Every finding on record at Monroe Health & Rehab Center

Based on observations, staff interviews, and facility document review, the facility staff failed to properly store, prepare and distribute food in the facility kitchen in a manner that would prevent foodborne illnesses.The findings included:The facility staff failed to maintain one of two kitchen freezers in proper working order, freezer #2 contained multiple food items that were not fully frozen. The facility staff had stacked wet pans nesting them while wet and a large scoop was stored inside an uncovered container of powdered thickener. There was a white cloth lying on the floor of the refrigerator and a roll of buffet ham was stored above produce, creating a risk of cross-contamination. On 04/21/2026 at 5:55 a.m., during the initial kitchen tour, the survey team observed a clear plastic container of powdered thickener without a lid, with a scoop inside. Dietary Aide #1 removed the scoop. The survey team observed numerous silver pans stacked on a metal rack with visible water droplets present on several pans. When asked about the stacking of wet pans Dietary Aide #1 stated that items are typically placed on a drying rack. Kitchen refrigerator #1 was observed with a white cloth lying on the bottom of the refrigerator beneath a storage rack. Staff were observed to remove this cloth. A roll of buffet ham was stored on the second shelf above produce. The Dietary Manager (DM) confirmed the ham should not have been stored above produce. Freezer #2's internal temperature was observed to be 16 degrees Fahrenheit, with visible water accumulation on the bottom shelf and wet cardboard boxes present. Several food items were not frozen including sherbert, bags of onions and peppers, pulled pork, broccoli florets, French toast, ribs, seafood, turkey sausage, Canadian bacon, pizza, flounder, broccoli and cheese soup, mighty shakes, chicken and beef dinner balls, turkey thighs, chicken and wild rice soup, chicken tenders, manicotti, and a mixture of corn and mixed vegetables. The staff did not access any of this food for the breakfast meal and stated that a food delivery had been received the previous day. Multiple boxes were dated 04/20/2026. On 04/21/2026 at 6:20 a.m., the DM stated the unfrozen food items would be discarded, and they had previous issues with this freezer.On 04/21/2026 at 8:50 a.m., during an interview, the Maintenance Director (MD) stated this was the first issue with the new freezer and stated the unit may have been overpacked and confirmed that a technician had been contacted to evaluate the equipment. Documentation provided by the MD indicated the freezer had been ordered on 02/27/2026 and delivered to the facility during the first week of 03/2026. On 04/21/2026 at 3:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Director of Clinical Services, and Regional [NAME] President of Operations the issues in the facility kitchen were reviewed. On 04/22/2026 at 8:20 a.m., during a follow-up observation in the facility kitchen the Administrator stated the freezer door had been left ajar, the freezer was too full of product, causing the freezer to freeze up. The freezer was observed to have been emptied. On 04/22/2026 at 9:50 a.m., during a follow-up interview with the DM and Dietary Aide #1, the Dietary Aide reported she had not worked over the weekend but noted on Friday the freezer temperature kept dropping. The DM stated that maintenance had been notified, the temperature went back to normal, and she assumed there was too much product in the freezer. The DM stated maintenance came in checked the freezer and stated the door was not fully closed. On 04/22/2026 at 11:15 a.m., the DON provided the survey team with a copy of a service ticket dated 04/21/2026. The service technician reported the fans had frozen in the freezer with excessive ice buildup in the evaporator. The freezer was cleaned and manager made aware. On 04/22/2026, the DM provided the surveyor with a copy of the Freezer & Refrigerator Temperatures Log. For 04/21/2026 the dietary staff recorded a temperature of 9.2 for the morning freezer temperature. Recorded temperatures from the previous day were -1 Fahrenheit (morning) and -6 Fahrenheit (evening). The facility kitchen included a second freezer with no problems being observed by the survey team.No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, family interview, staff interview, clinical record review, and facility document review, the facility staff failed to utilize appropriate adaptive devices for meals for (1) one of (28) twenty-eight current sampled residents, Resident #58. The findings included:For Resident #58, the facility staff failed to utilize a plate guard and a two-handled cup with lid for the resident's meal on 4/21/26 as ordered by a medical provider. Resident #58's diagnosis list indicated diagnoses that included, but were not limited to, sequelae of cerebral infarction, vascular dementia, depression, weakness, and cognitive communication deficit. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 1/26/26, assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. On 4/21/26 at 11:44 AM, Resident #58's Family Member #1 (FM#1) was interviewed via phone conversation and stated the resident has a plate guard to assist with eating meals, but facility staff fail to put it on the resident's plate. On 4/22/26 at 8:33 AM, Resident #58 was observed sitting up in bed eating from a plate of breakfast that was placed on the over-the-bed table. The lid to the plate of breakfast was observed to be sitting on the bed near the resident and a plate guard and two-handled cup with lid were observed to be sitting inside the lid. Resident #58 stated they would like to have some black coffee. On 4/22/26 at 8:35 AM, Certified Nursing Assistant #1 (CNA#1) was interviewed and CNA#1 stated she did not set-up Resident #58's meal, but she would correct it. CNA#1 was observed to place the plate guard on Resident #58's plate and was informed the resident requested some black coffee. CNA#1 stated she would put the coffee in the two-handled cup. Resident #58 agreed they could hold the coffee better when it was in the two-handled cup with lid. A review of a medical provider orders disclosed an order with a start date of 1/23/26, which read in part, .ADAPTIVE FEEDING EQUIPMENT (Plate Guard).Special Instructions: Plate Guard with meals. A review of a medical provider orders disclosed an order with a start date of 1/23/26, which read in part, .ADAPTIVE FEEDING EQUIPMENT: (Two-Handled Cup with Lid). A review of the comprehensive person-centered care plan disclosed a focus with a start date of 1/24/26 and an edited date of 3/8/26 which read in part, .on mechanically altered diet. Adaptive equipment in place (.plate guard, two-handled cup with lid. Interventions associated with the focus read in part, .provide diet per order.Adaptive equipment as.ordered. This concern was discussed on 4/22/26 at the end of day meeting with the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Clinical Services, and Regional [NAME] President of Operations. Requested and received a facility policy titled, Adaptive Eating Devices Policy with a revision date of 1/17/25 which read in part, .Adaptive (assistive) eating devices are provided per provider order. No further information was provided prior to exit on 4/23/26.

