staff would Answer the resident's call light as soon as possible and that when staff answered a call light with the intent to come back with an item of information, do so promptly. A review of the undated Admissions Record, indicated Resident 22 was admitted to the facility on [DATE] with the diagnosis of hypertension (high blood pressure) and unsteadiness on feet. Resident 22's cognition (ability to remember, recall information, and think) was intact. During an interview on 11/13/23 at 9:24 am, Resident 22 stated Resident 22's roommate, Resident 14 vomited. Resident 22 stated pressing the call light, along with Resident 14 at approximately 4:30 am and it took one and a half hour for staff to respond to the call light. Resident 22 stated after 15 minutes with no staff response to the call light, Resident 22 turned on a timer, located on Resident 22's personal cell phone. The timer indicated, a time of one hour and 15 minutes, was dated 11/23/23 and the time indicted the personal cell phone timer started 4:45 am. A review of the undated Admissions Record indicated, Resident 55 was admitted to the facility on [DATE] with the diagnosis of repeated falls, muscle weakness, and difficulty in walking. Resident 55 had good cognition and was her own responsible party (RP, made own decisions). During an interview on 11/13/23 at 10:33 am, Resident 55 stated sometimes the facility was short staffed. Resident stated on the night of 11/12/23 at 9:45 pm, pressing the call light. Resident 55 stated, Resident 55 had urinated in the brief (adult diaper) and needed to be cleaned up. Resident 55 stated an hour and a half had passed before facility staff responded to the call light. During an interview in 11/14/23 at 5:22 am, Certified Nurse Assistant H (CNA) stated staffing in the facility had been a challenge due to staff being sick. CNA H stated last week, there were three CNAs for the NOC (nighttime) shift. CNA H stated resident outcomes that could occur when the facility was short staffed included longer call light wait times. During an interview on 11/14/23 at 5:28 am, Licensed Nurse I (LN) stated staffing the facility could be a challenge when you had unforeseen call offs and staff members who just don't show up for their shift. LN I stated normally the NOC shift had two LN and four CNAs. LN I stated one night, recently, only two CNAs had arrived to work the NOC shift. During an interview on 11/14/23 at 5:34 am, with CNA J and CNA K, CNA J stated, on 11/11/23, there were two CNAs on the NOC shift and on 11/12/23 there was three CNAs. CNA J and CNA K both stated when the facility was short staffed on the NOC shift, it was not possible to perform good resident care, there was an inability to perform every two-hour rounding (checking residents to see if they were incontinent of urine or stool and repositioning a resident to prevent wounds), and call light wait times were longer. During an interview on 11/14/23 at 5:41 am, LN M confirmed working a NOC shift with only two CNAs recently. A review of the undated Admissions Record indicated Resident 14 was admitted to the facility 3/12/18 with the diagnosis of chronic obstructive pulmonary disease (a lung disease that caused difficulty in breathing). A review of the record titled, Cognitive Patterns, dated 10/28/23, indicated, Resident 14 had good cognition. A review if the record titled, Functional Abilities and Goals, dated 10/28/23, indicated, Resident 14 was dependent (helper does all the work) with bathing, rolling from side to side in the bed, and was not able to sit up in bed without assistance from facility staff. During an interview on 11/14/23 at 8:15 am, Resident 14 stated around 4:30 am on 11/13/23, Resident 14 vomited all over self. Resident 14 stated pressing the call light for staff assistance and it took over an hour and half for staff to respond to the call light. Resident 14 stated, one time Resident 14 wanted out of bed and needed assistance getting into the chair. Resident 14 stated it took a long time before staff responded to the call light and I never got to sit in my chair. Resident 14 stated when staff did not respond to the call light it made me feel like I wasn't worth much and they don't care about me. Resident 14's roommate, Resident 22, stated feeling the same way when staff did not respond to the call lights in a timely manner. Resident 133 was admitted to the facility on [DATE] with a diagnosis including arthritis and muscle weakness. Resident 133 (R133) was at the facility for strengthening and rehabilitation for returning to her home. On 11/13/23 at 8:50 AM Resident 133 was observed having physical therapy. Resident 133 was interviewed regarding care and staffing in the facility. Resident 133 stated, There are slow responses to call lights. It takes up to 30 minutes before they come to answer them. I can hear them helping others and I don't need anything urgent. So, I just wait. Resident 133 denies having incontinence due to waiting for staff to answer her call light. Resident 136 was admitted to the facility on [DATE] with a diagnosis including Vertigo (Dizziness) and falling. Resident 136 needed assistance to get out of bed due to her history of falling and dizziness. On 11/13/23 at 9:04 AM Resident 136 was observed lying in bed at 9:04 AM with distinct odor of urine present in her room. Resident 136 was questioned of needing staff to assist with toileting. Resident 136 said, I have a wet bed and need changed. Resident 136 answered questions regarding incontinence and lying in a wet bed by stating, it happens all the time. Resident 136 turned on her call light and waited for staff to answer her call for help. It took 2 minutes 40 seconds for the call light to be answered by a hospitality aid (HA). The HA asked what Resident 136 needed. Resident 136 answered, My bed is wet, and I need to go to the restroom. The HA replied that she would send someone to help and left the room. An additional 39 minutes and 11 seconds passed before a CNA returned to provide incontinent care and change bedding. Resident 136 stated, This happens all the time. My bottom is getting sore. During a review of Resident #6's clinical record, indicated that Resident #6 was admitted to the facility on [DATE] with diagnoses which included stroke, affecting left non-dominant side, chronic pain, right below-knee amputation (a surgery to remove the right leg below the knee), and muscle weakness. She was her own healthcare decision maker. During a review of Resident #6's Minimum Data Set (MDS - an assessment and care screening tool),, dated 8/29/2023, the MDS indicated that Resident #6 had a brief interview for mental status (BIMS) score of 15, at section C Cognitive Patterns indicating that her cognition was intact. During an interview on 11/13/2023 at 9:27 am in Resident #6's room, Resident #6 stated they took forever to come her, they didn't have enough help .I pushed the bottom, waited for a long time to be changed. It's horrible. During a review of Resident #70's clinical record it indicated admission was on 9/22/23, with diagnoses of Systolic and Diastolic Congestive Heart Failure (CHF, heart works less efficiently pumping blood, oxygen, and nutrients), and Chronic Pulmonary Edema (long term and progressive fluid collecting in the air sacs of the lungs making it difficult to breathe). The facility's MDS (minimum data set, a standardized assessment tool) dated 9/26/23 rated Resident #70's cognition 13/15, cognitively intact. During an interview on 11/13/23 at 11:00 am with Resident #70, who stated, occasionally, it looks like they don't have enough staff, it takes a while for them to answer the call light. During a review of Resident # 8's clinical record it indicated admission was on 2/13/23, with diagnoses Acute and Chronic Respiratory Failure (condition that makes it difficult to breathe by oneself, which develops when the lungs cannot get enough oxygen in the blood and retain carbon dioxide), Chronic Obstructive Pulmonary Disease (COPD, progressive lung disease with respiratory difficulty and airflow limitations), and DM. The facility's MDS dated [DATE] rated Resident #8's cognition 13/15, cognitively intact. During an interview on 11/13/23 at 12:15 pm with Resident #8, who stated, On the day shift it is better for answering the call light. I always look at the clock when I push the button. I have waited up to an hour for the call light, mostly nights. There are Hospitality Aids during the day to help buffer the staff. I will press my light and the helpers will come in and ask what I need. I will say I need my CNA and they will turn my light off and say they will go get them, but never return. I just turn my light back on. During a review of Resident # 11's clinical record it indicated admission was on 5/20/23, with diagnoses COPD, Rectal Prolapse (part of the large intestine bulges outside the anus), right lower leg Cellulitis (RLL Cellulitis, bacterial infection involving inner layers of the skin causing redness, warmth, pain, and swelling). The facility's MDS dated [DATE], rated Resident #11's cognition 14/15, cognitively intact. During an interview on 11/14/23 at 09:00 am with Resident #11, who stated, two weekends in a row we were so short staffed, one CNA to 40 residents, today there were only two CNAs on. It happens on the weekend and mostly at nighttime. I stay awake at night worried when we are so short staffed. I have watched the clock and there was a time it took two hours. There was a time that I was sitting in liquid shit for an hour, I had the call light on for a hour. I had to call a FM to call the Nurse's station to have someone come help me. I do not feel safe with the lack of staff available to take care of me. When it takes a lot of time to answer the light, they usually will say that they are short staffed. I was told they have a special machine that keeps track of how long the lights were on. They hired a few Hospitality Aids that I have been told cannot touch me, but they come in and turn out the call light and ask me what I need. This stops the light timing. They will not do anything for me, they say they will tell the CNA or the nurse. They always turn the call light off, but don't always get back to me with the CNA or nurse timely. I will wake up covered in poop and then call the nurse, but it takes a long time for them to get to the call light to help me. During a review of Resident # 18's clinical record it indicated admission was on 11/28/15, with diagnoses Metabolic Encephalopathy (Chemical imbalance in the blood that causes problems in the brain), COPD, and Parkinson's Disease (Progressive central nervous system disorder affecting parts of the body controlled by nerves such as movement, often including tremors). The facility's MDS dated [DATE], rated Resident #18's cognition 15/15, cognitively intact. During an interview on 11/13/23 at 1:00 pm with Resident #18's family member, who stated, my only concerns is that they have such a turnover of workers and they do not know Resident 18's diagnoses or how to respond to symptoms, they do not know what is going on because they do not know the residents. Oftentimes, they seem very short staffed. During a review of the facility's P&P titled, Resident Council, revised 12/1/06, indicated, A Resident Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible to address the item(s) of concern. During a confidential interview on 11/15/23 at 1:50 pm, one out of 11 residents stated not receiving a scheduled shower and three out of 11 residents stated they experienced long call light wait times due to the facility not having enough staff. Residents expressed feelings of frustration, inability to sleep, and a burning sensation on the inner thighs due to sitting in a brief full of urine that was not changed in a timely manner. A review of the record titled, Resident Council Minutes, dated 9/14/23, indicated, old business (review of last month's meeting minutes) of call lights not answered timely (all shifts) had not been resolved. A review of the record titled Resident Council Minutes, dated 10/19/23, indicated, old business (review of last month's meeting minutes) of call light concerns had not been resolved. A review of the record titled Resident Council Minutes, dated 11/9/23, indicated, old business (review of last month's meeting minutes) of call light concerns had not been resolved. During a concurrent observation and interview on 11/15/23 at 3:23 pm, with Director of Nursing (DON), DON stated call light wait time expectancy was for staff to answer the call light within three to five minutes. DON stated all staff employed in the facility were expected to answer call lights. DON stated there was a display screen at the nurse station that showed which room had a call light on and for how long the call light had been ringing. DON walked over to the nurse station, where four staff members were sitting in chairs and one staff member was standing, using a cell phone. DON stated the call light display monitor indicated the resident in room [ROOM NUMBER]B had pressed the call light 10 minutes ago. DON requested staff to respond to the call light. DON stated barriers for timely call light answering could be due to lack of staff urgency, staff were caught up with other resident care, and when the facility was short staffed. DON stated it was a challenge to staff PM (evening) and NOC shifts. DON stated facility staffing ratios (the number of residents assigned to one LN or CNA) was dependent on resident census (number of residents that lived in the facility) as follows: AM (morning) shift required three LN and five to eight CNAs, PM shift was three LN, five to seven CNAs, NOC shift was two LN and three to five CNAs. DON clarified the number of CNAs required per shift did not include the Restorative Nursing Assistants. During an observation on 11/15/23 at 3:48 pm, located in hall 2, the call light for room [ROOM NUMBER] was on upon arrival. A housekeeper, the Social Services Director, and the DON were observed to walk past the call light without answering it. During a concurrent record review and interview on 11/16/23 at 9:20 am, with Human Resources (HR), an untitled record with the date 11/11/23 was reviewed. HR stated the untitled record was time punches for the staff members who worked on 11/11/23. HR stated the untitled record indicated, on 11/11/23, the PM shift had two LN, and two CNAs. The untitled record indicated there were no LN working the NOC shift and there were three CNAs. HR stated the facility would have utilized registry (travel nurse, employed by a third party) LN for NOC shift on 11/11/23. A request for registry time sheets had been made. HR reviewed the untitled record with the date of 11/12/23, and stated the untitled document indicated, the AM shift had three LN, the PM shift had two LN and three CNAs, the NOC shift had 1 LN. A review of the facility record titled Daily Census, dated Saturday, 11/11/23, indicated, the facility had 81 residents. A review of the facility record titled Daily Census, dated Sunday, 11/12/23, indicated the facility had 80 residents. On 11/16/23 at 1:15 pm, a second request was made for registry time sheets. During an interview on 11/16/23 at 1:26 PM, the facility's Administrator (ADMIN) stated when the facility had a census of 80, the staffing expectancy was as follows: the AM shift would have four LN and seven CNAs, the PM shift would have four LN and seven CNAs, the NOC shift would have two LN and four CNAs. ADMIN stated when facility staff called in, the expectation was to utilize the facility's own staff to cover the needed shifts and staff currently working would be asked to work a double (two, eight hour shifts in a row). ADMIN stated if the facility's staff was not able to work the extra hours, a registry service would be utilized. ADMIN stated if the facility was not able to obtain registry staff, a last resort would be for the facility would utilize department heads (DON, Social Services Director, Director of Staff Development, and Admissions Coordinator) to float (answer call lights, pick up meal trays, wiping down a bedside table, and provide water if needed). ADMIN stated the department heads being utilized as floaters were not required to change diapers and performed tasks as requested by the CNA who was responsible for direct resident care. ADMIN stated there had been low staffing on some weekends; when three to five CNAs do not show up for work, weekends were tough to staff, and confirmed low staffing could contribute to long call light wait times and showers not being provided to the residents. Registry time sheets were requested a third time and not provided. 43739 43031

Based on observation, interview, and record review, the facility failed to maintain the facility in a safe and operable manner and provide a homelike environment when: 1. A handrail at the end of Hall 3 was not attached securely to the wall, sections of the ceiling had missing and peeling popcorn texture (a sprayed on bumpy texture that was applied to the ceiling) on Hall 3 and near the nurse station. 2. Five of 13 sampled residents (Residents 18, 75, 46, 55, and 27) expressed that their belongings were missing. This failure had the potential to cause resident harm and resulted in residents' inability to access their own belongings and had the potential to foster an environment that was not home-like. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, revised 10/1/09, indicated Maintenance service shall be provided to all areas of the building, grounds, and equipment. The P&P indicated maintenance personnel were responsible for Maintaining the building in good repair. During a review of the facility's P&P titled, Homelike Environment, revised 5/1/22, indicated, Residents are provided with a safe, comfortable, and homelike environment During a concurrent observation and interview on 11/15/23 at 10:23 am with Maintenance Supervisor (MS) the handrail at the end of Hall 3 to the left was observed. MS stated maintenance staff performed daily rounding of the facility and would shake the handrails to assure they were attached securely to the wall. MS observed the handrail and confirmed it was no longer attached to the metal wall fastener and was not safe for resident use. MS observed an area of the ceiling, located on Hall 3, in-between the fire sprinkler and a light fixture, and confirmed a section of the popcorn texture on the ceiling was peeling and missing. MS observed a large section of the ceiling near the nurse's station and stated the popcorn texture was missing and the edges had a visible gap of space between the popcorn texture and the ceiling. MS stated over a year ago there had been a water leak from the facility's air conditioning unit that was located on the roof. MS stated the water leak had caused damage to the ceiling where the popcorn texture was missing near the nurse's station. MS stated the popcorn texture had been peeling in different sections throughout the facility, the plan was to replace the all the popcorn texture, and a company had been contacted to obtain a quote for the cost of the repair. A request was made to review a copy of the quote, MS stated there was no documentation and the quote was provided over the phone. 2. A review of the facility's policy titled, Resident Rights, revised October 2022, indicated that residents have the right to retain and use personal possessions A review of the facility's record titled discharge notes for resident 75, dated 11/14/23, indicated that resident 75's cell phone was missing upon discharge. In an interview on 11/13/23 at 9:15 AM, Resident 18 stated that he had brought in three shirts and two pair of pants that were laundered and misplaced by the facility. In a group resident interview on 11/15/23 at 1:45 PM, three of 11 sampled residents (Residents 46, 55, and 27) stated they were missing belongings. Resident 55 stated that she was missing two pairs of pants because there was another resident in the facility with the same name, so they get mixed up. Resident 46 stated that the facility lost her pair of purple sweatpants a week ago and she then saw a male resident wearing them. A family member of Resident 27 stated in the group interview that Resident 27 was given two beautiful blankets, and we've never been able to find them. I walk down the hallway and find other people wearing the things I brought for my mother. In an interview on 11/15/23 at 3:52 PM, Social Services Director (SSD) acknowledged that there had been quite a few residents who had missing items because families don't label them. The facility has been working on finding a way to ensure everything families bring in gets labeled and that they are working on ways to improve the situation. 41715

Based on observation, interview, and record review the facility failed to follow its Administrating Medications policy and procedure (P&P) for one out of one resident (Resident 53) when Resident 53 was provided a suppository (a meltable medication placed into the rectum) for self-administration. This failure had the potential for incorrect medication administration and could cause Resident 53 negative clinical outcomes. Findings: During a review of the facility's P&P titled, Administrating Medications, revised 12/1/22, indicated, Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. A review of the undated record titled Admission Record indicated Resident 53 was admitted to the facility with the diagnosis of morbid (severe) obesity (more than 80 to 100 pounds over the ideal body weight) and chronic obstructive pulmonary disease (a group of lung diseases that made it difficult to breath). The Admission Record indicated Resident 53 had good cognition (ability to think and recall information) and was her own responsible party (had the ability to make own medical decisions). During a concurrent observation and interview on 11/13/23 at 9:57 am, Licensed Nurse F (LN) was observed walking into Resident 53's room with a suppository. Resident 53 stated LNs did not administer the suppository and that Resident 53 would self-administer the suppository. LN F handed a suppository to Resident 53 and left the room. Resident 53 placed the suppository in a box on top of the bedside table and stated Resident 53 would administer the suppository later. During an interview on 11/14/23 at 2:47 pm, LN F stated being registry staff (a travel nurse that worked at the facility and was employed by a third party), it was LN F's first day at the facility, and was not familiar with the residents. LN F confirmed handing a suppository to Resident 53 and stated, another staff member told me that Resident 53 always administered her own suppositories. LN F stated unawareness if there was a physician's order for the suppository or if Resident 53 had been assessed for self-administration of medication. LN F confirmed LN F should have reviewed Resident 53's medical records prior to handing Resident 53 the suppository and did not. During a concurrent interview and record review on 11/14/23 at 4:10 pm, with Director of Nurses (DON), Resident 53's Orders was reviewed. DON stated the Orders indicated the physician had not provided an order for Resident 53 to self-administer medication. DON reviewed all IDT Meeting Notes that had been entered into Resident 53's medical record and stated there was not an IDT Meeting Note present that indicated the IDT team had assessed Resident 53 for safety of self-administration of medication and there should have been.

Based on observation, interview, and record review, the facility did not provide routine showers and/or baths consistent with the residents' needs and choices for 11of 23 (Resident 5, 8, 9, 10, 11, 14, 16, 17, 20, 25, and 26) sampled residents. This failure had the potential to result in depression, poor self-esteem, skin breakdown, infection, and denial of resident rights, all of which could lead to negative clinical outcomes for all residents. 49418 Findings: Review of a facility policy titled Bath; Bed Bath, No-Rinse Sponge Bath (undated) indicated baths were to be given to residents to provide cleanliness, comfort, and to prevent body odors. The policy indicated, All residents are given baths unless contraindicated (not advised). The policy indicated bath water should be comfortably warm (between 95- and 110-degrees Fahrenheit) and should be changed intermittently throughout the process when the water becomes too cool or dirty. During review of record titled Resident Council Minutes, dated 7/20/2023 at 1:45 pm, shower was indicated as a concern regarding nursing care. During observational tour of the facility on 10/13/2023 at 8:50 am, overheard Resident 8 ask Director of Nursing (DON) when hot water for showers would be available. DON stated, That was fixed Wednesday (10/11/2023). Resident 8 stated, It ' s been out for like a week. DON restated that maintenance staff had resolved the issue. During observation on 10/13/2023 at 12:30 pm, a facility staff member handed this surveyor a note indicating, the facility has not been giving residents showers due to no hot water! They do not have any shower caps for alternatives. -Anonymous (sic). During record review of Shower Day Skin Inspection for 19 residents, the records indicated: On 10/6/2023, Resident 17 refused a bath or shower. On 10/10/2023, the record did not indicate a shower or bath had been provided for Resident 5. On 10/11/2023, Residents 9 and 20 refused a bath or shower. On 10/12/2023, Resident 11 refused shower or bath. On 10/16/2023, Resident 8 refused [shower] due to water pressure. The form did not indicate a shower or bath had been provided for Resident 21. On 10/18/2023, Resident 9 refused a bath or shower. During an interview on 10/19/2023 at 9:05 am with Administrator (ADM 1), ADM 1 stated the facility had purchased a bunch of wipes for bed baths because the facility had no hot water since last night. ADM 1 stated the facility planned to bring in an extra Certified Nurse Assistant (CNA) when hot water was back to catch up on showers. ADM 1 stated one of two water heaters was shut off yesterday (10/18/2023) for repair, but since that time a new water leak had been discovered. During a concurrent interview on 10/19/2023 at 9:05 am with Maintenance Supervisor (MS), MS stated a water leak had been discovered in the dining room at 6:00 am, and water to the facility had been shut off shortly thereafter so the leak could be fixed. During an interview on 10/19/2023 at 9:20 am, CNA 3 stated water in the facility runs warm but cools quickly, which has caused residents to decline showers. CNA 3 stated the hot water had been an issue since last Friday. During an interview on 10/19/2023 at 9:35 am, CNA 5 stated the DON was not admitting to residents there was no hot water. During an interview on 10/19/2023 at 9:37 am, Resident 14 stated she hadn ' t had a shower and the water was cold. During an interview on 10/19/2023 at 9:38 am, Resident 25 stated it had been about a week with no shower or bed bath. During an interview on 10/19/2023 at 9:40 am, Resident 8 stated she had asked DON on 10/13/2023 about no hot water for showers. Resident 8 stated the hot water had been out about a week at that time, but now it's been two weeks. Resident 8 stated showers had been offered by staff, but the resident refused because showers were cold. Resident 8 stated wipes had been offered for bed baths, but that's not going to get me clean, either. Resident 8 stated she had refused wipes. During an interview on 10/19/2023 at 9:45 am, Resident 26 stated, It ' s about time you got here. I want a hot shower. It ' s been 15 days. Resident 26 stated he was very frustrated and had a fit about it. During an interview on 10/19/2023 at 9:50 am, Resident 9 stated there had not been hot water in the facility for 15 days. Resident 9 stated, That's close to elder abuse. Resident 9 stated her home was near the facility and that she was able to go home to shower, but she feels awful and is pissed she can't wash her hair at the facility. Resident 9 stated it has been a long time with no accommodation. Resident 9 stated, I feel left behind. I ' m pretty independent, so they don ' t check on me very much. During an interview on 10/19/2023 at 9:50 am, Housekeeper (HK) stated residents had been complaining about no hot water and not getting showers, particularly Resident 16. During an interview on 10/19/2023 at 11:10 am, CNA 1 stated the facility had no hot water for almost three weeks. CNA 1 stated a family complained about lack of bathing their bedbound family member and reported she heated water in a microwave to do a bed bath. CNA 1 reported another resident wanted a shower prior to dialysis. CNA 1 stated she reported the issue to Staffing Coordinator (SC) and was told to use a shower cap with soap in it to wash the resident's hair. CNA 1 stated, Residents are complaining about showers. I was told just do what you can.

Based on interview and record review, the facility failed to ensure a safe and orderly discharge for 1 of 12 sampled residents when Resident 1 was inappropriately discharged to a room and board (unlicensed living arrangement where lodging and food are furnished for a set price, non-medical, landlord tenant situation where resident does not need 24 hour supervision) where his physical and psychosocial needs could not be met, and without proper assessment, evaluation, preparation, ancillary healthcare services referrals (Home health nursing and physical and occupational therapies) and follow up physician appointments. This failure resulted in Resident 1 being discharged to a place that could not provide adequate care for his needs, such as supervision, behavior monitoring, medication administration, and wound care, jeopardizing his health and welfare, placing him at risk for harm. The room and board owners called 9-1-1 and the police responded and transported Resident 1 to a hospital for further evaluation and treatment, where he required constant hospital staff supervision and psychiatric evaluation and treatment. Immediate Jeopardy (IJ) was declared with the facility's administrator (Admin) on 10/19/16 at 3:30 pm, for the inappropriate, unsafe discharge of Resident 1. The IJ was removed on 10/24/16 at 1:30 pm, with the acting Admin and Registered Nurse Consultants (CRNs A and B) after the facility provided an acceptable immediate corrective action plan on 10/21/16 at 5:40 pm, and implementation of the corrective action plan was verified on 10/24/16 at 1:30 pm. Findings: On 10/10/16, the California Department of Public Health (CDPH) received a complaint alleging that Resident 1 was discharged to a room and board establishment and the facility did not disclose the resident's behavior. Resident 1 became agitated and threatened to kill his roommate and brought by the police to a hospital for further evaluation and treatment. The facility refused to take the resident back. The complainant alleged that the facility's administrator was involved in the transfer to the room and board. Review of a nursing progress note, dated 7/29/16 at 10:13 pm, indicated Resident 1 was a new admission to facility with [DIAGNOSES REDACTED]. The Director of Nursing (DON) was notified of these behaviors, and due to facility not being able to care for Resident 1 safely, he was sent back to the hospital. A review of Resident 1's record indicated he was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED].([MEDICAL CONDITION], lung condition that makes it difficult to breathe that is not curable), and [MEDICAL CONDITION] (afib, irregular heartbeat) on [MEDICATION NAME] (blood thinning medication used to prevent blood clots caused by [MEDICAL CONDITION]). Resident 1's record indicated he was not his own decision maker and he had a payee (a person who manages finances for an individual who cannot manage their own benefits) in place. Resident 1 was a full code (all resuscitative efforts are to be taken to save life). Review of a nursing progress note, dated 7/30/16 at 5:17 pm, indicated he was readmitted from the hospital, and did not include [DIAGNOSES REDACTED]. The facility notified Resident 1's daughter of his admission and she informed the facility that Resident 1 had a history of [REDACTED]., prior to hospitalization . Resident 1's daughter was informed by hospital staff that Resident 1 needed to be in a locked down facility. A review of the facility's Interdisciplinary team (IDT, a team of facility staff who meet to review and plan for resident care needs) progress notes, for Resident 1, dated 8/1/16 at 1:10 pm, included the attendees: Director of Staff Development (DSD), the Administrator (Admin), and Director of Nursing (DON). The IDT note indicated Resident 1's discharge plan was for Resident 1 to return to the community, closer to his sister. Resident 1's family, social services, and physician did not attend the IDT meeting. A review of an IDT conference note, dated 8/2/16, conducted by Social Services Director (SSD) with therapy staff present, attended by Resident 1 and Resident 1's sister (via telephone), indicated the family wanted Resident 1 to stay at the facility as a long term resident. Resident 1's sister stated she wanted Resident 1 to be conserved by the County (a legally appointed decision maker), and he already had a payee. Review of a social services progress note, dated 8/9/16 at 6:47 pm, indicated Resident 1 refused wound care and would not wear a [DEVICE] (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds). The progress note indicated Resident 1 wanted to return to his previous board and care. According to the California Advocates for Nursing Home Reform (CANHR) website, board and care and assisted living facilities are for care and supervision of people who are unable to live by themselves, but who do not need 24 hour nursing care. They are considered non-medical facilities and are not required to have nurses, certified nursing assistants, or physicians on staff. Review of a nursing progress note, dated 8/15/16, indicated Resident 1 required skilled nursing care related to his [MEDICAL CONDITIONS] and [MEDICAL CONDITION] (painful, inflamed, infected skin tissue) of left lower extremity (LLE). Resident 1 had a LLE open wound and prescribed wound care treatments, was forgetful, required supervision for all transfers, and received narcotic pain medication for leg pain. Resident 1 was prescribed [MEDICATION NAME] (blood thinning medication to prevent clots) and the dosage was being adjusted due to abnormal laboratory values per a international normalized ratio (INR, a lab measurement to determine the effects of [MEDICATION NAME] on the body's blood clotting) results. Resident 1 required frequent monitoring and redirection by nursing staff for inappropriate behaviors. A review of the facility's minimum data set (MDS, a resident assessment), dated 8/16/16, indicated Resident 1 had a BIMS score of 13 out of 15 (a mental capacity test that determines the ability to think and reason), no identified mood disorder, required limited assistance with bed mobility, transfers, walking, dressing and toileting, limited to extensive assistance with bathing and hygiene, was independent for eating, continent of bowel and bladder, and experienced pain, daily. A social services progress note, dated 8/17/16 at 10:17 am, indicated Resident 1 could not be readmitted to his previous board and care. Review of a Nurse Practitioner (NP) progress note, dated 8/22/16 at 10:34 am, indicated Resident 1 attempted to elope (leave the facility, undetected) several times. Resident 1 was only oriented to person (himself). Resident 1 was unable to return to previous board and care, due to family problems. NP Stated that his [DEVICE] was discontinued due to the resident removing it. A review of the facility's nurses notes, dated from 7/31/16 through 8/31/16 indicated the following: Resident removed his wound vac which had to be replaced by nursing. Laboratory values for [MEDICATION NAME] and INR were abnormal, requiring blood thinning medication ([MEDICATION NAME]) dosage adjustments. Resident 1 occasionally refused care but was noted to be mostly cooperative, pleasant, alert, confused, forgetful, required redirection and supervision for all transfers. Resident 1's diet included added nutritional supplements, vitamins and snacks twice daily for wound healing. Due to the resident removing the wound vac twice in 24 hours, it was discontinued, and new orders were received for an absorbent dressing to be applied and covered with kerlix and ace wrap. Resident required supervision for all transfers and toileting. Resident 1 had orders for ear drops and lavage and antibiotics for the LLE wound. Resident 1 was occasionally noncompliant with LLE wound dressing changes. Resident 1 exhibited