Based on observation, staff interview, and clinical record review, the facility physician failed to review the total program of care including medications at each visit for 1 of 28 residents in the sample, Resident #87 (R87).The findings include: On 4/21/2026 at 7:40 AM, R87 was observed asleep in bed. A container of Beet Root Heart Gummies (a nutritional supplement) and Sea Veg (a nutritional supplement) were observed on the bedside table.During an interview with R87 that took place on 4/21/2026 at 11:08 AM, a container of Beet Root Heart Gummies and a container of Sea Veg were again observed on the bedside table. When asked about these supplements, R87 stated that he had ordered these items online and that he was taking these supplements to improve his health. An interview was conducted with Medical Director on 4/22/26 at 1:56 PM. The Medical Director stated that he became aware that R87 was taking Beet Root Heart Gummies a couple of weeks ago. The Medical Director stated that he did not check R87's MAR (Medication Administration Record) to see if the Beet Root Heart Gummies or other supplements were present on the MAR. The Medical Director stated he was aware that R87 does not self administer medications. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, and clinical record review the facility staff failed to provide activities of daily living care for 1 of 28 residents, Resident #7. The findings included:Resident #7 was observed to have long, jagged fingernails. Resident #7's diagnoses included vascular dementia and major depressive disorder. Section C (cognitive patterns) of Resident #7's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/19/2026 included a brief interview for mental status (BIMS) score of 15, indicating Resident #7 was cognitively intact. Section GG (functional abilities) was coded to indicate Resident #7 required partial/moderate assistance with personal hygiene. Resident #7's comprehensive care plan identified a need for assistance with activities of daily living, dressing, grooming, toileting, feeding, and oral care. Approaches included check nail length and trim and clean as needed, per protocols (start date: 03/23/2026). On 04/21/2026 at 12:55 p.m., during an interview with Resident #7, their fingernails were observed to be long and jagged. The resident reported that someone had stated they would trim their nails but did not return. On 04/21/2026 at 3:00 p.m., this issue was reviewed during an end of the day meeting with the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Director of Clinical Services, and Regional [NAME] President of Operations. On 04/22/2026 at 9:16 a.m., during a follow-up observation with Resident #7 the Resident's fingernails were observed to have been trimmed. No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review and facility document review the facility staff failed to follow physician's orders for 3 of 28 residents, Resident #15, Resident #120 and Resident #58. The findings included:1. For Resident #15 the facility staff failed to administer GenTeal eye drops (used to treat dry eyes) and Voltaren gel (used to treat pain) per the physician's orders. Resident #15's face sheet listed diagnoses which included but not limited to other corneal scars and opacities and primary osteoarthritis, unspecified site. Resident #15's most recent quarterly minimum data set with an assessment reference date of 03/31/26 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #15's comprehensive care plan was reviewed and contained plans for Pain. Resident is at risk for pain secondary to Osteoarthritis and Visual Function. Resident has visual impairment r/t (related to) DX (diagnosis) of corneal scars and opacities. Interventions for these plans included administer medications as ordered and administer eye medication as ordered. Resident #15's clinical record contained a physician's order summary which read in part, Voltaren Arthritis Pain (diclofenac sodium) [OTC (over the counter)] gel; 1%; amt: 2 grams to both knees; topical. Twice A Day. 07:00-11:00, 19:00-23:00 and GenTeal Tears Moderate (PF {preservative free})(dextran 70-hypromellose (pf) [OTC] dropperette; 0.1-0.3%; amt: 2 drops; ophthalmic. Special Instructions: Instill 2 drops in Left eye two times a day for dry eyes. Twice A Day. AM Med Pass 07:00-11:00, PM Med Pass 19:00-23:00 [7:00 PM-11:00 PM]. Resident #15's electronic medication administration record (eMAR) for the month of April 2026 was reviewed and contained entries as above. The entry for GenTeal eye drops was coded as Not Administered: Drug/Item Unavailable on 04/09/26 evening, 04/13/26 evening, 04/14/26 evening and 04/20/26 evening. The entry for Voltaren gel was coded as Not Administered: Drug/Item Unavailable on 04/09/26 evening. Resident #15's progress notes were reviewed and contained a nurse's note which read in part, 04/21/2026 03:29. Call was placed to . (pharmacy) twice regarding resident's GenTeal Tears that is not available. Initial call was placed at 2358 (11:58 pm), at this time this RN (registered nurse) was informed that the medication was listed as 'house stock'. After validating that this medication was NOT available with the OTC medication as second call was placed at 0330 (3:30 AM) to ask for delivery of the medication. Surveyor spoke with the Director of Nursing (DON) on 04/22/26 at 3:05 pm regarding Resident #15's medication availability. DON stated the nurse administering the medications on the dates coded as unavailable was a new employee and did not know where to look for the medication. DON stated the medication was available for administration, and per the documentation it was not administered. Surveyor requested and was provided with a facility policy entitled General Dose Preparation and Medication Administration which read in part, 5.4 Administer medication within timeframes specified by facility policy or manufacturer's information. The concern of not administering Resident #15's medications per the physician's orders was discussed with the Administrator, DON, Assistant DON, Regional Vice-President of Operations, and Regional Director of Clinical Services on 04/22/26 at 4:50 pm. No further information was provided prior to exit. 2. For Resident #120 the facility staff failed to administer the medication methocarbamol (used to treat muscle spasms/pain) per the physician's order. Resident #120's face sheet listed diagnoses which included but not limited to other muscle spasm. Resident #120's most recent quarterly minimum data set with an assessment reference date of 04/14/26 assigned the resident a brief interview for mental status score of 13 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #120's clinical record was reviewed and contained a physician's order summary which read in part, methocarbamol tablet; 750 mg; amt: 1 tablet; oral. Twice A Day. AM Meds Pass 07:00-11:00, PM Med Pass 19:00-23:00. Resident #120's electronic medication administration record for the month of April 2026 was reviewed and contained an entry as above. This entry was coded as Not Administered: Drug/Item Unavailable on 04/10/26 AM med pass. Surveyor spoke with the Director of Nursing (DON) on 04/22/26 at 3:05 pm regarding Resident #120's medication availability. DON stated the nurse administering the medication on the date coded as unavailable was a new employee and did not know where to look for the medication. DON stated the medication was available for administration, and per the documentation it was not administered. Surveyor requested and was provided with a facility policy entitled General Dose Preparation and Medication Administration which read in part, 5.4 Administer medication within timeframes specified by facility policy or manufacturer's information. The concern of not administering Resident #120's medications per the physician's orders was discussed with the administrator, DON, Assistant DON, Regional Vice-President of Operations, and Regional Director of Clinical Services on 04/22/26 at 4:50 pm. No further information was provided prior to exit. 3. For Resident #58, the facility staff failed to follow a medical provider order to discontinue monthly weights with an order for comfort care measures. Resident #58's diagnosis list indicated diagnoses that included, but were not limited to, atherosclerotic heart disease of native coronary artery s/p (status-post) CABG (coronary artery bypass grafting), sequelae of cerebral infarction, vascular dementia, depression, weakness, and cognitive communication deficit. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 1/26/26, assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of a medical provider order with a start date of 2/21/26 read in part, .Comfort care.no weights. A review of the current comprehensive person-centered activity care plan disclosed a focus with an initiated date of 4/2/26, which read in part, .Resident is on Comfort Care. An intervention associated with the focus read in part, .No.weights. A review of Resident #58's weight records disclosed the resident's weight was obtained on 3/6/26 and 4/3/26. On 4/22/26 at 2:21 PM, the Director of Nursing (DON) was interviewed and stated the weights for Resident #58 on 3/6/26 and 4/3/26 were obtained in error. This concern was discussed at the end of day meeting on 4/22/26 at 4:00 PM with the Administrator, Director of Nursing, Regional Director of Clinical Services, Assistant Director of Nursing, and Regional [NAME] President of Operations. Requested and received a facility policy titled, Physician/Provider Orders Policy with a review date of 10/7/24 which read in part, .The Charge Nurse shall.review all physician/provider orders.The order must then be transcribed to all appropriate areas (eMAR (electronic medication administration record), eTAR (electronic treatment administration record) , etc.). No further information was provided prior to exit on 4/23/26.