behaviors of repeating himself verbally several times after spoken to and taking his clothes off several times throughout the day and required supervision for basic ADLs, bed mobility, and transferring. Resident 1 expressed having pain by removing LLE wound dressing and picking at his wound to left medial ankle described to have purulent drainage and reddened tissue surrounding the wound, and pain was treated with narcotic medication. Resident 1 required skilled care for his [MEDICAL CONDITION] and LLE [MEDICAL CONDITION]/wound. Resident 1's LLE wound was open and had deteriorated. Resident 1 had many verbal outbursts daily, pulled his pants down and urinated on a tree outside the facility in the presence of residents and visitors. Became verbally loud and aggressive with staff (treated with [MEDICATION NAME]). Required limited one person assistance required with transfers, dressing and hygiene, had multiple anger outbursts, and required supervision for all transfers and toileting. Occasionally refused medications. Required redirection for aggressive behaviors and many inappropriate verbal outbursts. A review of the facility's Discharge and Transfer-Notice of proposed transfer discharge, dated 9/6/16 at 2:46 pm, stated Resident 1 was to be discharged on [DATE] to a board and care, due to his health improving, no longer needing services provided by the facility. The document was not signed by Resident's responsible party or physician. There were no physician progress notes [REDACTED]. Resident 1 was still requiring wound care to his LLE and INR monitoring for his [MEDICATION NAME] dosage, which was being changed frequently due to his INR not being in a therapeutic range. Review of a NP progress note, dated 9/7/16 at 10:26 am, indicated Resident 1 was only oriented to himself and on [MEDICATION NAME] requiring INR monitoring. Resident 1 was started on [MEDICATION NAME] (an antipsychotic medication used to decrease mood instability) for elopement attempts and aggressive behavior toward staff. Resident 1 was to be discharged to an assisted living facility (a licensed 16+ bed, non-medical facility that provides room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring). The NP recommended Resident 1's [MEDICATION NAME] was to be discontinued because INR monitoring could not be done at an independent living facility, and Xarelto (another medication used to prevent blood clots) was to be started. Review of a social services progress note, dated 9/8/16 at 12:05 pm, indicated Resident 1 was not accepted to the retirement home because the owners of the home stated resident was unstable to go there. Review of a social services progress note, dated 9/12/16 at 10:37 pm, indicated despite receiving denials from two different board and care homes, due to Resident 1's inappropriate behaviors, declining orientation status, unable to make decisions on his own, the facility's plan continued to be look for lower level placement, for Resident 1. A review of nursing progress notes indicated he continued to have inappropriate behaviors from 9/9/16 through discharge on 9/27/16 despite the start of [MEDICATION NAME]. Review of a Physician's Report for Residential Care Facilities for the Elderly, signed by the physician (MD A) on 9/23/16, indicated residential care level includes primarily non-medical care and supervision to meet the needs of the person and DO NOT PROVIDE SKILLED NURSING CARE. The document indicated Resident 1 was examined on 9/23/16, was 6'1 tall and weighed 253 pounds, could not manage his own treatment/medication/ equipment, and had mild cognitive impairment (defined as a conditional state between normal aging and dementia). The document indicated Resident 1 did not have confusion or inappropriate, aggressive or wandering behaviors and was not able to leave the facility unassisted. The document indicated Resident 1 was not able to administer his own medications or oxygen. Physical health status was Good. A review of the facility's nurses notes, dated from 9/1/16 through 9/27/16 indicated the following: Resident 1 occasionally refused medications, was found walking outside nude, was uncooperative with care, continued to require [MEDICATION NAME] dosage adjustments for abnormal INR levels, his LLE wound measured 2.5 centimeters (cm) by 5.6 cm by 0.3 cm and was draining fluid. Required one person assistance for ADLs and daily skilled nursing care related to [MEDICAL CONDITION] and LLE [MEDICAL CONDITION]/wound and medicated for pain and anxiety, continued to require daily dressing changes performed by a treatment nurse, exhibited episodes of being verbally aggressive and inappropriate, requiring redirection for inappropriate behaviors and [MEDICATION NAME] for increased anxiety, and was started on a new antipsychotic medication, [MEDICATION NAME] 0.5 mg every bedtime, for mood instability. [MEDICATION NAME] was stopped and a new medication, Xarelto, was started. Resident 1 was educated by the speech therapist to stop verbal inappropriateness and behavior with the new facility. On 9/7/16 at 5:40 pm, new order received from NP for OK to discharge to Columbian Retirement Home with meds, HH/PT/OT for strengthening when arrangements made. On 9/8/16, Columbian owner's refused to take Resident 1. On 9/9/16, [MEDICATION NAME] medication was increased to 0.5 mg bid and bid prn. On 9/10/16, Resident 1 required one person assist with ADLs and minimal assistance with transfers, and was alert and oriented to himself only. Resident 1 continued to require daily skilled nursing care for [MEDICAL CONDITION] and LLE [MEDICAL CONDITION]/wound. Resident 1 went outside unattended for about 5 minutes, and after unsuccessful attempts to redirect, exhibited verbal outbursts towards staff. Resident 1 continued to receive narcotic pain medication for leg pain, [MEDICATION NAME] for anxiety, and wound dressing changes (cleanse with normal saline, pat dry, cover with calcium alginate rope and dry dressing). On 9/19/16, Resident 1 required redirection for angry outbursts. Review of the facilities September 2016 Medication Administration Record [REDACTED]. A review of the facility's Discharge/Transfer Report indicated Resident 1 was discharged home on 9/27/16. Resident 1's records indicated he was discharged from the facility on 9/27/16 to a room and board establishment. There was no indication of a plan or orientation process in place to smooth Resident 1's transition from one facility to another. The records showed no discharge summary with medications list that provided important information for the new accepting facility to adequately care for Resident 1. During Resident 1's entire stay at the facility there was no IDT note indicating resident was adequately assessed for appropriate discharge to a lower level of care. A written Right of Appeal of Discharge was not in his record for discharge on 9/27/16. During an interview with hospital staff A (a registered nurse) on 10/11/16 at 10:30 am she stated Resident 1 was brought to the hospital by police officers after he was arrested at a room and board establishment. She stated that Resident 1 had a history of [REDACTED]. Resident 1 made multiple attempts to elope from the hospital and numerous threats to kill staff, requiring a one to one sitter (medical professional designated to directly supervise resident at all times). Hospital staff A stated the facility was called about the status of Resident 1 and they refused to take the resident back. Hospital staff A stated Resident 1 was dumped by the facility, resulting in an inappropriate discharge. During an interview with room and board (to where the administrator drove Resident 1 in a car) owner (RB) on 10/11/16 at 1:34 pm and continued on 10/13/16 at 1:00 pm, he stated, we are a room and board, not a board and care. RB stated the facility told him Resident 1 was independent, high functioning and did not need help with his medications. RB stated the plan was to provide Resident 1 with three meals a day, a room to sleep in, and for him to be independent and compliant with normal landlord/tenant rules. The owner stated Resident 1 arrived at 3:15 pm on 9/27/16, with a large bag of medications, and no instructions. He did not know anything about Resident 1's wound on his left leg. RB described Resident 1 as having aggressive behaviors towards the other room and board tenants. RB stated Resident 1 was stealing food from others, threatening to hurt them, and shoved his roommate and said I'll kick your ass . pour this soda in your face. Resident 1 arranged the stolen food in a line and told his roommate not to touch my food. RB's wife attempted to speak with Resident 1 about his behaviors, he threatened to hurt her. RB stated the resident had been at his room and board for less than 24 hours when they had to call 9-1-1 for assistance with Resident 1. The police arrived and Resident 1 threatened his roommate in front of the police, they arrested him and stated he was not appropriate to stay at the room and board establishment. During an interview with SSD on 10/11/16 at 2:55 pm, she stated she was not involved in Resident 1's discharge, the Admin was involved with arrangement of the discharge. SSD indicated Resident 1 wanted to go back to his original board and care, but they would not take him back due to issues surrounding resident and family. She stated he was originally accepted to another local board and care, but was denied admittance due to his behaviors. SSD stated Resident 1's family wanted resident to go to a locked facility due to his behaviors. SSD described Resident 1 to be loud and stated he would get in people's faces, he liked to sunbathe and would get naked outside. SSD stated Resident 1 had improved physically while at the facility because he was able to walk on his own, however, mentally and psychosocially he declined and was not a good candidate for a board and care. The SSD stated she had not made the ordered referrals for HH/PT/OT, prior to or on the day of, Resident 1's discharge on 9/27/16. During an interview with Resident 1's daughter on 10/12/16 at 8:45 am, she stated the only information given to her in regards to Resident 1's discharge was that he was being transferred to an assisted living place in Sacramento. She stated the facility gave her the name and address and she was not notified in writing or given discharge appeal rights. She stated that Resident 1 had a history of [REDACTED]. She stated that Resident 1 needed constant supervision due to his behaviors and she was under the impression that the assisted living would be able to provide constant supervision to her father. During an interview with the Admin on 10/12/16 at 10:25 am, he stated Resident 1 was desperate to leave the facility and his daughter was excited for him to go. The Admin stated, I didn't give them anything in writing, and indicated he texted the name and address of the accepting facility to the daughter, further stating, There was no reason to give them the right to appeal. A review of the facility's Observation Report: Discharge and Transfer-Discharge plan of care, originally created by the SSD on 9/6/16 at 2:40 pm, indicated Resident 1 was to be discharged on [DATE]. The 9/8/16 date was lined out and replaced with a different hand written discharge date of [DATE], and timed 2:00 pm. A new observation report was never generated for Resident 1's actual discharge that occurred on 9/27/16. The report stated the NHA (nursing home administrator, Admin) personally transported Resident 1 to his new living arrangement via car. During an interview with NP on 10/12/16 at 12:35 pm, she stated she will never forget Resident 1; he had loud, inappropriate behaviors. When asked about the facility's discharge and IDT processes, NP stated she was not part of the IDT. She stated she referenced a facility provided binder that included the facility's recommendations for residents who should be discharged , and wrote the order to discharge Resident 1 to a board and care facility. She indicated that a board and care facility should be able to provide care to Resident 1 because they give him his medications and meals. In regards to Resident 1's orientation status and confusion, NP stated resident was alert and oriented to person and place depending on his level of agitation. Concurrent record review of her progress note, dated 9/27/16 at 2:10 pm, indicated Resident 1 was alert and oriented to self only. NP stated Resident 1 had good days and bad days and his orientation depended on his level of agitation. NP stated she thought a psychiatrist had seen Resident 1 during his stay at the facility and had ordered medication for him. A concurrent record review showed no evidence that Resident 1 had ever been seen by a psychiatrist at the facility. NP asserted that Resident 1 was a candidate to be transferred to the board and care despite his leg wound requiring wound care, stating, his wound was healing, his dressing was clean, dry and intact. A concurrent record review of an order, dated 9/22/16, indicated cleanse ankle with normal saline, pat dry, apply [MEDICATION NAME] calcium alginate rope (a specialized dressing that provides a moist healing environment), cover with kerlix (absorbent cotton) and ace wrap, change every other day for 14 days and then re-assess. NP stated she was under the impression assisted living staff could help with wound treatments. A review of physician orders [REDACTED]. On 10/13/16 at 2 pm, Resident 1's room and board roommate was interviewed. He stated It was hell explaining that Resident 1 was as big as a house and pushed him, stole his food, and said he was going to kick my (his) ass. A record review conducted on 10/13/16 indicated there was no discharge summary with medication list for Resident 1. The facility's Observation Report: Discharge and Transfer-Discharge plan of care form, originally dated on 9/6/16, with date lined out and new date of 9/27/16 hand written next to it, indicated, medications upon discharge: see physician orders. A review of the Physician order [REDACTED]. 1. Carvedilol (a medication that lowers blood pressure, adverse reactions include low blood pressure and low heart rate) 3.125 milligrams (mg) twice a day-hold if systolic blood pressure is less than 110. 2. Potassium Chloride (medication used to replace potassium loss with use of [MEDICATION NAME], needs to be taken with food and water to prevent upset stomach) 10 milliequivalents (mEq) daily. 3. Aspirin (used to prevent blood clots in people who have [MEDICAL CONDITION], increased risk of bleeding can occur when taking this medication) 81 mg daily. 4. [MEDICATION NAME] (slows heart rate in people with [MEDICAL CONDITION], side effects include dizziness and nausea and vomiting, severe toxicity can occur if [MEDICATION NAME] levels not monitored) 125 micrograms (mcg) daily- hold for apical pulse less than 60. 5. [MEDICATION NAME] (treats and prevents irritations in the stomach) 20 mg daily. 6. [MEDICATION NAME] (used to decrease fluid in the body, adverse reactions include severe dehydration and potassium depletion) 20 mg daily. 7. Xarelto (thins the blood to decrease blood clots from forming, adverse reactions include increased chances of bleeding including bleeding into an important organ resulting in death) 20 mg daily. 8. Cranberry extract (supplement to help prevent urinary tract infections) 425 mg daily. 9. [MEDICATION NAME] (medication that decreases anxiety, increased sleepiness can occur when taking this medication and potential for overdose if not taken correctly can lead to injury and death) 0.5 mg twice a day, and [MEDICATION NAME] 0.5 mg twice a day, as needed for anxiety. 10. [MEDICATION NAME] (medication used to decrease mood instability, manufacturer warning states use in elderly people with dementia can increase risk of death) 0.5 mg at bedtime. 11. [MEDICATION NAME] (used to treat and prevent dizziness) 25 mg three times a day as needed for [MEDICAL CONDITION] (dizziness). 12. [MEDICATION NAME] (used to treat pain, side effects include nausea, vomiting, constipation and potential for overdose if not taken correctly) 5-325 mg 1 tab every six hours as needed for pain. Review of a physician's orders [REDACTED]. Due to the inappropriate, unsafe discharge that jeopardized the health and welfare of Resident 1 and others, an immediate jeopardy (IJ) was declared with the facility's administrator (Admin) on 10/19/16 at 3:30 pm. On 10/19/16, the Admin involved in the unsafe discharge of Resident 1 was terminated. On 10/20/16 and 10/21/16, the facility presented immediate corrective actions plans which were unacceptable. The IJ was removed on 10/24/16 at 1:30 pm, with the acting Admin and Registered Nurse Consultants (CRNs A and B) after the facility provided an acceptable immediate corrective action plan on 10/21/16 at 5:40 pm, and implementation of the corrective action plan was verified on 10/24/16 at 1:30 pm which included in part: -All residents will have safe and appropriate discharges; -All residents and/or responsible parties will be notified of the physician's discharge plan, involved in the discharge planning process, and included in all decisions made concerning discharges; -Written discharge notice will be provided to all residents and/or RPs, per regulatory requirements; -The IDT (interdisciplinary team, to include nursing staff and the Director of Nursing or RN designee, the administrator, and social services and therapy staff) will evaluate all discharges to ensure appropriateness and safety for all residents; -The facility's Medical Director will evaluate all discharges to ensure appropriateness and safety for all residents; -All staff were educated on appropriate and safe discharge practices and expectations and are empowered to stop any discharge that is not safe or appropriate for a resident; and -Administrative staff are available to staff 24 hours per day, seven days per week, to prevent potentially inappropriate or unsafe resident discharges. During a follow up interview with Hospital Staff A on 11/3/16 at 3:30 pm, she stated Resident 1 was sent to another skilled nursing facility on 11/1/16, with one to one 24 hour supervision and psychiatric care. Hospital Staff A stated there were no locked facilities who could take Resident 1. A review of hospital records indicated Resident 1 was treated with antibiotics at the hospital for LLE [MEDICAL CONDITION].

Based on interview and record review, the facility failed to have an acceptable discharge reason for one of 12 sampled residents (Resident 1) when the facility discharged Resident 1 to a room and board establishment (unlicensed living arrangement where lodging and food are furnished for a set price, non-medical, landlord tenant situation where resident does not need 24 hour supervision) without the residents health improving sufficiently to be moved to this lower level of care. This failure resulted in Resident 1 being discharged to a place that could not provide adequate care for his needs, such as supervision, behavior monitoring, medication administration, and wound care, jeopardizing his health and welfare, placing him at risk for harm. The room and board owners called 9-1-1 and the police responded and transported Resident 1 to a hospital for further evaluation and treatment, where he required constant hospital staff supervision and psychiatric evaluation and treatment. Immediate Jeopardy (IJ) was declared with the facility's administrator (Admin) on 10/19/16 at 3:30 pm, for the inappropriate, unsafe discharge of Resident 1. The IJ was removed on 10/24/16 at 1:30 pm, with the acting Admin and Registered Nurse Consultants (CRNs A and B) after the facility provided an acceptable immediate corrective action plan on 10/21/16 at 5:40 pm, and implementation of the corrective action plan was verified on 10/24/16 at 1:30 pm. Refer to F 202, F 203, and F 204. Findings: On 10/10/16, the California Department of Public Health (CDPH) received a complaint alleging that Resident 1 was discharged to a room and board establishment and the facility did not disclose the resident's behavior to the room and board owner. Once Resident 1 arrived at the room and board he became agitated and threatened to kill his roommate, was then brought to the hospital by police officers for further evaluation and treatment. The complainant alleged that the facility's administrator was involved in the transfer to the Room and Board and the facility refused to take the resident back indicating Resident 1's functional level was too high for skilled nursing level of care. A review of Resident 1's record on 10/11/16 indicated he was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED].(lung condition that makes it difficult to breathe that is not curable), and [MEDICAL CONDITION] (afib, irregular heartbeat) on [MEDICATION NAME] (blood thinning medication used to prevent blood clots caused by [MEDICAL CONDITION]). Resident 1's record indicated he was not his own decision maker and he had a payee (a person who manages finances for an individual who cannot manage their own benefits) in place. He had resided at a board and care (a licensed 4 to 16 bed non-medical facility that provided room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring) . for many years prior to being hospitalized and admitted to facility. Resident 1 was a full code (all resuscitative efforts are to be made in the event of cardiopulmonary arrest). A review of Resident 1's Interdisciplinary Team (IDT, a team of facility staff who meet to review and plan for resident care needs) conference notes dated 8/2/16 conducted by Social Services Director (SSD) with attendees including a therapist, Resident 1 and Resident 1's sister via phone, indicated that family wanted Resident 1 to stay at the facility as a long term resident. Resident 1's sister stated she wanted resident to be conserved by the County and that he already had a payee. During an interview with the SSD on 10/11/16 at 2:55 pm, she stated Resident 1 wanted to go back to his original board and care, but they would not take him back. She stated he was originally accepted to another local board and care, then denied admittance, due to his behaviors. SSD stated Resident 1's family wanted resident to go to a locked facility due to his behaviors. SSD stated Resident 1 was loud and would get in people's faces, he liked to sunbathe and would get naked outside. Review of a social services progress note, dated 8/17/16 at 10:17 am, indicated Resident 1 could not be readmitted to his previous board and care. Review of a social services progress note, dated 9/8/16 at 12:05 pm, indicated Resident 1 was not accepted to the retirement home because the owners of the home stated resident was unstable to go there. A review of Resident 1's physician progress notes [REDACTED]. He is alert and oriented to self. Facility is trying to find placement for him being followed by wound medical doctor for right (wrong ankle documented by medical doctor) ankle wound. Wound vac was discontinued due to patient continuously pulling vac out. Resident is on [MEDICATION NAME] for afib and will continue to monitor international normalized ratio (INR, a lab measurement to determine the effects of [MEDICATION NAME] on the body's blood clotting) continues to work with physical therapy and occupational therapy (PT/OT) Left ankle wound clean/dry/intact. A review of Resident 1's physician progress notes [REDACTED]. He is currently on [MEDICATION NAME] and INR is monitored .Resident currently on [MEDICATION NAME] (an antipsychotic medication used to decrease mood instability) for mood stability after elopement (run away) attempts and aggressive behavior towards staff .left ankle wound clean/dry/intact .discontinue [MEDICATION NAME] as resident is not a candidate for INR monitoring in an independent living facility. Will start on Xarelto (another medication used to prevent blood clots) .for anticoagulation. A review of Resident 1's physician progress notes [REDACTED].has a wound, left ankle .still having behavior issues on and off. A review of Resident 1's physician progress notes [REDACTED]. He is discharging to a board and care in Sacramento .currently on [MEDICATION NAME] for mood stability after elopement attempts and aggressive behavior towards staff. Left ankle wound clean/dry/intact. A review of Resident 1's nurses notes, dated 7/29/16 through 9/27/16, indicated Resident 1 had multiple episodes of inappropriate behaviors including yelling, shouting, leaving the facility unattended, resident to resident altercations and undressing himself in public. Resident 1 was administered [MEDICATION NAME] (sedating medication to decrease anxiety) twice a day and [MEDICATION NAME] was started. During an interview with Resident 1's daughter on 10/12/16 at 8:45 am, she stated that Resident 1 had a history of [REDACTED]. She further stated that Resident 1 needed constant supervision, due to his behaviors. During an interview with Nurse Practitioner (NP) on 10/12/16 at 12:35 pm, she stated she will never forget Resident 1; he had loud, inappropriate behaviors. She wrote the order to discharge Resident 1 to a board and care facility. She indicated that a board and care facility should be able to provide care to Resident 1 because they could give him his medications and meals. NP asserted that Resident 1 was a candidate to be transferred to the board and care despite his leg wound requiring wound care, further stating, his wound was healing, his dressing was clean, dry and intact. A concurrent record review of an order, dated 9/22/16, indicated to cleanse ankle with normal saline, pat dry, apply [MEDICATION NAME] calcium alginate rope (a specialized moist dressing), cover with kerlix (absorbent cotton) and ace wrap, change every other day for 14 days and then re-assess. NP stated she was under the impression assisted living staff could help with wound treatments. In regards to Resident 1's orientation status being acceptable for a board and care, NP stated he had good days and bad days depending on his level of agitation. NP stated she thought a psychiatrist had seen Resident 1 about his behaviors. A concurrent record review showed no evidence that a psychiatrist had seen Resident 1 during his stay at the facility. During a review of Resident 1's Physician's Report for Residential Care Facilities for the Elderly, (a California Department of Social Services form used to help a board and care or assisted living determine if a resident or prospective resident is a good fit for the facility), signed by the discharging MD (MD A) on 9/23/16, indicated residential care level includes primarily non-medical care and supervision to meet the needs of the person and THESE FACILITIES DO NOT PROVIDE SKILLED NURSING CARE. The document indicated Resident 1 was 6'1 tall and weighed 253 pounds, could not manage his own treatment/medication/ equipment, and had mild cognitive impairment. The document indicated Resident 1 did not have confusion or inappropriate, aggressive or wandering behaviors and was not able to leave the facility unassisted. The document indicated Resident 1 was not able to administer his own medications or oxygen. Physical health status was Good. The document did not depict any of Resident 1's behaviors that had been documented in his facility record. Review of a social services progress note, dated 9/12/16 at 10:37 pm, indicated despite two denials from different board and care homes, Resident 1's inappropriate behaviors, poor orientation status with inability to make decisions on his own, left leg wound requiring nursing care and no documentation supporting Resident 1's health status had improved sufficiently, the facility's plan continued to be look for lower level placement, for Resident 1. A review of Resident 1's nursing progress note, dated 9/24/16, indicated treatment nurse (LVN F) documented Resident 1's wound to the left medial ankle measured 2.0 centimeters (cm) by 5.0 cm by 0.1 cm. The wound bed was described to have granulation tissue (lumpy, pink tissue), light to moderate amount of serosanguinous drainage (light red to clear liquid coming from wound) continue with current order Resident 1 was discharged from facility on 9/27/16. A physician's orders [REDACTED]. During an interview on 10/11/16 at 10:30 am, with Hospital Staff A (a registered nurse) she stated, Resident 1 had a history of [REDACTED]. She indicated Resident 1 was reportedly throwing furniture, threatening to kill staff and his roommate at the room and board where he was discharged to, and that the room and board staff were not notified of Resident 1's inappropriate behaviors, prior to his arrival. Hospital Staff A stated the only suitable placement for Resident 1 would be a locked unit facility. Resident 1 required a one to one sitter (a person designated to directly supervise him at all times) while at the hospital for multiple elopement attempts and threats to kill staff. Hospital Staff A stated the facility dumped Resident 1 and the hospital believes his discharge was inappropriate. During an interview with room and board owner (RB) on 10/11/16 at 1:34 pm and continued on 10/13/16 at 1:00 pm, he stated we are a room and board, not a board and care. RB stated the facility told him Resident 1 was independent, high functioning and did not need help with his medications. RB stated the plan was to provide Resident 1 with three meals a day, a room to sleep in, and for him to be independent and compliant with normal landlord/tenant rules. The owner stated Resident 1 arrived at 3:15 pm on 9/27/16, with a large bag of medications, and no instructions. He did not know anything about Resident 1's wound on his left leg. RB described Resident 1 as having aggressive behaviors towards the other room and board tenants. RB stated Resident 1 was stealing food from others, threatening to hurt them, and shoved his roommate and said I'll kick your ass . pour this soda in your face. Resident 1 arranged the stolen food in a line and told his roommate not to touch my food. RB's wife attempted to speak with Resident 1 about his behaviors, he threatened to hurt her. RB stated the resident had been at his room and board for less than 24 hours when they had to call 9-1-1 for assistance with Resident 1. The police arrived and Resident 1 threatened his roommate in front of the police, they arrested him and stated he was not appropriate to stay at the room and board establishment. During an interview with SSD on 10/11/16 at 2:55 pm she stated Resident 1 was discharged to a board and care. During an interview with Resident 1's daughter on 10/12/16 at 8:45 am, she stated, she did not know the facility Resident 1 was being admitted to was a room and board, she was under the impression the facility was an assisted living. During an interview with NP on 10/12/16 at 12:35 pm, she indicated Resident 1 was discharged to a board and care. (Resident 1 was discharged to a non-licensed, non-medical room and board establishment that could not provide the care he needed. He was not discharged to a board and care establishment like the facility staff had indicated). On 10/13/16 at 2 pm, Resident 1's room and board roommate was interviewed. He stated, It was hell explaining that Resident 1 was as big as a house and pushed him, stole his food, and said he was going to kick my (his) ass. According to the California Advocates for Nursing Home Reform (CANHR) website, board and care and assisted living facilities are for care and supervision of people who are unable to live by themselves, but who do not need 24 hour nursing care. They are considered non-medical facilities and are not required to have nurses, certified nursing assistants, or physicians on staff. They provide room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring. Board and care homes typically provide seniors with the same services available in larger assisted living communities; the difference is that these facilities are regular houses in residential neighborhoods that are equipped, adapted and staffed to care for a small number of seniors. A review of the Physician order [REDACTED]. 1. Carvedilol (a medication that lowers blood pressure, adverse reactions include low blood pressure and low heart rate) 3.125 milligrams (mg) twice a day-hold if systolic blood pressure is less than 110. 2. Potassium Chloride (medication used to replace potassium loss with use of [MEDICATION NAME], needs to be taken with food and water to prevent upset stomach) 10 milliequivalents (mEq) daily. 3. Aspirin (used to prevent blood clots in people who have [MEDICAL CONDITION], increased risk of bleeding can occur when taking this medication) 81 mg daily. 4. [MEDICATION NAME] (slows heart rate in people with [MEDICAL CONDITION], side effects include dizziness and nausea and vomiting, severe toxicity can occur if [MEDICATION NAME] levels not monitored) 125 micrograms (mcg) daily- hold for apical pulse less than 60. 5. [MEDICATION NAME] (treats and prevents irritations in the stomach) 20 mg daily. 6. [MEDICATION NAME] (used to decrease fluid in the body, adverse reactions include severe dehydration and potassium depletion) 20 mg daily. 7. Xarelto (thins the blood to decrease blood clots from forming, adverse reactions include increased chances of bleeding including bleeding into an important organ resulting in death) 20 mg daily. 