Based on observation, resident and staff interview, clinical record review, and facility document review the facility failed to ensure the safe storage of biologicals for 1 of 28 residents in the sample, Resident #87 (R87).The findings include:A Resident Face Sheet indicated that R87 was admitted to the facility on [DATE] with a medical history that included hypertension (high blood pressure), heart failure, and hypothyroidism.On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 4/15/26, R87 scored a 14 out of 15 on the Brief Interview for Mental Status indicating that R87 was cognitively intact. A comprehensive review of R87's clinical record revealed that on 1/15/25 the facility documented an assessment to determine R87s ability to self administer medications. This assessment revealed that R87 did not wish to self administer medications therefore R87 was not screened for the ability to self administer medications.R87's current medical provider orders and the April 2026 MAR (Medication Administration Record) for R87 demonstrated that R87 took Levothyroxine (a medication for low thyroid function) daily, Bumetanide (a medication used to treat heart failure and high blood pressure) daily, and Entresto (a medication used to treat heart failure and high blood pressure) twice daily. On 4/21/2026 at 7:40 AM, R87 was observed asleep in bed. A container of Beet Root Heart Gummies (a nutritional supplement) and Sea Veg (a nutritional supplement) were observed on the bedside table unsecured and within reach of R87.During an interview with R87 that took place on 4/21/2026 at 11:08 AM, a container of Beet Root Heart Gummies and a container of Sea Veg were again observed on the bedside table within reach of the resident. When asked about these supplements, R87 stated that he had ordered these items online and that he was taking these supplements to improve his health. Review of R87's current medical provider orders failed to demonstrate a medical provider order for Beet Root Heart Gummies and Sea Veg. Neither Beet Root Heart Gummies nor Sea Veg were present on the April 2026 MAR. Review of the product label on Beet Root Heart Gummies demonstrated a precaution to consult a physician prior to use when taking other medications or in the presence of medical conditions. Review of the product label on Sea Veg supplement demonstrated a precaution to consult a physician prior to use if taking thyroid medications. The DON (Director of Nursing) and Administrator were made aware of the presence of these supplements at the bedside at 3:30 PM on 4/21/2026.During an interview with LPN (Licensed Practical Nurse) #5 on 4/22/2026 at 12:02 PM, LPN #5 stated that R87 has a history of ordering things online and has them delivered in the mail to his room or the resident's sister will bring things in for the resident. LPN #5 stated that a couple of weeks ago R87 refused his medication for hypertension because he was interested in taking some sort of Beet Root supplement for high blood pressure. LPN #5 stated they educated R87 about the risks of refusing medication and encouraged R87 to speak with their physician before purchasing any supplements. When asked if LPN #5 was aware that R87 had Beet Root Heart Gummies and Sea Veg gummies at the bedside, LPN #5 stated they were not aware and would immediately remove the supplements from the bedside and address the situation with R87 and the physician. Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals effective 12/1/07 with a most recent revision date of 6/30/25 indicated that Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Regarding bedside medication storage, the policy stated that Facility should store bedside medications or biologicals in a locked compartment within the resident's room.No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review the facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary, comfortable environment for 2 of 28 residents, Resident #72 Resident #115. The findings included: 1. For resident #72 the facility staff failed to ensure transmission-based precautions were followed for a resident with active influenza. The policy entitled, Transmission Based Precautions and Isolation Policy with an effective date of 05/19/2025 was reviewed. The document read in part, 2. Droplet Precautions- intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. A. A single patient room is preferred but not required. Assess the various risks associated with other resident placement options. Maintain a spatial separation of greater than 3-6 feet (when space allows) and draw the curtain between resident beds. B. A mask is worn for close contact with infectious resident. C. Gloves, gown are worn adhering to Standard Precaution guidelines. The Resident Face Sheet revealed the facility admitted resident #72 on 02/25/2025. According to the Resident Face Sheet the resident had a medical history that included diagnoses of quadriplegia, chronic obstructive pulmonary disease, congestive heart failure and cough. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/17/2026 assigned the resident a brief interview for mental status (BIMS) score of 14 which indicated intact cognition. Resident #72's comprehensive person-centered care plan included a focus that read, Infection: Resident has a respiratory infection related to influenza with antiviral medication. The last approach listed read, Staff will follow droplet precautions/isolation as ordered, including PPE (personal protective equipment) and proper hand hygiene. Keep door to room closed. The clinical record included a medical provider order dated 04/13/2026 that read, Isolation/Transmission Based Precautions: Combined droplet/contact precautions/isolation related to Influenza B. During an observation of medication pass on 04/22/2026 at 8:55 AM resident #72's door was noted to be closed. A sign that read, STOP- DROPLET-CONTACT PRECAUTIONS; Perform hand hygiene, Wear mask before entering room, Gown before entering room, Gloves before entering room, Eye protection before entering room was noted on the door. The Activities Assistant approached the door, read the sign, opened each drawer of the bin that stored the PPE, applied a mask and entered the room. The Activities Assistant, who was wearing eyeglasses, did not apply gown or gloves. Certified Nursing Assistant (CNA) #1 entered the room directly after the Activities Assistant and did not apply any PPE. CNA #1 exited the room at 9:02 AM. When asked if they were aware that resident #72 was on droplet precautions she stated No, I wasn't, I didn't see the sign, and I don't usually work with him. The Activities Assistant was interviewed on 04/22/2026 at 10:46 AM and stated, I know, I should have put a gown and everything on. I don't know what I was thinking. I read the sign. On 04/22/2025 at 4:51 PM the survey team met with the Administrator, Director of Nursing (DON), Assistant Director of Nursing, and the Regional Director of Clinical Services. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference. 2. For resident #115 the facility staff failed to follow infection control standards of practice to reduce cross contamination during the administration of eye drops. The facility policy entitled Omnicare Medication Administered Through Certain Routes with a revision date of 11/15/2024 stated: 7.7 Wipe off tears or excess solution with a clean tissue. Two different tissues should be used, one for each eye, to prevent cross contamination. The Resident Face Sheet for resident #115 revealed the facility admitted the resident on 01/15/2025. According to the Resident Face Sheet, resident #115 had a medical history that included the diagnosis of dry eye syndrome of both lacrimal glands (glands in the upper, outer corner of each eye that produce tears to lubricate and protect the surface of the eye). A quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/15/2026 assigned the resident a brief interview of mental status (BIMS) score of 03 indicating severe cognitive impairment. The medication administration record (MAR) for resident #115 was reviewed. The MAR included an order that read, Refresh Classic (PF) (polyvinyl alcohol-povidon(pf)) [OTC] dropperette; 1.4-0.6 %; Amount to Administer: 2 drops in both eyes; ophthalmic (eye). On 4/22/2026 at 8:54 AM during observation of a medication pass for resident #115, Licensed Practical Nurse (LPN) #2 was observed administering eye drops to resident #115. During observation, LPN #2 administered 2 drops of refresh solution into each eye. LPN #2 then used a tissue to wipe from the inner corner of the right eye to the outer corner, then used the same tissue to wipe the left eye in the same manner. 4/22/2026 at 11:24 AM The Director of Nursing (DON) was informed of the above concern and provided the policy referenced above. On 04/22/2025 at 4:51 PM the survey team met with the Administrator, DON, Assistant Director of Nursing, and the Regional Director of Clinical Services. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to develop a comprehensive care plan (CCP) for 2 of 28 residents, Resident #11 and Resident #105. The findings included:1. For Resident #11, the facility staff failed to develop a CCP for enhanced barrier precautions. Resident #11 had a percutaneous endoscopic gastrostomy (PEG) tube in place for nutritional support. Resident #11's diagnoses included malignant neoplasm of tonsils and Parkinsons disease. Section C (cognitive patterns) of Resident #11's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/05/2026 included a brief interview for mental status (BIMS) score of 15, indicating Resident #11 was cognitively intact. Section K (swallowing/nutritional status) was coded to indicate this resident had a PEG tube in place. During initial tour the surveyor observed an enhanced barrier precautions sign and personal protective equipment (PPE) outside of Resident #11's room. Staff were observed in this room with PPE in place. Resident #11's clinical record included a provider order dated 04/03/2026 for enteral-bolus tube feeding four times a day. A review of Resident #11's clinical record failed to identify a CCP for enhanced barrier precautions.On 04/21/2026 at 3:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), Assistant Director of Nursing/Infection Preventionist, Regional Director of Clinical Services, and Regional [NAME] President of Operations the omission of enhanced barrier precautions on Resident #11's CCP was reviewed. On 04/22/2026, the DON provided the surveyor with a copy of an updated CCP. Under the identified area of feeding tube the facility staff had added the approach enhanced barrier precautions for PEG tube (created date: 04/21/2026). The facility staff also provided a policy titled, Comprehensive Care Planning Policy last reviewed on 02/24/2026. This policy read in part, The facility will develop a comprehensive person-centered care plan for each resident.to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. On 04/23/2026 at 9:35 a.m., the Infection Preventionist confirmed that Resident #11 should have had a CCP in place for enhanced barrier precautions. No additional information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #105, the facility staff failed to develop a CCP for their gastrostomy tube (g-tube) and for enhanced barrier precautions. Resident #105 had a g-tube in place for water flushes only. Resident #105's diagnoses included Guillain-Barre syndrome and polyneuropathy. Section C (cognitive patterns) of Resident #105's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/24/2026 included a brief interview for mental status (BIMS) score of 15, indicating Resident #105 was cognitively intact. During initial tour the surveyor observed an enhanced barrier precautions sign and personal protective equipment (PPE) outside of Resident #105's room. On 04/21/2026 at 10:31 a.m., during an interview with Resident #105 this resident identified themselves as having a g-tube. Resident #105's clinical record included a provider order dated 03/31/2026 for enteral-free water flush: 60 cc of water via g-tube every shift. A review of Resident #105's CCP failed to identify a care plan for the resident's g-tube flush or for enhanced barrier precautions. On 04/21/2026 at 10:55 a.m., during an interview with the MDS nurse, this staff reviewed Resident #105's clinical record and confirmed there was not a care plan in place for their g-tube or enhanced barrier precautions. On 04/21/2026 at 3:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), Assistant Director of Nursing/Infection Preventionist, Regional Director of Clinical Services, and Regional [NAME] President of Operations the omission of Resident #105's g-tube and enhanced barrier precautions on their CCP was reviewed. On 04/22/2026 at 8:00 a.m., the DON provided an updated CCP that identified this resident as having a PEG tube that was used for routine flushes and as being on enhanced barrier precautions due to PEG tube (updated date: 04/21/2026). The facility staff also provided a policy titled, Comprehensive Care Planning Policy last reviewed on 02/24/2026. This policy read in part, The facility will develop a comprehensive person-centered care plan for each resident.to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. On 04/23/2026 at 9:35 a.m., the Infection Preventionist confirmed that Resident #105 should have had a CCP in place for enhanced barrier precautions. No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to accurately complete an admission minimum data set (MDS) assessment for 1 of 28 residents, Resident #84.The findings included:The facility staff failed to accurately code section A1550 (conditions related to intellectual and/or developmental disabilities [ID/DD]) on the admission MDS assessment.Resident #84 has a documented diagnosis of Coffins-Siris Syndrome, a genetic disorder characterized by developmental delays and intellectual disability. Section C (cognitive patterns) of Resident #84's admission MDS assessment with an assessment reference date (ARD) of 02/26/2026 included a brief interview for mental status (BIMS) score of 15, indicating Resident #84 was cognitively intact. Section A1550 was coded to indicate the resident had no conditions related to ID/DD.A review of Resident #84's clinical record revealed a Level I Preadmission Screening and Resident Review (PASSR), dated 02/20/2026, which referred the individual for a Level II assessment due to intellectual developmental disability (IDD) or a related condition. The Level II assessment dated [DATE], confirmed a diagnosis of Coffins-Siris Syndrome prior to age [AGE].On 04/21/2026 at 3:00 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), Assistant Director of Nursing, Regional Director of Clinical Services, and Regional [NAME] President of Operations the inaccurate coding of section A in Resident #84's admission MDS assessment was reviewed.On 04/22/2026, the DON provided the surveyor with an updated MDS and stated the MDS had been modified. Section A1550 was revised to reflect that Resident #84 has an organic condition related to ID/DD.No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to revise the comprehensive care plan for 2 of 28 residents, Resident #58 and Resident #138. The findings included:1.For Resident #58, the facility staff failed to revise the comprehensive person-centered care plan to reflect a medical provider order for comfort care measures on 2/21/26. Resident #58's diagnosis list indicated diagnoses that included, but were not limited to, atherosclerotic heart disease of native coronary artery s/p (status-post) CABG (coronary artery bypass grafting), sequelae of cerebral infarction, vascular dementia, depression, weakness, and cognitive communication deficit. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 1/26/26, assigned the resident a brief interview for mental status (BIMS) summary score of 4 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of a medical provider order with a start date of 2/21/26 read in part, .Comfort care.no labs, no IVs, no weights, no hospitalization. A review of the current comprehensive person-centered activity care plan disclosed a focus with an initiated date of 4/2/26, which read in part, .Resident is on Comfort Care due to advanced dementia. A goal associated with the focus read in part, .Resident will receive comfort care measures to provide comfort care and emotional support. Interventions associated with the focus read in part, .comfort measures as ordered. On 4/22/26 at 2:21 PM, the Director of Nursing (DON) was interviewed and agreed comfort care was not added to the care plan at the time of the medical provider orders on 2/21/26. The DON stated an audit of the care plan was performed on 4/2/26 and the comfort care focus was added at that time. This concern was discussed at the end of day meeting on 4/22/26 at 4:00 PM with the Administrator, Director of Nursing, Regional Director of Clinical Services, Assistant Director of Nursing, and Regional [NAME] President of Operations. Requested and received a facility policy titled, Comprehensive Care Planning Policy with a reviewed date of 2/24/26, which read in part, .An interdisciplinary plan of care will be.updated as indicated.The care plan is.revised as indicated by the resident's needs.or a change in condition.If additional problem areas are identified.the care plan will be updated to reflect these area(s). Changes to the care plan due to.changes in the resident's status will be implemented as indicated. No further information was provided prior to exit on 4/23/26. 2. For Resident #138 (R138), who had behaviors that included aggressiveness with staff, the facility failed to revise the person-centered comprehensive care plan to include updated interventions that address continued and/or escalating behaviors. A Resident Face Sheet indicated that the facility admitted R138 on 3/9/22 with a most recent re-admission date of 8/8/25. According to the Resident Face Sheet the resident had a medical history that included bipolar disorder and dementia with other behavioral disturbance. The most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 4/8/26 demonstrated that R138 had a BIMS (Brief Interview for Mental Status) score of 3 out of 15 indicating severe cognitive impairment. A comprehensive review of the clinical record for R138 revealed a care plan for Behavioral Symptoms that was initiated on 11/5/25. Interventions include: -Encourage resident to express feelings, listen with empathy and nonjudgemental acceptance, compassion (initiated 11/5/25) -If resident is disruptive to others, remove resident from scenario and attempt to calm resident (initiated 11/5/25) -Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behaviors, encourage seeking out of staff member when agitated (initiated 11/5/25) The Care Plan problem statement was revised on 11/19/25, 12/17/25, 12/24/25, 12/31/25, 1/28/26, 2/4/26, 2/25/26, 3/11/26, and 3/18/26 to include the presence of continued and further behaviors including yelling/cursing at staff and being aggressive with care. No interventions were added to this care plan after the initial date of 11/5/25, and no revisions were made to the interventions initiated on 11/5/25. During an interview that was conducted with MDS (Minimum Data Set) Coordinator on 4/22/26 at 4:05 PM, the MDS Coordinator stated that interventions are not always updated, and that redirection worked best when managing R138's behaviors. When asked if the current interventions in place would be considered effective noting the documentation of continued and/or escalating behaviors, the MDS coordinator stated that they did not appear effective. The MDS Coordinator stated that additional interventions should be considered and added to R138's care plan to address the continued and/or escalating behaviors. A facility policy titled Comprehensive Care Planning Policy developed 1/27/11 and last reviewed on 2/24/26 stated that the care plan is revised as indicated by the resident's needs, wishes, or a change in condition. At a minimum, this will occur with each comprehensive and quarterly assessment. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care in a manner to minimize/prevent accidents/injury for one resident (Resident #17-R17) in a survey sample of eighteen residents, which resulted in harm for R17. The findings included:1. For R17, the facility staff failed to transfer the resident with a mechanical lift in a manner to prevent accidents and injury, which resulted in a significant injury, which was harm. The facility self-identified the deficient practice and achieved past non-compliance on 10/9/24. On 8/19/25-8/20/25, attempts were made to visit with and interview R17 but were not successful since R17 was out of the facility due to a medical procedure. On the evening of 8/20/25, a clinical record review was conducted of R17's chart. According to a progress note dated 10/7/24, the entry read, The CNA [certified nursing assistant] reported to this nurse that the resident was bleeding from his R. [right] leg. Upon assessment, the back of the right leg had a cut he had sustained while being transferred to bed using a Hoyer lift. The resident stated that his leg was caught on the wheelchair's footrest. This nurse had to apply pressure to the area to stop bleeding. NP was notified and will see the resident. There was no documentation with regard to the cut, to include an assessment of the area, what it looked like, treatment applied, other than pressure to stop the bleeding. According to a skin observation dated 10/8/24, it noted that R17 had a new skin issue, the site and description read, Laceration to outer right calf area with dressing in place. There were no details of the laceration, measurements, how it appeared, what was being done, etc. According to physician orders and treatment administration records, on 10/8/24-10/9/24, the order was clean laceration to right rear leg with NC [sic] [normal saline], pat dry, apply dry dressing. On 10/9/24, a wound management detail report was completed that read in part, wound type: other-traumatic injury, wound location: right calf lateral calf, Date/time identified: 10/9/24 at 2:48 p.m. The details were as follows: Length 8 cm, width 5.6 cm, healing status: improving, comments: monitor area for s/s [signs and symptoms] of infection, follow current tx [treatment] plan. Keep clean, dry and covered. On 10/9/24, R17 was seen by the wound specialist, who noted, Staff report patient new injury occurring from use with the ‘sit to stand' mechanical lift. Pt [patient] reports his right lower leg caught the edge of ‘hoyer' lift, causing a painful laceration. Pt rates current pain to RLE [right lower extremity] an 8 on 0 to 10 pain scale with relief from medication. Right lateral calf (+) full thickness ulceration that measures 8.0 x 6.0 x 0.8 cm [length, width, depth]. Wound base 100% granular. Edges adherent to wound base, moderate non-odorous serious drainage, periwound without erythema, no induration or cellulitis. Patient does not demonstrate evidence of pain when area is palpated. Plan: Wound care to right lateral calf as follows: cleanse with NS [normal saline] or wound cleanser, pat dry. Pack with 1/4 strength Dakin's moistened gauze. Cover with gauze and kerlix dressing. (tx [treatment] for moist wound healing and/or autolytic debridement), change dressing QD [every day] and as needed for saturation or soilage. According to the wound care provider notes dated 10/16/24, the injury to R17's right lateral calf was noted with . full thickness ulceration that measured 8.0 x 5.6 x 0.6 cm. Wound base 25% slough, 75% granular prior