8. Cranberry extract (supplement to help prevent urinary tract infections) 425 mg daily. 9. [MEDICATION NAME] (medication that decreases anxiety, increased sleepiness can occur when taking this medication and potential for overdose if not taken correctly can lead to injury and death) 0.5 mg twice a day, and [MEDICATION NAME] 0.5 mg twice a day, as needed for anxiety. 10. [MEDICATION NAME] (medication used to decrease mood instability, manufacturer warning states use in elderly people with dementia can increase risk of death) 0.5 mg at bedtime. 11. [MEDICATION NAME] (used to treat and prevent dizziness) 25 mg three times a day as needed for [MEDICAL CONDITION] (dizziness). 12. [MEDICATION NAME] (used to treat pain, side effects include nausea, vomiting, constipation and potential for overdose if not taken correctly) 5-325 mg 1 tab every six hours as needed for pain. Review of a physician's orders [REDACTED]. Due to the inappropriate, unsafe discharge that jeopardized the health and welfare of Resident 1 and others, an immediate jeopardy (IJ) was declared with the facility's administrator (Admin) on 10/19/16 at 3:30 pm. On 10/19/16, the Admin involved in the unsafe discharge of Resident 1 was terminated. On 10/20/16 and 10/21/16, the facility presented immediate corrective actions plans which were unacceptable. The IJ was removed on 10/24/16 at 1:30 pm, with the acting Admin and Registered Nurse Consultants (CRNs A and B) after the facility provided an acceptable immediate corrective action plan on 10/21/16 at 5:40 pm, and implementation of the corrective action plan was verified on 10/24/16 at 1:30 pm which included in part: -All residents will have safe and appropriate discharges; -All residents and/or responsible parties will be notified of the physician's discharge plan, involved in the discharge planning process, and included in all decisions made concerning discharges; -Written discharge notice will be provided to all residents and/or RPs, per regulatory requirements; -The IDT (interdisciplinary team, to include nursing staff and the Director of Nursing or RN designee, the administrator, and social services and therapy staff) will evaluate all discharges to ensure appropriateness and safety for all residents; -The facility's Medical Director will evaluate all discharges to ensure appropriateness and safety for all residents; -All staff were educated on appropriate and safe discharge practices and expectations and are empowered to stop any discharge that is not safe or appropriate for a resident; and -Administrative staff are available to staff 24 hours per day, seven days per week, to prevent potentially inappropriate or unsafe resident discharges. During a follow up interview with Hospital Staff A on 11/3/16 at 3:30 pm, she stated Resident 1 was sent to another skilled nursing facility on 11/1/16, with one to one 24 hour supervision and psychiatric care. Hospital Staff A stated there were no locked facilities who could take Resident 1. A review of hospital records indicated Resident 1 was treated with antibiotics at the hospital for LLE [MEDICAL CONDITION].

Based on interview and record review, the facility failed to ensure four of 12 sampled residents (Residents 3, 4, 5, and 12) received sufficient fluid intake based on individual needs to maintain proper hydration and health when: 1. Resident 4's care plan was not comprehensive and individualized to address Resident 4's risk for dehydration. Resident 4's fluid intake was not monitored, his hydration status was not assessed, and his use of [MEDICATION NAME] (a diuretic, a medication that removes excess fluid from the body) was not evaluated when he experienced decreased oral intake, weight loss, had no [MEDICAL CONDITION] (excess fluid), and made frequent requests for water. This resulted in Resident 4 being transferred and admitted to the acute care hospital with acute kidney failure and [MEDICAL CONDITION] (low blood pressure) due to dehydration. 2. Resident 5's care plan was not comprehensive and individualized to address Resident 5's risk for dehydration. There was no ongoing assessment of fluid balance and hydration status when Resident 5's fluid intake was less than 1200 cubic centimeters (cc) in 24 hours and was less than her physician ordered fluid restriction parameter, her fluid intake was not monitored per facility policy, and a comprehensive metabolic panel (CMP, a blood test that measures fluid and electrolyte balance and kidney function) and a complete blood count (CBC, a blood test used to evaluate overall health) were not completed timely. This resulted in Resident 5 being transferred to the acute care hospital with critically abnormal (high) BUN (Blood Urea Nitrogen, a test that measures kidney function) level where she was treated with IV (through the vein) fluids and her [MEDICATION NAME] was held. Refer to F 502 for additional information. 3. Resident 3's hydration status was not assessed when she developed nausea and vomiting (increasing her risk for dehydration), and her fluid intake was not monitored upon readmission to the facility. This contributed to Resident 3's transfer to the acute care hospital with acute [MEDICAL CONDITION] secondary to dehydration. 4. Resident 12's fluid intake was not monitored, per facility policy, and he exceeded his physician ordered fluid restriction parameter. This potentially contributed to Resident 12 being transferred to the acute care hospital with shortness of breath and wheezing. Findings: 1. The facility admission record was reviewed and indicated Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 4's physicians orders, dated 1/13/16, included [MEDICATION NAME] (a diuretic) 80 milligrams (mg, a unit of measure) once daily for [MEDICAL CONDITION]. Resident 4's dehydration care plan, dated 7/2/16, was reviewed and indicated Resident 4 was at risk for dehydration related to altered skin turgor (a sign used to assess degree of dehydration), impaired mobility, need for assistance with eating, swallowing problems, history of weight loss, urinary incontinence (no control over urination), history of dehydration, history of refusing fluids, and thickened liquids. The care plan included dementia, diabetes, [MEDICAL CONDITION], history of urinary tract infections [MEDICAL CONDITION], psychiatric disorder, [MEDICAL CONDITION], and use of [MEDICAL CONDITION] medications as contributing factors to Resident 4's dehydration risk. The care plan approaches included Intake and Output (I & O, measurement of fluids that enter the body and the fluids that leave the body) monitoring as indicated, to observe hydration status as indicated (skin turgor, moist mucous membranes), and to offer fluids as tolerated or as indicated by diet order. Documentation of Resident 4's Activities of Daily Living (ADLs, basic self-care tasks) for June and July 2016 was reviewed. The documentation did not indicate the amount of fluid Resident 4 was offered or consumed. The documentation indicated Resident 4 was incontinent of urine, but did not include measurements or indicate the number of incontinent episodes per shift. The documentation indicated Resident 4 had a decrease in meal intake beginning on or about 6/19/16. Between 7/1/16 and 7/8/16 Resident 4 refused 7 of 24 meals and consumed only 25% of his meals on three occasions. There was no documentation of food or fluid intake for three meals during the same time period. Resident 4's Progress Notes were reviewed. A note by the Registered Dietician (RD), dated 7/7/16, indicated Resident 4 had a 10 pound (lb) weight loss in 30 days and a 20 lb loss in 90 days, and that his estimated need for fluids was 2215-2658 cc daily. The note indicated Resident 4 was seen by the Nurse Practitioner (NP) on 7/7/16 and that he had no [MEDICAL CONDITION]. The note indicated Resident 4 was observed on two occasions slumped while eating and that he frequently asked for water. Resident 4's Weekly Nursing Summaries, dated 7/1/16 and 7/8/16, were reviewed. The summaries included a section titled Clinical Hydration Evaluation that indicated Resident 4 was not on I & O monitoring and had no signs of dehydration. Resident 4's Progress Notes, dated 6/25/16 through 7/8/16, contained no documented evidence nursing staff or the RD considered Resident 4's weight loss, decreased intake, and frequent requests for water as possible indicators for dehydration. There was no documentation Resident 4's [MEDICATION NAME] was evaluated or changed when his oral intake decreased and he had no [MEDICAL CONDITION]. There was no documentation Resident 4's hydration status was assessed daily and that his fluid intake was measured or monitored to ensure sufficient fluids to prevent dehydration. A Progress Note, dated 7/8/16 at 3:15 pm, indicated the NP ordered stat (urgent) laboratory (lab) tests for Resident 4 due to increased weakness and a change in condition. A Progress Note, dated 7/9/16 at 3:22 am, indicated Resident 4 was transferred to the acute care hospital at 1:05 am due to critically abnormal (high) laboratory test levels. A Nephrology Consult from the acute care hospital, dated 7/9/16, was reviewed. The consult included a HISTORY OF PRESENT ILLNESS that indicated, (Resident) was brought in with altered mental status and he is extremely dry with very severe metabolic abnormalities (abnormal chemical reactions in the body) including severe [MEDICAL CONDITION] (high level of sodium in the blood) with a sodium level of 161 (normal range is between 135-146) and he also has severe acute [MEDICAL CONDITION] (kidney failure) with a BUN of 176 and a creatinine of 7.99. (BUN and creatinine are blood tests used to evaluate kidney function. The normal range for BUN is between 7-25 mg/dL, a unit of measure, and the normal range for creatinine is 0.7-1.3 mg/dL.) The PHYSICAL EXAMINATION indicated, (Resident) is very dry . Very thin with no trace of [MEDICAL CONDITION] whatsoever. The IMPRESSION AND PLAN indicated, The patient came in with severe volume depletion and [MEDICAL CONDITION]ly secondary to severe free water losses. (Dehydration occurs when free water losses exceed free water intake.) His water deficit is quite significant and I expect he has at least 5-6 liter absolute water deficit. He is also in acute [MEDICAL CONDITION] from tubular necrosis (damage to kidneys) and volume depletion and no evidence of obstruction (blockage). An interview was conducted with the Director of Nursing (DON) on 10/13/16 at 4:20 pm. The DON acknowledged Resident 4 was at risk for dehydration. The DON acknowledged Resident 4's I & O was not monitored, and stated I & O was only monitored when the physician or nursing staff identified the presence of signs/symptoms of dehydration. 2. The facility admission record was reviewed and indicated Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, a clinical assessment tool), dated 6/9/16, indicated Resident 5 was at risk for dehydration due to presence of a wound and use of a diuretic. Review of Resident 5's physicians orders, dated 6/14/16, included to increase Resident 5's [MEDICATION NAME] from 40 mg to 80 mg per day, and for a fluid restriction of 1800 cc every 24 hours. Resident 5's dehydration care plan, dated 6/2/16, was reviewed and indicated Resident 5 was at risk for dehydration related to impaired mobility and urinary incontinence. The care plan included diabetes, depression, [MEDICAL CONDITION], presence of infection, and use of an antidepressant as contributing factors to Resident 5's dehydration risk. The care plan approaches included fluid restrictions if ordered and I & O as indicated. The care plan did not specify the amount of fluid to be provided by the dietary and nursing departments in accordance with facility protocol. Resident 5's I & O records were reviewed. There was no documentation Resident 5's I & O was monitored on 6/14/16, 6/15/16, 6/16/16, and 6/29/16 through 7/6/16 following the implementation of the fluid restriction. The Weekly I & O Evaluation, located at the bottom of the I & O record was incomplete. The I & O records indicated Resident 5's daily fluid intake was less than 1200 cc per day for 14 out of 18 days. Resident 5's record contained no documented evidence the physician was notified when her fluid intake was less than 1200 cc per day, and less than her physician ordered fluid restriction of 1800 cc per day. Resident 5's blood test results were reviewed and indicated an increase in BUN and creatinine levels as follows: 5/29/16 BUN 57, creatinine 2.2 6/6/16 BUN 69, creatinine 2.3 6/17/16 BUN 76, creatinine 2.4 Review of Resident 5's physicians orders, dated 7/7/16, included two orders written the same day for a CMP and a CBC. Resident 5 had a physician's orders [REDACTED]. Resident 5's record contained no documented evidence the blood tests were completed on 7/7/16 and 7/12/16, as ordered. Resident 5's Nursing Progress Notes, dated 7/12/16 through 7/14/16, were reviewed. The notes indicated Resident 5 was being monitored for a decrease in blood pressure and situational awareness. The notes indicated Resident 5 had increased confusion, weakness, lethargy, difficulty standing to ambulate to the toilet, and presence of hallucinations. A Progress Note, dated 7/13/16, indicated the Interdisciplinary Team (IDT, a team of facility staff who meet to review and plan for resident care needs) met to discuss Resident 5's functional decline, including unsteady gait, weakness, and increase in hallucinations. The Progress Notes contained no documented evidence the team considered Resident 5's behavioral changes as possible indicators for dehydration. There was no documented evidence the RD completed an initial evaluation to determine Resident 5's estimated need for fluids. There was no documentation Resident 5's hydration status was reassessed and her care plan revised following an increase in her [MEDICATION NAME] dose and when she was placed on fluid restrictions. There was no documented evidence Resident 5's fluid intake was accurately measured or monitored to ensure sufficient fluids to prevent dehydration. A Progress Note, dated 7/14/16 at 3:23 pm, indicated Resident 5 had been declining over the past week and was sent to the acute care hospital due to critically high labs with a BUN of 107. A review of the hospital physicians history and physical examination [REDACTED]. An interview was conducted with the DON on 8/4/16 at 3:20 pm. The DON acknowledged Resident 5 was at risk for dehydration. The DON stated Resident 5's I & O was monitored when she was placed on a fluid restriction, but was unable to provide a complete accounting of I & O documentation upon request. A second interview was conducted with the DON on 10/13/16 at 5 pm. The DON acknowledged Resident 5 had three orders for the same blood tests and that the tests were not completed until 7/14/16, seven days after the original order. The DON was unable to provide documentation or identify why the tests were not done timely. (Refer to F 502). 3. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's Dehydration Care Plan, dated 4/26/16, indicated Resident 3 was at risk for dehydration related to impaired mobility, history of weight loss, dehydration, poor appetite and urinary tract infections (UTIs). Resident 3's goal indicated will have evidence of adequate hydration as evidenced by: stable vital signs, good skin turgor within normal limits of age, and moist mucous membranes. The facility approach to achieving the goal included to observe hydration status as indicated, observe resident for swallowing problems, refer to speech therapy as appropriate, and to offer fluids as tolerated or as indicated per diet. A review of progress notes, dated 8/3/16 at 4:19 pm, indicated the IDT met to review Resident 3's weight loss of 9 lbs in 31 days. The listed risk factors included lower lip [MEDICAL CONDITION], history of UTI, diabetes, [MEDICAL CONDITION] (abnormally low [MEDICAL CONDITION] function), Vitamin B-12 deficiency, and depression. IDT review indicated Resident 3 had a recent decline in ADLs. The IDT note did not indicate Resident 3 was assessed for hydration. Interventions implemented were to downgrade diet to a mechanical soft diet, an RD referral, and weekly weights x 4 weeks. A review of Resident 3's ADL log for 8/2016 indicated fluids were offered, but did not show the amount of fluids offered or consumed. The record indicated Resident 3 was incontinent of urine, but did not show a measurement of urine output or indicate the number of incontinent episodes per shift. A review of a weekly summary report, dated 7/28/16, indicated Resident 3's weight was 116 lbs and average meal intake was 1-25%. Resident 3 was not on I &O monitoring and no signs/symptoms of dehydration were identified. A weekly summary report, dated 8/11/16, indicated Resident 3's weight was 106 lbs, average intake was 26-50%, I & O was not being monitored, and indicated no signs/symptoms of dehydration. A review of Resident 3's progress notes, dated 8/8/16 at 5:53 pm, indicated an RD evaluation was done and estimated resident needs per RD note on 7/21/16 to be 1100-1210 calories, 53-63 grams of protein, and 1318-1581 cc of fluid. The note indicated Resident 3's intake was less than 25% with 9 refusals out of 22 meals and her needs were not being met. The note indicated to monitor oral intake and weight trends, but did not indicate any monitoring of fluid intake and output to ensure that hydration needs were being met. A progress note, dated 8/13/16 at 7:31 pm, indicated resident had one episode of vomiting and on 8/14/16 at 10:18 pm, a progress note indicated, Resident being sent out to emergency room (ER) for further evaluation. Patient has had vomiting for the past two days. A review of the hospital physician's history and physical examination [REDACTED]. The report indicated at the time of observation the resident was barely able to talk as her mouth is too dry, unable to understand her, per nurse report from the facility, the patient's respiratory rate was 30 and she was not eating much, only 25-30% of meals, and feeling nauseous with a few episodes of vomiting. The facility did not know when her last bowel movement was. The section Laboratory Data, indicated Resident 3 had a BUN level of 63 and a creatinine of 1.7. Assessment and Planning indicated this is 1) probable aspiration pneumonitis, partial small bowel obstruction secondary to constipation and obstipation .2) acute [MEDICAL CONDITION], BUN is very high, consistent with prerenal azotemia (the most common form of kidney failure), secondary to dehydration with nausea and vomiting. The report indicated Resident 3 was admitted to hospital with a diet of nothing by mouth, NG tube( a tube passed into the stomach via the nose and used for short term decompression of intestinal obstruction), oxygen, fluids via IV, and treatment with three different antibiotics. A review of Resident 3's nursing progress notes indicated Resident 3 was readmitted to the facility on [DATE] at 8:23 pm. An weekly summary report, dated 8/25/16, indicated Resident 3 had no signs/symptoms of dehydration and I & O was to be monitored due to being newly admitted . An interview was conducted with Registered Nurse (RN) B on 10/13/16 at 5:30 pm. RN B confirmed, according to facility policy, staff monitored the I & O for all new admissions, residents with a urinary catheter, and residents with signs and symptoms of dehydration. During a telephone interview with Medical Records staff (MR) on 10/14/16 at 1 pm, MR stated she was unable to locate any records of I & O documentation for Resident 3. 4. Resident 12's record was reviewed and indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. A review of the 10/2016 Medication Administration Record [REDACTED]. An I & O record, dated from 10/12 through 10/18/16, was reviewed. The record included night, morning, and evening fluid intake sections for Med Pass, Meals, Other and Total and indicated Resident 13 exceeded his physician ordered fluid restriction parameters on 10/13 and 10/17/16. The record indicated fluid intake was not completed on 10/18/16 for the evening shift and there was no total documented for the 24 hour period. A review of a physician's history and physical examination [REDACTED]. The physician's plan was to obtain a repeat chest X-ray and restrict fluid intake. The physician indicated Resident 12 may go home in a few days. Review of a nurses note, dated 10/18/16, indicated Resident 12 was noted to have had a significant drop (low 80's %) in oxygen saturation when walking to the restroom. Review of a nurses note, dated 10/19/16, timed 4:39 pm, indicated Resident 12 complained of shortness of breath after walking to the restroom, his oxygen saturation was low (82%), he was assisted to bed and oxygen was placed back on him, and he had a temperature of 101.2 degrees Fahrenheit. The physician was notified of the change in condition and Resident 12 was transferred to the hospital on [DATE] for shortness of breath and wheezing. The facility policy titled Hydration - Clinical Protocol, revised 9/12, was reviewed. The policy included the following, in part: Assessment and Recognition: The physician and staff will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance; for example those with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitors and who are not eating or drinking well. Treatment/Management: If medications are contributing to fluid and electrolyte imbalance, they should be tapered or stopped (at least temporarily), or the physician should provide clinically valid reasons why they cannot or should not be changed, even temporarily. Monitoring and Follow-Up: The physician will help monitor for the development . of fluid and electrolyte imbalance in at risk individuals. The facility protocol for Resident FLUID INTAKE DAILY CHARTING GUIDELINES, undated, was reviewed. The protocol included the following, in part: 2. All residents to have a nursing order: Notify MD for fluid intake less than 1200 cc/day unless contraindicated. 3. RD to calculate fluid needs on Initial, Annual, (Significant Change of Condition) or ([MEDICAL CONDITION]) diagnosis . 4. For Patients on FLUID RESTRICTION (FR): Fluid restriction order to include cc provided by nursing and dietary. This should also be in the care plan . (To total all fluids (Licensed Vocational Nurse) must print report from Facility Reports: Resident Info . Intake & Output report. EVERY SHIFT).

Based on interview and record review, the facility failed to provide the necessary intervention of bowel care medications as needed (PRN) per physicians orders for one out of 12 sampled residents (Resident 3). This failure led to Resident 3 being admitted to the acute care hospital on [DATE] related to probable aspiration pneumonitis (lung infection related to inhaling materials such as vomit, food or liquids), partial small bowel obstruction (blockage) secondary to constipation (difficulty emptying the bowels, usually associated with hardened stools) and obstipation (severe or complete constipation) , acute [MEDICAL CONDITION] (condition in which kidneys suddenly cannot filter waste from the blood) secondary to dehydration (more water is moving out of our cells and bodies than what we take in through drinking) with nausea and vomiting. Requiring treatment that included fluid replacement via IV (through the vein), NG tube placement (a tube passed into the stomach via the nose and used for short term decompression of intestinal obstruction), a diet of nothing by mouth, oxygen therapy and three different antibiotics. Findings: Resident 3's record was reviewed and indicated Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's constipation care plan, dated 4/26/16, indicated Resident 3 was identified to be at risk for constipation secondary to decreased mobility with a goal to have continued satisfactory bowel movements every 1 to 3 days, as evidenced by soft formed stools. The facility's approach to achieving this goal included: administer medications per MD order, encourage fluid intake unless contraindicated and notify MD if decreased bowel sounds/abdominal pain/distention/decreased appetite or fever. A review of the nursing progress notes for Resident 3 indicated that on 6/30/16 at 10:17 am resident was noted to have a bruise and swelling, painful to touch upper left arm. X-ray report, dated 6/30/16 at 2:50 pm, showed a slightly displaced fracture involving the proximal humerus. The shoulder joint is grossly intact. A review of physicians orders, dated 7/19/16, indicated Resident 3 was prescribed Tylenol with [MEDICATION NAME] 300-30 milligrams (mg) 1 tablet twice a day, in addition to Tylenol with [MEDICATION NAME] 300-30 mg every 4 hours PRN for pain. physician's orders [REDACTED]. A review of physician's orders [REDACTED]. According to Lexi-comp (on-line program that provides drug information modules and clinical databases) Tylenol with [MEDICATION NAME], Warnings and Precautions: May cause or aggravate constipation; chronic use may result in obstructive bowel disease. [MEDICATION NAME], Warnings and Precautions: May cause [MEDICATION NAME] effects constipation, xerostomia, blurred vision, [MEDICAL CONDITION]; use with caution in patients with decreased gastrointestinal motility. [MEDICATION NAME], Warnings and Precautions: may aggravate symptoms of decreased GI motility (Lexi-comp Online, retracted 11/2/16.) A review of nursing progress notes, dated 7/21/16 at 10:15 pm, indicated resident is now on routine pain management, Tylenol [MEDICATION NAME] (twice daily). On 8/01/16 at 3:25 pm, nursing progress note indicated Resident 3's pain is managed with scheduled medications. Earlier today (resident) had a hard bowel movement and had some rectal bleeding, treatment nurse aware and monitoring. On 8/3/16 at 4:19 pm, nursing progress note indicated that IDT met to review weight loss of 9 pounds in 31 days. Listed risk factors included lower lip [MEDICAL CONDITION], history of UTI, diabetes, [MEDICAL CONDITION] (a condition in which the [MEDICAL CONDITION] does not produce enough [MEDICAL CONDITION] hormone), vitamin B-12 deficiency and depression. IDT review indicated that the resident had a recent decline in activities of daily living (ADL) and was not assessed for a fecal impaction. Interventions implemented were to downgrade diet to mechanical soft diet, Registered Dietitian (RD) referral and weekly weights x 4 weeks. On 8/13/16 at 7:31 pm, nursing progress notes indicated that resident had one episode of vomiting and on 8/14/16 at 10:18 pm, progress notes indicated resident being sent out to ER for further evaluation. Patient has had vomiting for the past two days. A review of the facility's PRN Medication Flowsheet, dated 8/1/16-8/31/16, indicated Resident 3 received one dose of MOM on 8/8/16 and one dose on 8/9/16. There was no indication that the medication was effective or that Resident 3 received any dose of the [MEDICATION NAME] suppository or Fleet enema during the dates of 8/1/16-8/31/16, as ordered by MD. A review of the facility's bowel care log records, dated 8/1/16-8/14/16, showed that no bowel movement was documented between the dates of 8/3/16 through 8/11/16 for Resident 3. A review of Resident 3's ADL flow sheet, dated 8/2016, showed no bowel movement was documented between the dates of 8/2/16-8/11/16. A review of the hospital physician's history and physical examination [REDACTED]. The document indicated at the time of observation the resident was barely able to talk as her mouth is too dry, unable to understand her. Indicated that per nurse report from the facility, the patient's respiratory rate was 30 and she was not eating much, only 25-30% of meals, and feeling nauseous with a few episodes of vomiting. The facility did not know when her last bowel movement was. The section, Laboratory data, indicated Resident 3 had a BUN level of 63 and creatinine of 1.7 (BUN and creatinine are blood tests to assess how well the kidneys are functioning Normal BUN range is between 7-20 mg/dl (a unit of measurement) and normal creatinine range for women is 0.6-1.1 mg/dl). Chest X-ray showed bilateral coarse infiltrates consistent with aspiration pneumonitis. CT scan of the abdomen showed partial small bowel obstruction. Assessment and planning indicated this is 1) probably aspiration pneumonitis, partial small bowel obstruction secondary to constipation and obstipation . 2) acute [MEDICAL CONDITION], BUN is very high, consistent with prerenal azotemia (the most common form of kidney failure), secondary to dehydration with nausea and vomiting. Resident 3 was admitted with a diet of nothing by mouth, NG tube (a tube passed into the stomach via the nose and used for short term decompression of intestinal obstruction), oxygen, fluid replacement via IV (through the vein), and treatment with 3 different antibiotics. A review of Resident 3's facility nursing progress notes, dated 8/19/16 at 8:23 pm, indicated that resident was transferred back to the facility and arrived in stable condition with an admitting [DIAGNOSES REDACTED]. During an interview and concurrent record review with the Director of Nurses (DON) on 10/13/16 at 3:20 pm, the DON reviewed all records and searched through electronic records and stated he was unable to find documentation indicating Resident 3 had a bowel movement, unable to find any documentation of intervention done to manage constipation other than the two doses of MOM given, one dose on 8/8/16 and one dose on 8/9/16 and he stated he could not find any charting to indicate when or if the physician was notified that Resident 3 had not had a bowel movement for a period of nine days. The DON stated the facility did not have a policy or specific protocol to address bowel care or constipation.

Based on interview and record review, the facility failed to ensure the use of a necessary assistance device (Hoyer lift, a mechanical lifting device used for transfers) to prevent an avoidable accident with significant injury to Resident 1. This failure resulted in two broken bones in Resident 1's right leg and severe pain, requiring hospitalization where Resident 1 was determined to not be a good candidate for surgery and was transferred to another facility for comfort care (non-invasive care interventions to maximize comfort) until her death eight days after the fall. Findings: The facility's undated policy titled, Falls Management System indicated the facility was to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Residents will be reassessed for risk upon a decline or improvement which meets the criteria for significant changes in status. The care plan interventions will be developed to prevent falls and will consider the particular elements of the assessment that put the resident at risk. The care plan will have ongoing evaluations and revisions. The care plan interventions will address those elements determined by investigation as the probable cause that contributed to the fall. The updated plan will be reviewed and revised by the Interdisciplinary Team. A review of the facility's admission records indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The heart is unable to provide adequate blood flow to other organs such as the brain, liver and kidneys) and kidney failure (the inability of the kidneys to remove wastes from the blood) and a stroke which resulted in right sided weakness. Resident 1 was unable to make health care decisions for herself. Resident 1 was transported three times a week to a Dialysis center for treatment to remove body waste from her blood, due to her end stage kidney disease. The facility's Minimum Data Set (MDS, a resident assessment), dated [DATE], indicated Resident 1 had impairment to her upper extremities(shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle foot) extremities. Resident 1 was totally dependent, requiring the assistance of two persons with transfers. A Physical Therapy (PT) evaluation, dated [DATE], indicated Resident 1 had poor safety secondary to right sided weakness. Resident 1 wanted to work on standing and turning for transfers and did not want to be transferred with a Hoyer lift (a mechanical lifting device used for transfers. Resident 1 was a maximum transfer with a mechanical lift since admission). A PT evaluation, dated [DATE], indicated Resident 1 had slow steady progress towards transfers with staff assistance for moderate to maximum assistance of two persons for stand and turn. PT gave direct care staff extensive instruction to prevent further injury to Resident 1's extremities during transfers. A PT evaluation, dated [DATE], indicated Resident 1 declined in transfer ability. Resident 1 was discharged from PT after 4 weeks on [DATE], due to no progress being made. A review of Resident 1's record indicated there were no transfer assistance recommendations found in the record, based on the PT evaluation. A nursing note, dated [DATE] at 1:25 pm, indicated Resident 1 was on the bathroom floor. Resident 1 fell while being assisted from the toilet to a shower chair by four nursing students who could not get a shower chair under the resident fast enough. A full body assessment was completed with no injuries reported. The nursing note indicated, after assessment three person assist by Certified Nursing Assistants (CNAs) into shower chair to toilet resident. A Fall Management committee note, dated [DATE], indicated the nursing students transferred Resident 1 without CNAs present. The corrective action was to educate the nursing students on being trained on residents care needs (such as mobility limitations and levels of assistance needed) before attempting resident transfers and the students were reported to their instructors. There was no PT evaluation after the incident to determine if Resident 1's transfer ability had declined. The last PT evaluation of Resident 1 was on [DATE], two years prior. A nursing note, dated [DATE] at 9 pm, indicated Resident 1 reported a CNA transferred her from wheelchair to bed and her right leg (weak side from stroke) swelled and hurt. Resident 1 was unable to move the leg and an X-ray was ordered. The X-ray report was negative for fracture. A Fall Management committee note, dated [DATE], indicated while transferring Resident 1, her right knee and leg hit the side of the bed. PT assessed the resident and implemented transfer precautions i.e. changed w/c (wheelchair) and assisted CNAs in transfer training and to work c (with) resident + (and) CNAs x (times) 2 wk (weeks). A nursing note, dated [DATE] at 10:30 am, indicated a new physician's orders [REDACTED]. Resident 1 continued to refuse a Hoyer lift during transfers. The PT evaluation, dated [DATE], indicated Resident 1 was discharged from PT on [DATE]. PT trained CNA staff to transfer Resident 1 to a wheelchair with two people. PT recommended a Hoyer lift only due to the CNA staff reporting Resident 1 was unpredictable during transfers. Resident 1 became a Hoyer lift only to ensure safety of the resident and staff and to decrease the risk for falls. A Fall Management Committee note, dated [DATE], indicated Resident 1 fell on [DATE], while CNAs walked Resident 1 to the bathroom. Resident 1 requested to go to the bathroom and was in a hurry. CNA staff stated they offered a bed pan and Resident 1 refused, then they offered to get the Hoyer lift and the resident refused. Two CNAs walked her to the bathroom when Resident 1's right leg buckled (gave out) and Resident 1 was lowered to the floor. Resident 1 had pain at right leg/knee and was sent to the hospital emergency room to be evaluated. During an interview on [DATE] at 3:50 pm, CNA A stated Resident 1 normally would refuse to use the bed pan and transfers with the Hoyer lift. CNA A went and requested the assistance of another CNA to take Resident 1 to the bathroom. CNA A stated something happened with her knee and her legs just went out next to her bed. During a interview on [DATE] at 2:15 pm, CNA B stated Resident 1 did not like the Hoyer lift and was able to convince certain staff not to use it during transfers. CNA B stated she lost control of her legs quite often during transfers since being admitted to the facility. During a concurrent interview on [DATE] at 2:45 pm with CNAs C, D, and E, they all confirmed Resident 1 was a Hoyer lift for most of the time she was at the facility. CNAs C, D and E confirmed Resident 1 would cry to get her way so staff would not use the Hoyer lift. CNAs C, D, and E confirmed staff would not always use the Hoyer lift when taking Resident 1 to the bathroom. During a concurrent record review and interview on [DATE] at 12:30 pm, the Director of Nursing (DON) stated if a resident was assessed by PT to need a Hoyer lift the staff should always use the lift. The DON stated there were no exceptions including resident preference. The DON stated nursing students should be monitored by facility staff and their instructor. The DON stated Resident 1 was not an appropriate resident assignment for nursing students. The DON stated Resident 1 should be evaluated by PT after every fall or transfer incident. The acute care hospital records, dated [DATE], indicated Resident 1 suffered a right femur (leg bone) and tibia (smaller leg bone) fracture. A surgeon evaluated Resident 1 and determined medical management only (no surgery) due to her significant osteoporosis and osteopenia (bone loss disease) and she had damage on the right side from a previous stroke. The report indicated the physician explained to the family that Resident 1's pain was going to be hard to control, due to the extreme pain whenever she moved the knee, due to the broken bones. Hospice (end of life care) was recommended due to the difficulty of being able to control Resident 1's severe pain with movement which would prevent her from going to the Dialysis center for treatment of [REDACTED]. Resident 1 was transferred on [DATE], from the acute care hospital to a skilled nursing facility for comfort care end of life orders. On [DATE], Resident 1 expired and the death certificate issued on [DATE], indicated Resident 1 expired from heart failure.

Based on observation, interview, and record review, the facility failed to ensure prompt medical evaluation and treatment for [REDACTED]. Resident 17 had a decrease in level of consciousness and altered mental status which was not properly assessed or promptly acted upon, per the facility's change in condition policy. The facility did not report Resident 17's significant change in condition immediately to a physician and emergency response (911) staff were not promptly called, resulting in a delay in medical evaluation and treatment. Licensed nursing staff did not monitor Resident 17's vital signs (temperature, blood pressure, heart rate/rhythm and breathing rate/rhythm) and oxygen saturation levels (measures blood oxygenation), per the facility's change in condition policy, or ensure the use of [MEDICAL CONDITION] (Bilevel positive airway pressure changes the pressure per the breathing pattern, making it easier to breathe. [MEDICAL CONDITION] (continuous positive airway pressure ([MEDICAL CONDITION]) delivers air pressure at a single level. Both [MEDICAL CONDITION] and [MEDICAL CONDITION] are used to treat obstructive sleep apnea, a serious sleep disorder where breathing is not adequate during sleep caused by a blockage of the airway), as ordered by the physician. Resident 17 received potent narcotic pain medications that have the potential to adversely decrease breathing effort and alter mental status. Prescribed narcotic pain medication dosages were not adjusted (reduced) in consideration of Resident 17's [DIAGNOSES REDACTED]. These failures contributed to Resident 17 being over-medicated with potent narcotic pain, and potentially [MEDICATION NAME], and [MEDICATION NAME] medications, and resultant decreased breathing and level of consciousness, requiring evaluation and treatment in a hospital emergency room (ER) and subsequent hospital admission to the Intensive Care Unit (ICU) where she received treatment to reverse the effects of narcotic medication overdose, and diuretic medication determined to be contributing to her change in condition were stopped. Resident 17 was diagnosed with [REDACTED]. Refer to F 329 and F 389. Findings: Resident 17's record was reviewed. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission Resident Data Collection admission assessment, completed by Registered Nurse (RN) D on 9/3/15 at 4:30 pm, documented that Resident 17 was alert, cooperative, had quick comprehension and was oriented. However, additional check-marked information indicated Resident 17 was disoriented to time, place, and person. Resident 17's skin was dry and she had no [MEDICAL CONDITION] (excess fluid/swelling). Review a vital signs flow sheet indicated on 9/3/15, day of admission, Resident 17's vital signs were: Temperature of 97.5° Fahrenheit, heart rate 72 beats per minute, breathing rate 18 breaths per minute, and blood pressure 126/60 mm/Hg. An admission pain assessment, dated 9/3/15, documented Resident 17's pain to her left leg and ankle (described to ache and burn) with a diagram showing her current pain scale severity level to be 8 to 10 out of 10 (a standardized pain assessment where zero means no pain and 10 means the worst possible pain). There was no information in the record of what pain medication(s) had been previously prescribed or effective for Resident 17 in the past, at home. On 9/3/15, Resident 17 signed an Advance Directive indicating her desire for hospitalization and treatment should her condition change. This document was signed by her physician on 9/7/15. Resident 17's admission physician's orders [REDACTED]. of 7 to 10), and [MEDICATION NAME] 1 mg orally at bedtime for anxiety manifested by inability to relax. A physician's orders [REDACTED]. Resident 17 was also receiving [MEDICATION NAME] (used to treat [MEDICAL CONDITION] to remove excess fluid from the body) 80 mg orally every day for [MEDICAL CONDITION], [MEDICATION NAME] (treats fluid retention in patients with [MEDICAL CONDITIONS], or kidney problems) 25 mg orally every day for [MEDICAL CONDITION], and [MEDICATION NAME] 800 mg orally twice daily for [MEDICAL CONDITION] (nerve related pain). Review of a Dehydration-Fluid Maintenance care plan, dated 9/4/15, indicated Resident 17 was at risk for dehydration due to diuretic use. Resident 17 was to be monitored for signs and symptoms of dehydration such as low blood pressure, confusion, and increased weakness. Review of a care plan for blood pressure, dated 9/4/15, indicated Resident 17 was at risk for abnormally low or high blood pressure and her blood pressure was to be monitored and abnormalities were to be reported to the physician. Review of a Nutrition care plan, dated 9/4/15, indicated Resident 17 was at risk for altered nutritional intake. The care plan goal included Resident 17 would consume 75% or more of her meals and maintain adequate hydration. Substitutes were to be offered for intake less than 75%. Snacks and beverages were to be offered at bedtime. Fluids were to be encouraged. Review of a Nutritional Screening, dated 9/5/15, indicated Resident 17's appetite was Good 75-100% (percentage of meal (food/fluid) intake). On 9/5/15 at 2 pm, a telephone order was documented from Resident 17's physician, the Medical Director (MD) of the facility, to discontinue Resident 17's routine [MEDICATION NAME] ER 10 mg every 12 hours for pain, and start [MEDICATION NAME] mg orally every 12 hours. Review of an admission assessment by the MD for Resident 17, dated 9/7/15, indicated she had a medical history of [REDACTED]. Under alcohol illicit drug use, the MD documented Resident 17 was a former smoker. The MD did not document a history of alcohol or drug abuse. Resident 17's 9/2015 MAR and Controlled Drug Record (tracking of date, time and dose) were reviewed with the Administrator (Admin) and Director of Nursing (DON) to evaluate how many doses of the [MEDICATION NAME] IR (short acting narcotic) Resident 17 received, ordered 5 to 10 mg every four hours as needed for pain, on 9/3/15. Resident 17 received the following: 9/3/15, 10 mg at 9:30 pm; 9/4/15, 10 mg at 2 am, 11 am, 3 pm, 7 pm, and 11 pm (a total of 50 mg); 9/5/15, 10 mg at 3 am, 7 am, 12:05 pm, 4 pm, and 8 pm (a total of 50 mg); 9/6/15, 10 mg at 8:05 am, 12 pm, 4 pm, 8 pm (a total of 40 mg); 9/7/15, 10 mg at 1:15 am, 5:15 am, 9:45 am, 1:45 pm, and 11 pm (a total of 50 mg); 9/8/15, 10 mg at 4:30 am, 10:20 am, and 4 pm (a total of 30 mg); and 9/9/15, 10 mg at 2:10 pm. Resident 17 received 240 mg [MEDICATION NAME] IR from 9/3/15 at 9:30 pm to 9/9/15 at 2:30 pm. The MAR, dated 9/2015, indicated, from 9/7 to 9/9/15, Resident 17 received [MEDICATION NAME](potent [MEDICATION NAME]) 15 mg twice a day at 8 am and 8 pm, in addition to the [MEDICATION NAME] IR. There were no vital signs recorded on 9/6, 9/7, 9/8, 9/9 or 9/10/15. There were no documented pulse oximeter (records oxygen saturation level in the blood) levels recorded on this flow sheet nor the nurses notes until 9/11/15 at 9 am, when Resident 17 was noted to have shallow breathing and an abnormally low oxygen saturation level of 80% (normal range 91 to 100%), prior to being sent to the ER. On 9/10/15 at 2:30 pm, nurses notes indicated, during the change of shift report, day shift staff reported Resident 17 was very sedated during the shift. A LN wrote when she went to Resident 17's room it took several attempts to awaken her and she appeared very drowsy. It was discussed that the resident was too sedated ? the new pain medication. Documentation in the nurse's notes read, the MD was called and a message was left on the answering machine to call the facility back. The same