to debridement. According to the facility's wound management detail report, R17 traumatic injury to the right lateral calf continued to receive treatment and was not healed until five months later on 3/12/25. On 8/21/25, during another clinical record review, according to R17's activities of daily living (ADL) records for October 2024, the resident was noted to have been totally dependent on facility staff for transfers from bed to chair and chair to bed. According to R17's care plan with a start date of 5/1/24, it read, resident is limited in ability to transfer self, related to impaired mobility and requires the use of Hoyer lift to complete transfers. Associated interventions included, but were not limited to: Minimize hazards and risks while completing transfer with lift, provide Hoyer lift assistant for transferring w/ [with] assist of 2 . On 8/21/25 at 8:10 a.m., an interview was conducted with R17. When asked about the incident in October 2024, the resident said, What happened was, it was night and he was getting me up, the leg rests were still on the chair. When he started to raise me in the lift the lift came up and the pedal on the right side got jammed in my leg, it [the lift] continued to come up and it caused it to be cut. R17 identified that certified nursing assistant #4 (CNA #4) was the one assisting the resident at the time of the incident and was using the mechanical lift/Hoyer lift without assistance of another staff member. On 8/21/25 at 9:10 a.m., an interview was conducted with the unit manager, licensed practical nurse #2 (LPN #2), where R17 resided. LPN #2 stated she was not a unit manager at the time of R17's incident that occurred in October 2024. When asked about transfers with a Hoyer lift, she said, Two people with the Hoyer at all times, for safety. Two people are required so there are two sets of eyes, one to maneuver the lift and one to maneuver the resident. According to the facility policy titled, Mechanical Lift Policy with a revision date of 1/7/22, which read in part, . 3. Two staff person assist/oversight is required for total body lifts while one person assist is satisfactory for sit-to-stand lifts. On 8/21/25, at approximately 9 a.m., the director of nursing (DON) was notified that the surveyor was reviewing the incident involving R17 from October 2024 and was asked to provide any information she had. On 8/22/25, the DON provided the survey team with a quality assurance performance improvement (QAPI) Action Plan in response to R17's incident. The facility re-enacted the incident, obtained statements, identified other residents who use the Hoyer lift and interviewed them, educated staff and conducted audits to ensure ongoing compliance. Included was a statement from CNA #4 that said, [R17's name redacted] had a cut to his leg when I was transferring him from wheelchair to bed with Hoyer lift by myself. The facility completed their plan and achieved past non-compliance on 10/9/24, upon completion of the skin checks. 2. For R17, the facility staff failed to provide care in a way to prevent accidents. During activities of daily living (ADL) care, R17 rolled out of bed, sustained injury that required evaluation at the hospital, which constituted harm. On 8/19/25-8/20/25, attempts were made to visit with and interview R17 but were not successful since R17 was out of the facility due to a medical procedure. On the evening of 8/20/25, a clinical record review was conducted of R17's chart. According to R17's progress notes dated 7/29/25, which read, Resident rolled off of bed onto floor during ADL care. Observed skin tear to right flank area. Left thigh/knee area with edema. Resident denies pain r/t [related to] fall. Resident states that he did not hit head. MD/RP [medical doctor/responsible party] aware. There was no description of the skin tear other than the location. There was no documented size/length of the tear or any description of the skin injury's appearance, bleeding status or condition of surrounding tissue. Nursing listed notification to the physician about the injury/incident. According to physician orders dated 7/30/25, which read, cleanse skin tear to right flank area with wound cleanser, pat dry, apply xeroform and dressing QD. On 7/31/25, that order was discontinued and a new order was written that read, Apply skin prep to skin tear/right flank QD x 7/days. According to R17's activities of daily living records, he required substantial/maximal assistance to roll left and right. According to R17's care plan, a problem area was initiated on 6/15/24 that noted, Resident at risk for falling r/t [related to] weakness. An intervention was added on 7/30/25 that read, Resident fell out of bed while turning during ADL care. Sent to ER for eval, no major injury. X 2 person for ADL care. Remains on therapy caseload. On 8/21/25 at 8:10 a.m., an interview was conducted with R17. R17 explained the incident on 7/29/25 and reported, I have to use the bed pan and the aide was trying to clean me up. She was having difficulty getting the feces out of my [NAME]. When I turned, she pushed and I was on my side and went off the bed, my legs hit and got tangled up in this thing [pointing to the over bed table]. When asked if he was injured, he said, Yes. It didn't manifest until later that day, there were no visible cuts, but bruised the heck out of my left thigh. It started to swell later in the day and [the nurse practitioner's name redacted] came and looked at it and he said to keep an eye on it. About 4 p.m., he came back and said it had gotten bigger and thought I needed to go to the ER, they sent me to [hospital name redacted]. They [the hospital] didn't even do an x-ray which I thought was odd, they put two big ace bandages on it and when I got back they [the facility staff] decided I needed to go back and I was sent to [different hospital name redacted], they confirmed it was a hematoma and also found other issues that were not related to the fall and kept me for several days. The resident reported he felt like he was too far to the side of the bed when he turned, and the aide pushed him; it caused him to fall off the bed. On 8/21/25 at 8:45 a.m., the DON was asked to provide hospital records from R17's hospital visits. On 8/21/25 at 9 a.m., an interview was conducted with certified nursing assistant #2 (CNA #2). CNA #2 confirmed she had been providing care to R17 on 7/29/25, when he rolled out of bed. CNA #2 reported, I had him and was cleaning him. He was turned facing the window and his legs fell off the bed which threw the rest of him out of the bed. Now if we turn him, we have to have two people. It happened so fast, I couldn't catch him. He had a small skin tear on his back, when he fell somehow this part of his leg [pointing to her left thigh] swelled. The nurse assessed him and later that day he went to the hospital. I felt so bad. On 8/21/25 at 9:10 a.m., an interview was conducted with licensed practical nurse #2 (LPN #2), who was the unit manager. LPN #2 stated, I got report that she was doing ADL care and was cleaning him alone. When she turned him, he was too close to the edge of the mattress and when he turned, he rolled to the right side of the bed. We offered him a lip mattress [mattress with a raised edge] but he declined, said it wasn't the mattress that he wasn't properly positioned during ADL care. He got an abrasion to his left buttock; he went to the hospital two days later. We did an x-ray here and it was no injuries. They kept him at the hospital for abnormal lab values; this was all per his wife. While in the hospital his wife would come to get items out of his room and she would give us bits and pieces of information, we never got any documentation from the hospital. The DON provided the surveyor with a progress note from the nurse practitioner dated 7/29/25 that read in part, I saw and examined the patient per nursing request s/p [status post] a fall from his bed. Nursing reported to me that the patient rolled off his bed and onto the floor as personal care was being performed around 12:00 s/p having had a bowel movement. He reportedly fell onto the floor landing on his left lower extremity; he apparently did not hit his head. I did notice swelling on the lateral distal left thigh/knee area which appeared to be a hematoma. This was of particular concern to me as the patient was on chronic anticoagulation with apixaban for chronic atrial fibrillation. There was a soft but firm to palpation without any focal area of acute tenderness. There was a distinctly demarcated line between the developing hematoma and the unaffected surrounding tissue. I marked the affected area with a pen establishing an area of 19 cm along the distal lateral femur and 14 cm wide transverse to the leg on my initial visit. I discussed the value of XR [x-ray] imaging to rule out any type of fracture. The patient refused having the leg imaged at this time. I spoke with nursing and ordered to keep the leg elevated, and to apply an ice pack. I promised to return in about an hour to re-evaluate the hematoma and developing situation. I re-examined the patient at 15:30. The patient was in no acute distress, but clearly uncomfortable and appeared frustrated. My examination revealed expansion of the hematoma now to 21 cm long x 18 cm wide. Given my concern r/t [related to] his chronic anticoagulation and hematoma development, and subsequent blood loss, I strongly encouraged the patient to consider being sent out via EMS [emergency medical services] to the ED [emergency department] for emergent evaluation +/- x-ray imaging and blood testing. He agreed to going out. On 8/21/25 at 10 a.m., the DON was again asked about the hospital records and stated they were working to obtain them. The surveyor asked the medical director if he had access to the records and he said he did not, that perhaps the resident or his spouse could access the records. On 8/21/25 at 10:30 a.m., the surveyor met with the DON and asked if she had a QAPI plan for the incident involving R17 for the 7/29/25 incident like she had for the incident in October 2024. The DON stated that she did not and stated, the skin tear was superficial. When asked about an x-ray, the DON stated that the resident refused so no x-ray was obtained at the facility. On 8/21/25 at 10:45 a.m., the survey team met with the facility administrator, DON, and corporate staff to review the above findings. They reported they had no further information to provide. The assistant director of nursing confirmed they had reached out to the hospital to obtain copies of the records from where R17 had been sent to the hospital on 7/29/25. When asked if they had reached out to the hospital prior to that day, when the surveyor started asking for the documents, the assistant director of nursing stated, not that I am aware of. All of the administrative staff in attendance confirmed that the expectation would have been for the hospital records to be contained within R17's clinical record. On 8/21/25, during a meeting with the facility administrator, director of nursing, medical director, and corporate staff, the above concerns were discussed. No additional information was provided.

Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an effective pest control program on three of three resident units and in the main kitchen and common areas of the facility. The findings included:On 8/19/25 at 1:55 p.m., a review of resident council minutes revealed that on 7/7/25, the resident council reported that Residents are seeing gnats and roaches. Both residents listed on the grievance lived on the 200 South unit. During the resident council meeting held Dec. 18, 2024, it noted . The group all mentioned an increase in cockroach sightings. In the September 2024 meeting it noted, . Resident [name redacted] stated he spotted a cockroach in his room by his bed recently. During the August 2024 resident council meeting, notes included, . Cockroaches have recently been spotted in [three resident's names redacted] and in the phone booth. Group stated that all has already been reported. On March 20, 2024, during the resident council meeting another resident mentioned seeing roaches in her bathroom last week. On 8/19/25, a review of pest control logs was conducted. It revealed the monthly pest service was being performed by an outside contractor. The reports included ongoing sightings and evidence of pest activity that included roaches. Each of the reports from January 2024-July 2025, there were recommendations to the facility each month that were not resolved. The pest control company indicated that the identified areas could be contributing to pest access/entry. The same areas of concern were noted month after month, dating as far back as [DATE], without facility resolution. On 8/19/25 at 2:40 p.m., another tour was conducted of the second-floor unit. During the tour, Resident #20's (R20) room was noted to have a glue trap under the heating/air conditioning unit. The surveyor entered the room and interviewed R20. R20 was asked about pests and reported seeing roaches, every morning and every night ever since I've been here a year. They crawl up the wall, on the bed. R20 went on to report that he requested the glue traps and they have put them in the ceiling, but he continues to see them. There were four glue traps observed in the room and two of the four had a copious number of roaches in the trap and a third had a few roaches present. On 8/19/25 at 2:53 p.m., an interview was conducted with a housekeeper, (Other Staff #7- OS7). OS7 reported she had worked at the facility for three years and sees roaches throughout the unit routinely. When asked about pest control services, OS7 reported they come and spray and usually following the pest control visit she observes an increase in the roaches. On 8/19/25 at 3:02 p.m., an interview was conducted with the environmental services director (EVSD) (other staff #6- OS6). The EVSD reported that a pest control company is contracted and comes monthly. He confirmed they have had on-going issues with roaches and said, they bait areas and spray problem areas. When asked what the pest control company has reported regarding the roach problem, the EVSD said, They think it is from different avenues like residents bringing in items from outside. When asked about R20's room, the EVSD stated he was not aware of that being a problem area. The EVSD reported that the glue traps are changed monthly unless he notes they are dirty, he will change them in between the monthly pest control visits. He was made aware of the glue traps in R20's room having a heavy number of roaches in them. During the above interview with the EVSD he was asked about the problem areas identified in the pest control report from the contractor and that the same areas are noted month after month, indicating the facility is not taking action to resolve the matter. The EVSD reported he has been working to resolve the issues, but it is not always effective. The surveyor asked to tour with the EVSD to look at some of the areas identified in the pest control report. The pest control reports noted that high severity area of concerns on reports dating back to 1/17/2023, was the lobby: gap between double doors lobby allowing pest access. Please repair to prevent pest entry. During the tour it was noted that there were two sets of double doors for entry into the lobby and both had visible gaps which would allow pests to enter. The EVSD reported he has put weather stripping on the doors to seal the gaps, but wheelchairs tend to knock it off. On 8/19/25 at 3:20 p.m., a tour of was conducted of the kitchen with the EVSD. According to the pest control reports it noted cracks or damage to wall behind dishwasher allowing pest access, was a high area of concern since April 15, 2025. Also noted in the pest control report dated 7/16/25, it read, wall around the dishwasher machine needs to be removed and clean all the food and standing water from inside the wall, also sealed opening around pipes, wall and floor, we recommend this so many time [sic]! During the tour of the kitchen, it was noted that in the dish room there was still openings around the pipes under the dish machine, broken tiles, standing water, and many of the areas identified on the pest control reports were still present. The EVSD reported that he had caulked some holes in the kitchen walls, re-caulked around the base of the wall/floor, removed one wall on the far side of the dish room and felt that he had corrected the issues identified in the pest control reports. On 8/19/25 at 3:30 p.m., the surveyor and EVSD went to the ice machine on the second floor. It was observed that roaches were actively crawling along the floor in that room, water was standing in the floor, and gaps were noted in the wall around the pipes, which had been previously identified on the pest control reports as well. On 8/19/25 at 3:40 p.m., during an interview with the EVSD he was asked if he felt the current pest control program was effective. He reported that they had changed companies a few years ago because the prior company was not effective and he felt it was better than in the past. On 8/20/25 at 9:37 a.m., the surveyor used the bathroom located in the lobby and observed a roach crawling on the wall. On 8/20/25 at 9:45 a.m., during an interview with a licensed practical nurse (LPN #6), she was asked about pests. LPN #6 reported they do have a problem with roaches and said, It waxes and wanes, they come and spray. When asked if residents complaint about it, LPN #6 reported that residents complain about roaches frequently. On 8/20/25, during a clinical record review of a resident in the survey sample, it was noted that in Resident #5's progress notes there was an entry dated 2/19/25, regarding an issue due to pests. The noted read, Maintenance spoke with SS [social services] and indicated that the resident had piles of books, magazines and newspapers that needed to be thrown away and also indicated that roaches was in his radio and that it needed to be discarded also. SS spoke with the resident and informed that he needed to discard the items including his radio. Resident acknowledged understanding and stated that he would be purchasing another radio. SS and nursing assistant discarded the resident's radio. SS notified UM that the radio had been discarded [sic]. On 8/20/25 at 4 p.m., during an end of day meeting with the facility administrator, director of nursing and regional director of operations, they were made aware of the above findings regarding pest control. On 8/21/25 at 8:55 a.m., when the surveyor was walking on the first-floor unit, a roach was noted crawling on the floor in the hallway. Review of the facility policy titled, Pest Control Policy was conducted. This policy read, Routine pest control procedures will be in place to prevent pest infiltration. If pests are seen in the kitchen, the director of food and nutrition services or designee shall be informed. Appropriate action will be taken to eliminate any reported pest situation in the department. No additional information was provided.

Based on observations, resident interview, staff interview, clinical record review, and facility documentation review the facility staff failed to assess a resident's ability to safely self-administer medications for one resident, Resident #9 (R9) out of a survey sample of 18 residents. The findings included:Facility staff allowed R9 to keep medication at the bedside for self-administration without completing a self-administration assessment.On 8/19/25 at 11:10 a.m., an observation was conducted of medications at R9's bedside. At that time, an inhaler, CBD pain ointment, menthol pain ointment, and vitamin D3 were observed in a basket.On 8/19/25 at 11:15 a.m., an interview was conducted with R9 regarding the medications observed. R9 stated that she keeps the pain ointments in her room because she was undergoing chemotherapy and uses them for pain relief. R9 then said, I take my inhaler twice a day and the nurse brings it in here in the morning and leaves it with me to take it in the morning and at bedtime.On 8/19/25 at 11:40 a.m., an interview was conducted with a licensed practical nurse, LPN#1 (LPN1). LPN1 stated that there was a form completed for residents to be approved to self- administer medications. She further stated, skilled residents sometimes bring in their own medications and we don't know anything about it. If I was to see the medications, I would remove the medicine and explain why we were not allowed to leave medicine at the bedside.On 8/19/25 at 12:45 p.m., an interview was conducted with unit manager on unit one, LPN#2 (LPN2). LPN2 stated that she thought R9 had a self-administer assessment completed and was not aware that one had not been done. She explained that medicines found in the room that morning severed as a prompt to complete an assessment. She reported she was under the impression an assessment had already been completed due to R9's pain needs. LPN2 stated that she told R9 she was going to speak with the physician about having the medications at bedside, and then she completed a self-administration assessment.On 8/19/25 at 1:00 p.m., a follow-up observation was conducted in R9's room. The inhaler remained in the basket at the bedside. The self-administration form had been completed by LPN2; however, no locked compartment was observed for the medication storage.A review of R9's clinical record revealed there was no self-administration assessment completed prior to medications being left at bedside. R9's care plan had not addressed self-administration of medications for pain or inhaler use. The Minimum Data Set did not reflect that R9 was independent with medications.A review of facility documentation was conducted. The facility policy titled, Self-Administration of Medications, read in part, .3. To ensure safe and appropriate self-administration, facility should educate residents to ensure that a resident is able to: 3.1 state the name, dose, strength, frequency and purpose for use of their medications. 3.2 Understand the possible medication side effects and that they should notify facility staff if they experience any such side effects. 3.3 correctly administer, inject, or apply all prescribed medications. 3.4 correctly store their medications in a locked compartment.On 8/20/25 at approximately 4:00 p.m., an end of day meeting was held with the Regional Director of Clinical Services, [NAME] President of Operations and Director of Nursing. They were made aware of the concerns above.No additional information was provided.