LN documented at 10 pm (seven and a half hours later) the MD had not returned her call and Resident 17 was still very sedated and her [MEDICATION NAME] were held. Documentation indicated Resident 17's Family Member (FM) AB had called upset about Resident 17's condition, and that all the above was reported to the Director of Nurses (DON). A 24 hour report/Change of Condition Report, dated 9/10/15, indicated Resident 17 was very sedated throughout the shift and her 8 pm [MEDICATION NAME] were held. The documentation indicated a message was left on the physician's answering machine concerning Resident 17 and a family member had called upset yelling at staff. The following night shift, 9/10 to 9/11/15, there were no nurses progress notes documentation about Resident 17. On 9/11/15 at 9 am, a LN documented she called the MD and left a message that Resident 17 needed to be sent to the local ER. The note indicated that upon assessment, Resident 17 was extremely lethargic with a decreased level of consciousness and unable to make her needs known. Oxygen saturation was 80% on room air and she was having twitching movements to body. The MD called back and Resident 17 was sent to the hospital ER for evaluation. A review of Nursing Assistant Daily Flow Sheets for September 2015 indicated Resident 17's meal (food/fluid) intake percentages had decreased below 75%; Zero to 50% for 10 of 22 meals and N, indicating no, snacks/nourishments were offered from 9/4 through 9/11/15. On 9/17/15 at 1:50 pm, Licensed Vocational Nurse (LVN) M was interviewed. LVN M stated Resident 17 was very lethargic but would respond when spoken to, prior to sending her to theER on [DATE]. On 9/17/15 at 7:30 pm, FM AB was interviewed. FM AB stated on Wednesday (9/9/15), prior to Resident 17's hospitalization , she called Resident 17 and she was wiped out sounding. FM AB stated she called the next day and Resident 17 could not answer her questions. FM AB stated she went to see Resident 17 on 9/11/15 around 7 am, and Resident 17 did not know her name, where she was and thought there was water on the ceiling. FM AB stated she got the Charge Nurse and demanded something be done. FM AB stated the nurse said Residents 17's breathing and blood pressure were low and FM AB stated she feared what would have happened if she had not shown up that morning. FM AB stated the nurse in the ER told her that Resident 17 was over-medicated. FM AB stated Resident 17 was in the ICU. On 9/18/15 at 10 am, in an interview, the MD stated that it was the nurse's responsibility to assess residents before administering narcotic pain medication and he would expect them to take the residents respirations and use the pulse oximeter. On 9/18/15, after interviewing the MD, at 10 am, the DON stated she could not believe the nurses were not taking Resident 17's vital signs or pulse ox especially when they documented she was sedated on 9/10/15 since the day shift. The DON stated she was not aware that Resident 17 used a [MEDICAL CONDITION] at night. On 9/18/15 at 10 am, MD and the Pharmacy Consultant (PC) were interviewed. The MD stated he had no prior contact with Resident 17 until he saw her on 9/7/15, four days after her admission. The MD stated he was aware of how much narcotic medication she was receiving and was not concerned with the amount unless she was receiving over 60 mg of [MEDICATION NAME] in a 24 hour period. The PC stated the physician's narcotic orders for pain medication were appropriate. The MD stated he was aware of her [MEDICAL CONDITION] and chronic kidney failure history. The MD explained the difference between the [MEDICATION NAME] ER and IR was that the ER was long acting and the IR was short acting, stating, .you're lucky if it lasts for two hours. The MD and the PC stated that Resident 17's comorbidities (multiple chronic health conditions) had nothing to do with pain and response to the [MEDICATION NAME] IR and the MS Contin. The PC stated that the conversion (change) from [MEDICATION NAME] IR to [MEDICATION NAME] a reasonable conversion and that it equaled five [MEDICATION NAME]. The MD stated that the nurses told him that Resident 17 took [MEDICATION NAME] at home, although it was not documented. The PC stated that recently she has seen this type of reaction, an unavoidable drug event when [MEDICATION NAME] is changed to [MEDICATION NAME] two other residents (not at the facility), that ended up in the hospital with altered levels of consciousness. The PC continued to state, it is either stronger or dissolves too quickly in the stomach. I believe it's an adverse drug event to the product. The PC stated this was something that the FDA needed to review. The PC stated she had not evaluated Resident 17's medications since she was admitted to the facility. Review of the hospital ER documentation, dated 9/11/15, indicated, Resident 17 presented to the ER at 9:58 am with noted changes in mentation. Resident 17's blood pressure was 76/33, breathing rate was 16 breaths per minute, and pupils were abnormal (pinpoint and sluggishly reactive). Resident 17 was administered oxygen at 2-3 liters flow per minute to maintain acceptable oxygen saturation levels. Resident 17 was administered intravenous (IV, via the vein) [MEDICATION NAME] (a medication used to reverse the side effects of narcotic overdose) times three doses and IV fluid replacement wide open (rapid infusion) times two Liters, then continuous infusion at 150 ml per hour. Resident 17 was diagnosed with [REDACTED]. At 4:20 pm, Resident 17 was hallucinating (seeing water on the ceiling with rambling speech). At 6:36 pm, Resident 17 was described to have tics (spasm type movements) to all four extremities. At 6:43 pm, Resident 17 was described to have slurred speech and was not coherent. Resident 17 was admitted to the ICU for a higher level of care and treatment for [REDACTED]. A Nephrology (physician kidney specialist) Consult, dated 9/11/15, indicated that upon admission it was first suspected that Resident 17's altered level of consciousness was due to too many oral narcotics. A Chem panel (laboratory blood test) showed Resident 17 had severe metabolic abnormalities with [MEDICAL CONDITION] (low sodium, 126) and elevated blood urea nitrogen (BUN) of 162 (normal range 10 to 20 mg/dl) and creatinine (Cr) of 5.93 (normal range 0.5 to 1.1 mg/dl), indicative of kidney failure. The Nephrologist documented Resident 17's baseline BUN/Cr levels were usually in the 50's and Cr of 1.7, and suspected Resident 17 might have been taking too much diuretics (medications that remove water from the body) at the facility, and due to her history of [MEDICAL CONDITION], she was not able to absorb fluids by mouth and was extremely volume (fluid) depleted with severe [MEDICAL CONDITION]. The Nephrologist indicated Resident 17 was disorganized and delusional likely due to toxic metabolic [MEDICAL CONDITION], narcotic medication, UTI, dehydration and uremia. The Nephrologist noted [MEDICATION NAME] dose should be restricted to no more than 300 mg for a renal patient. IV fluids were continued at 150 ml per hour infusion to treat dehydration, [MEDICAL CONDITION], and metabolic acidosis. An IV antibiotic and iron replacement therapy were started to treat UTI and severe [MEDICAL CONDITION]. An FDA [MEDICATION NAME] and side effects warning indicated in bold letters to include life threatening respiratory depression (stopping breathing). It instructed that each patient's risk should be assessed prior to prescribing [MEDICATION NAME] be monitored regularly for the development of respiratory depression especially within the first 24 to 72 hours of initial therapy. Under conversion (changing) from other opioids to [MEDICATION NAME] recommended to discontinue all other around the clock opioids drugs when [MEDICATION NAME] is initiated and initiate dosing just using the MS Contin. It additionally instructed that residents with renal impairment may accumulate a much higher blood level due to their inability to excrete (pass the medication from their body) the medication compared to residents with normal renal function. The National Institutes on Health article titled, Opiates and elderly: Use and side effects dated June 2008, indicated that patients with renal/hepatic (kidney/liver) dysfunction, dose escalation (increases) percentages should be reduced. When using PRN orders, it is important to use these orders in a range to provide options, but narrow enough to ensure safety, keeping in mind renal/hepatic functions of the individual patients. The difference should be no more than 4 times the lowest dose. It is also important to acknowledge patient's exposure to opioids. In opioid naïve (are not used to taking opiates) patients, the lowest dose is recommended as opposed to patients who have received prior opioids with inadequate pain relief where a higher dose is justified. In the older population, start low and go slow monitoring side effects and pain tolerance. Debilitated patients or those with respiratory insufficiency are more at risk for [MEDICAL CONDITION] if over sedated. Elimination of drugs can be altered with age related reductions in renal blood flow and glomerular filtration rate. When converting from one opiate to another, the new opiate should be given at 50% to 67% of the calculated dose for all opiates, except [MEDICATION NAME] and [MEDICATION NAME], to allow for incomplete cross-tolerance. Cross-tolerance effects can cause the new opiate to have more adverse effects and [MEDICATION NAME] (anti-pain) properties. On 9/18/15 at 2:30 pm, Certified Nursing Assistant (CNA) AA stated she cared for Resident 17 on 9/10/15 on the pm shift, the day before she was sent to the hospital. CNA AA stated she does not remember any vital signs or oxygen saturation levels taken. She stated Resident 17 was snoring loudly and was not wearing her [MEDICAL CONDITION] machine on the evening of 9/10/15. CNA AA stated Resident 17 was, out of it and she could not get her to wake up. She stated FM called, and was very upset stating that they were overmedicating Resident 17. On 9/18/15 at 3:30 pm, the Administrator (Admin) stated that it was the policy of the facility that if the nurses could not get a hold of a physician or MD they were to call him first and then the DON. It's our policy to call 911 if you can't get a hold of the physician. He confirmed the nurses did not follow the facility policy and that Resident 17 was noted to have a change of condition during three shifts which was not acted on for 19 hours. Review of the facility's undated Condition Change of the Resident (Observing, Recording and Reporting) policy indicated staff were to observe and report any condition changes to the attending physician, so prompt treatment would be implemented. The policy instructed after a change of condition is identified, vital signs would be monitored along with alteration in consciousness, dyspnea (difficulty breathing) or variations of respirations (breathing). The policy directed to have someone stay to monitor the resident while the charge nurse called the physician, or the physician on call. If the attending physician or physician on call was unavailable, the policy instructed staff to call the emergency physicians. When an emergency situation required immediate response, the policy instructed staff to call an emergency physician on the telephone list. A hand written note on the policy read, or call the Medical Director. Another hand written entry read, If resident needs immediate attention call 911. On 9/21/15 at 10 am, the Director of Nurses (DON) and the Admin were interviewed while reviewing Resident 17's records. The DON confirmed that when the [MEDICATION NAME] ER was not available on admission a physician's orders [REDACTED]. She stated the nurse that took the physician's orders [REDACTED]. The Admin called the pharmacy, and then stated that the [MEDICATION NAME] not delivered to the facility until 9/6/15 at 10:05 pm. The Admin stated, typically when a resident is admitted , the physicians orders are reviewed by the nurses, then faxed to the physician and the pharmacy the same day. On 9/22/15 at 9:30 am, Resident 17's Family Member (FM) AB stated on 9/11/15 around 7:30 am, she observed Resident 17's [MEDICAL CONDITION] on her bedside table still inside the case, not in use. During an observation and interview on 9/22/15 at 12:25 pm, Resident 17 stated she did not remember her admission or her stay at the facility except for when another family member visited, and when something happened with her bed. She stated she did not take [MEDICATION NAME] at home but took [MEDICATION NAME] 5/325 mg for pain. She stated she did not take [MEDICATION NAME] daily at home, just as needed, depending on how much activity she did. She stated currently she is on [MEDICATION NAME] at her new facility every six hours and it is controlling her pain. She stated she has been told in the past that she does not process medications like most people because of her [MEDICAL CONDITION] and kidney problems.

Based on interview and record review, the facility failed to provide necessary services, to maintain the resident's highest practicable well-being, in accordance with the plan of care for one of four sampled residents (Resident 3). Resident 3's routine narcotic medication, (used to treat her chronic pain) was not administered for three consecutive days. This failure resulted in daily avoidable episodes of severe pain that included one episode of unrelieved excruciating pain. Findings: Resident 3's record was reviewed on 9/2/14 and 12/4/14. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool), dated 8/26/14, indicated Resident 3 was able to communicate effectively and had no memory impairment. Resident 3's record was reviewed. A physician's orders [REDACTED]. Resident 3's Medication Administration Records (MAR), dated 7/2014 and 8/2014, indicated the MS-contin was administered as ordered for the next 22 days until 8/12/14, when six consecutive doses were not administered over a period of three days. The MARs included documentation that indicated the MS-contin was not administered because the facility had not received it from the pharmacy. Resident 3's MAR indicated [REDACTED]. Documentation in the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. According to Lexicomp (a pharmaceutical standard reference resource), MS-contin is addictive, and should not be stopped suddenly, to avoid withdrawal symptoms that can include excruciating pain. Review of the MAR indicated [REDACTED]. On 9/2/14 at 4 pm during an interview, Resident 3 stated that a week or so ago, her pain was so bad she was crying. Resident 4 stated the medications they gave her were not effective to relieve her pain and the pain was almost unbearable. On 9/2/14 at 4:45 pm during an interview, LN B remembered that on 8/15/14, the 3rd day that Resident 3 had missed her routine MS-contin, her pain was unrelieved with pain medication ordered to be given as needed for breakthrough pain. LN B explained that Resident 3 was crying and upset from the pain. LN B stated that her pain was finally relieved, by a one time order for a stronger pain medication, two hours later. LN B stated that the routine MS-contin finally arrived from the pharmacy and was administered that same evening. On 12/4/14 at 2:30 pm during an interview and concurrent record review, Licensed Nurse Unit Manager (LNUM) was asked if the physician had been notified that Resident 3 had not received the ordered pain medication during the three day period it was not supplied by the pharmacy. LNUM stated that documented evidence of physician notification was not found. LNUM stated that facility practice required that the physician be notified immediately, when a resident does not receive their routine doses of narcotic pain medication. On 9/2/14 at 5 pm, the DON confirmed that Resident 3 experienced avoidable pain when her routine pain medication was not administered for three days.