Based on staff interviews and clinical record review the facility failed to ensure reasonable care for the protection of personal property for one of eighteen residents, Resident #3 (R3). R3 did not have a personal property invoice completed upon admission to help track valuables. The Findings Include:Diagnoses for R3 included contusion of left lower leg, status post left knee surgery, obesity, depression, kidney disease, and deep vein thrombosis. The most current MDS (minimum data set) was a discharge assessment with an ARD (assessment reference date) of 08/1/2024. R3 was assessed with a cognitive score of 15 indicating cognitively intact.R3 was reviewed due to a report of possible missing medication (Ozempic brought from home to the facility) and two gift cards.Review of R3's clinical record did not evidence an inventory form had been filled out upon admission or at any time during R3's stay at the facility.On 8/19/25 at 2:30 p.m. license practical nurse (LPN #7) was interviewed regarding documentation of resident's inventory list. LPN #7 explained when a resident is admitted an inventory form is filled out. Review of the facilities grievance logs indicated that R3 had reported missing gift cards on 7/22/24 and indicated the concern was being investigated by license practical nurse (LPN #2, unit manager).On 8/19/25 at 3:00 p.m. the director of nursing (DON) was interviewed regarding R3's missing inventory list. The DON said that she would look for it.On 8/20/25 at 10:30 a.m. the DON verbalized R3 inventory list could not be found. The DON stated that she would not list medications on a personal property list but would put the medication in the refrigerator with the resident's name on it. On 8/20/25 at 11:50 a.m. The DON was able to evidence through pharmacy records that R3's personal Ozempic was used by the facility and then was being filled by the pharmacy. On 8/20/25 at 12:00 p.m. LPN #2 (who investigated the missing gift cards) was interviewed. LPN #2 was able to evidence via Concern Form that R3's gift cards were replaced by the facility. The DON presented a personal property policy that read in part The facility will take reasonable care to prevent loss, or theft of, resident's personal property while residing at facility [.]. No other information was presented prior to the exit conference on 8/21/25.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care regarding assessment documentation for two of eighteen residents in the survey sample (Residents #3 and #17).The findings include:1. For Resident #3, nursing staff failed to document a descriptive assessment and immediate care interventions implemented for a skin tear. Resident #3 (R3) was admitted to the facility with diagnoses that included iron deficiency anemia, human immunodeficiency virus, gout, obesity, depression, hypertension, chronic kidney disease, anxiety, cryptococcosis, and deep vein thrombosis. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact. R3's clinical record documented a Focused Head to Toe Observation form dated 6/28/24. This observation form documented, res [resident] unbuckled seatbelt in transportation van and fell onto floor recving [receiving] skin tear. This form documented an assessment of the resident that included skin tear to LLE [left lower extremity] with trace amount of swelling of left lower leg and intermittent pain rated at 3 (on scale of 0 = no pain, 10 = worst pain). The observation form dated 6/28/24 documented no description of the skin tear other than the location on the left lower leg. There was no documented size/length of the tear or any description of the skin injury's appearance, bleeding status or condition of surrounding tissue. Nursing listed notification to the physician about the injury/incident but there was no documentation regarding care orders or response from the physician. There was nothing documented regarding immediate care provided for the skin tear such as pressure, cleansing or dressing application. R3's clinical/nursing notes had no entries on 6/28/24 referring to the incident or injury. On 8/20/25 at 1:05 p.m., the director of nursing (DON) was interviewed about a descriptive assessment and care implemented for R3's skin tear on 6/28/24. The DON stated first aid was provided and that nurses were not required to get an order for first aid. The DON stated the nurse cleaned and dressed the skin tear. On 8/20/25 at 1:15 p.m., licensed practical nurse (LPN #5) caring for R3 at the time of the 6/28/24 injury was interviewed. LPN #5 stated R3 obtained a skin tear after falling in the transportation van coming back from an appointment. LPN #5 stated R3's skin tear was a small place and that he cleaned the tear and applied a 1 x 1 Band-aid. LPN #5 stated he texted the physician but did not recall the physician's response or if an order was given for care. When asked why he did not enter a nursing note or document a description of the injury, LPN #5 stated the skin tear was superficial and nothing I would have been alarmed over. LPN #5 stated the observation form was completed and included a head-to-toe assessment in addition to pain and neurological checks. LPN #5 stated he did not remember if vital signs were obtained and that the only actions he remembered were cleansing the wound and applying a Band-aid. LPN #5 stated he did not know why a nursing note was not entered and he recalled only that he completed the observation form. On 8/21/25 at 8:00 a.m., the DON provided a copy of the facility's wound/incident policies the described required documentation regarding wound assessment. The facility's policy titled Incident/Accident Policy (revised 10/1/24) documented, .Documentation/assessment post-incident will be completed, including neurological assessment when indicted [indicated]. Further assessments will be conducted as ordered by the provider or as indicated by nursing judgement . The facility's policy titled Pressure Injury Prevention and Treatment Policy - Skin and Wound Care (revised 9/18/23) documented, .Pressure injuries identified will be assessed initially and at least weekly thereafter, until closed. Other wound types will be assessed every shift to determine presence of ordered dressing and wound characteristics if observable .All assessments will include the following elements .Location .Size .Exudate .Pain .Wound bed .Color and type of tissue .Appearance of surrounding tissue .Any evidence of infection . The Lippincott Manual of Nursing Practice 11th edition on page 15 documents regarding common departures from the standards of nursing care, .A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . (1) This finding was reviewed with the director of nursing, regional nurse consultant and director of operations during a meeting on 8/20/25 at 4:00 p.m. with no further information provided prior to the end of the survey. (1) [NAME], [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME], 2019. 2. For Resident #17 (R17), the facility staff failed to document a detailed assessment of a skin tear/abrasion sustained on two occassions and the immediate nursing interventions/care provided. On 8/19/25-8/20/25, attempts were made to visit with and interview R17 but were not successful since R17 was out of the facility due to a medical procedure. On the evening of 8/20/25, a clinical record review was conducted of R17’s chart. According to a progress note dated 10/7/24, the entry read, “The CNA [certified nursing assistant] reported to this nurse that the resident was bleeding from his R. [right] leg. Upon assessment, the back of the right leg had a cut he had sustained while being transferred to bed using a Hoyer lift. The resident stated that his leg was caught on the wheelchair’s footrest. This nurse had to apply pressure to the area to stop bleeding. NP was notified and will see the resident.” There was no documentation with regard to the cut, to include an assessment of the area, what it looked like, treatment applied, other than pressure to stop the bleeding. According to a skin observation dated 10/8/24, it noted that R17 had a new skin issue, the site and description read, “Laceration to outer right calf area with dressing in place.” There were no details of the laceration, measurements, how it appeared, what was being done, etc. According to physician orders and treatment administration records, on 10/8/24-10/9/24, the order was “clean laceration to right rear leg with NC [sic] [normal saline], pat dry, apply dry dressing.” The first instance of documentation regarding details of the wound/injury was on 10/9/24, as noted below. According to a wound management detail report, there was an entry dated 10/9/24 that noted, “wound type: other-traumatic injury, wound location: right calf lateral calf, Date/time identified: 10/9/24 at 2:48 p.m.” The details were as follows: Length 8 cm, width 5.6 cm, healing status: improving, comments: monitor area for s/s [signs and symptoms] of infection, follow current tx [treatment] plan. Keep clean, dry and covered.” On 10/9/24, R17 was seen by the wound specialist, who noted, “Staff report patient new injury occurring from use with the ‘sit to stand’ mechanical lift. Pt [patient] reports his right lower leg caught the edge of ‘hoyer’ lift, causing a painful laceration. Pt rates current pain to RLE [right lower extremity] an 8 on 0 to 10 pain scale with relief from medication… Right lateral calf (+) full thickness ulceration that measures 8.0 x 6.0 x 0.8 cm [length, width, depth]. Wound base 100% granular. Edges adherent to wound base, moderate non-odorous serious drainage, periwound without erythema, no induration or cellulitis. Patient does not demonstrate evidence of pain when area is palpated… Plan: Wound care to right lateral calf as follows: cleanse with NS [normal saline] or wound cleanser, pat dry. Pack with ¼ strength Dakin’s moistened gauze. Cover with gauze and kerlix dressing. (tx [treatment] for moist wound healing and/or autolytic debridement), change dressing QD [every day] and as needed for saturation or soilage…” According to R17’s progress notes dated 7/29/25, which read, “Resident rolled off of bed onto floor during ADL care. Observed skin tear to right flank area. Left thigh/knee area with edema. Resident denies pain r/t [related to] fall. Resident states that he did not hit head. MD/RP aware.” There was no description of the skin tear other than the location. There was no documented size/length of the tear or any description of the skin injury's appearance, bleeding status or condition of surrounding tissue. Nursing listed notification to the physician about the injury/incident. According to physician orders dated 7/30/25, which read, “cleanse skin tear to right flank area with wound cleanser, pat dry, apply xeroform and dressing QD.” On 7/31/25, that order was discontinued and a new order was written that read, “Apply skin prep to skin tear/right flank QD x 7/days.” On 8/21/25 at 8:10 a.m., R17 was visited in his room. R17 was asked about the two incidents documented above. R17 reported that the incident in Oct. 2024 was when the CNA was getting him up from the chair with the hoyer lift and the leg rests were still on the wheelchair. “When he started to raise me on the lift, the lift came up and the pedal on the right leg got jammed into my leg, it continued to come up and caused it to be cut.” R17 explained the incident on 7/29/25 and reported, “I have to use the bed pan and the aide was trying to clean me up. She was having difficulty getting the feces out of my [NAME]. When I turned she pushed and I was on my side and went off the bed, my legs hit and got tangled up in this thing [pointing to the over bed table].” When asked if he was injuried, he said, “Yes. It didn’t manifest until later that day, there were no visible cuts, but bruised the heck out of my left thigh. It started to swell later in the day and [the nurse practitioner’s name redacted] came and looked at it and he said to keep an eye on it. About 4 p.m., he came back and said it had gotten bigger and thought I needed to go to the ER, they sent me to [hospital name redacted]. They [the hospital] didn’t even do an x-ray which I thought was odd, they put two big ace bandages on it and when I got back they [the facility staff] decided I needed to go back and I was sent to [different hospital name redacted], they confirmed it was a hematoma and also found other issues that were not related to the fall and kept me for several days.” On 8/21/25, in the morning, an interview was conducted with the director of nursing. She reported that the skin tear was “superficial” and therefore no detailed documentation was made into the clinical record other than the treatment orders noted above. The facility's policy titled Incident/Accident Policy (revised 10/1/24) documented, .Documentation/assessment post-incident will be completed, including neurological assessment when indicted [indicated]. Further assessments will be conducted as ordered by the provider or as indicated by nursing judgement . The facility's policy titled Pressure Injury Prevention and Treatment Policy - Skin and Wound Care (revised 9/18/23) documented, .Pressure injuries identified will be assessed initially and at least weekly thereafter, until closed. Other wound types will be assessed every shift to determine presence of ordered dressing and wound characteristics if observable .All assessments will include the following elements .Location .Size .Exudate .Pain .Wound bed .Color and type of tissue .Appearance of surrounding tissue .Any evidence of infection . The Lippincott Manual of Nursing Practice 11th edition on page 15 documents regarding common departures from the standards of nursing care, .A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . On 8/21/25, during a meeting with the facility administrator, director of nursing, medical director, and corporate staff, the above concerns were discussed. No additional information was provided. (1) [NAME], [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME], 2019.

Based on observations, resident interview, staff interview, clinical record review, and facility documentation review the facility staff failed to follow physician orders for two residents, Resident #10 (R10) and Resident #16 (R16) out of a survey sample of 18 residents.The findings included:Staff failed to transcribe physician orders for compression bandages, ace wraps, and discontinuation of furosemide 20 mg daily for R10.On 8/19/25 at 11:10 a.m., during an observation of R10's room, her spouse expressed concerns that lower extremity treatments were not being done. The spouse stated the last treatment occurred on the Wednesday before R10's admission on [DATE].On 8/20/25 at 9:50 a.m., an interview was conducted with the unit manager on unit one, licensed practical nurse, LPN#2 (LPN2). LPN2 stated that the resident R10 was admitted around 5 p.m. on 8/8/25, and that she had orders for, Pro-fore that was never carried over. It was missed on admission. The resident wanted to use the Pro-fore wraps for her edema, and only three wraps came with her, so they used those, and when that was completed, they went to the ACE wraps per the physician's order at the facility. She felt that the doctor here had talked to the wound nurse about the ACE wrap order, but she didn't see a note, so that was missed.On 8/20/25 at 10:50 a.m., an interview was conducted with the facility physician regarding missed orders. He was informed that compression bandages, ACE wraps, and furosemide discontinuation were not transcribed. The physician stated that on R10's admission day (8/8/25), he observed compression wraps but did not remove them, as he could not reapply them. He prefers not to use Pro-fore wraps because they prevent daily skin inspection and potential breakdown, so he ordered ace wraps to allow daily evaluation. He referred to R10 for a wound assessment by the wound nurse scheduled the following week and monitored her over the weekend. On 8/12/25, when the wraps were removed, he noted decreased edema, wrinkle-like skin, and no breakdown. At that time, he ordered daily ace wraps and discontinued furosemide 20 mg daily. The physician had written this in his progress notes and stated that the nurses put his orders in the system.On 8/20/25 at 11:10 a.m., LPN #3 (LPN3, wound nurse) stated that she removed the Pro-fore wraps and assessed R10's lower extremities. The legs showed improvement with no skin breakdown. The physician then ordered ace wraps to be applied in the morning and removed in the evening. LPN3 noted that verbal order was given to floor nurses or unit manager to enter it in the system. LPN3 stated that the verbal order was not given to her or entered by her.On 8/20/25, a clinical record review revealed that R-10's hospital discharge summary included an order for compression bandages that was not transcribed at admission. A facility physician's progress notes on 8/12/25 indicated discontinuation of furosemide 20 mg daily and a verbal order for ace wraps to be applied in the morning and removed in the evening, which was also not transcribed in the clinical record.On 8/20/25 at approximately 4:00 p.m., an end of day meeting was held with the Regional Director of Clinical Services, [NAME] President of Operations and Director of Nursing. They were made aware of the concerns above.On 8/21/25, a review of the facility document titled, Physician/Provider Orders, stated that the charge nurse shall transcribe and review all physician/provider orders. It further directed that telephone orders must be repeated back for verbal confirmation, recorded exactly as dictated. On admission the orders were to be transcribed from the transfer form to the Facility admission Physician Order Form. admission orders must include all information reviewed from the referring facility or agency. On 8/21/25 at 9:50 a.m., the Director of Nursing (DON) sought clarification regarding the Pro-fore order from the hospital. She was informed the order was written as compression bandages, but facility staff referred to Pro-fore because that was what had been removed from R10's lower extremities. The DON was satisfied with this clarification. When asked about providers entering orders into the clinical record, she stated that providers do not enter orders; nurses enter them.No additional information was provided.

Based on resident interview, staff interviews, and clinical record review, the facility staff failed to maintian a complete and accurate clinical record for one resident (Resident #17- R17) in a survey sample of eighteen residents. The findings included:For R17, who was hospitalized following an incident of rolling out of bed and sustained a hematoma, the facility staff failed to have the hospital report/records available in R17's clinical record. On the evening of 8/20/25, a clinical record review was conducted of R17's chart. According to R17's progress notes dated 7/29/25, which read, Resident rolled off of bed onto floor during ADL care. Observed skin tear to right flank area. Left thigh/knee area with edema. Resident denies pain r/t [related to] fall. Resident states that he did not hit head. MD/RP [medical doctor/responsible party] aware. On 8/21/25 at 8:10 a.m., an interview was conducted with R17. R17 explained the incident on 7/29/25 and reported, I have to use the bed pan and the aide was trying to clean me up. She was having difficulty getting the feces out of my [NAME]. When I turned, she pushed and I was on my side and went off the bed, my legs hit and got tangled up in this thing [pointing to the over bed table]. When asked if he was injured, he said, Yes. It didn't manifest until later that day, there were no visible cuts, but bruised the heck out of my left thigh. It started to swell later in the day and [the nurse practitioner's name redacted] came and looked at it and he said to keep an eye on it. About 4 p.m., he came back and said it had gotten bigger and thought I needed to go to the ER, they sent me to [hospital name redacted]. They [the hospital] didn't even do an x-ray which I thought was odd, they put two big ace bandages on it and when I got back they [the facility staff] decided I needed to go back and I was sent to [different hospital name redacted], they confirmed it was a hematoma and also found other issues that were not related to the fall and kept me for several days. The resident reported he felt like he was too far to the side of the bed when he turned, and the aide pushed him; it caused him to fall off the bed. On 8/21/25 at 8:40 a.m., R17's clinical record was reviewed again and hospital records from 7/29/25 were not able to be located within the chart.On 8/21/25 at 8:45 a.m., the DON was asked to provide hospital records from R17's hospital visits. On 8/21/25 at 9 a.m., an interview was conducted with certified nursing assistant #2 (CNA #2). CNA #2 confirmed she had been providing care to R17 on 7/29/25, when he rolled out of bed. CNA #2 reported, I had him and was cleaning him. He was turned facing the window and his legs fell off the bed which threw the rest of him out of the bed. Now if we turn him, we have to have two people. It happened so fast, I couldn't catch him. He had a small skin tear on his back, when he fell somehow this part of his leg [pointing to her left thigh] swelled. The nurse assessed him and later that day he went to the hospital. I felt so bad. On 8/21/25 at 9:10 a.m., an interview was conducted with licensed practical nurse #2 (LPN #2), who was the unit manager. LPN #2 stated, I got report that she was doing ADL care and was cleaning him alone. When she turned him, he was too close to the edge of the mattress and when he turned, he rolled to the right side of the bed. We offered him a lip mattress [mattress with a raised edge] but he declined, said it wasn't the mattress that he wasn't properly positioned during ADL care. He got an abrasion to his left buttock; he went to the hospital two days later. We did an x-ray here and it was no injuries. They kept him at the hospital for abnormal lab values; this was all per his wife. While in the hospital his wife would come to get items out of his room and she would give us bits and pieces of information, we never got any documentation from the hospital. The DON provided the surveyor with a progress note from the nurse practitioner dated 7/29/25 that indicated R17 had been sent to the hospital, the read in part, I saw and examined the patient per nursing request s/p [status post] a fall from his bed. Nursing reported to me that the patient rolled off his bed and onto the floor as personal care was being performed around 12:00 s/p having had a bowel movement. He reportedly fell onto the floor landing on his left lower extremity; he apparently did not hit his head. I did notice swelling on the lateral distal left thigh/knee area which appeared to be a hematoma.I marked the affected area with a pen establishing an area of 19 cm along the distal lateral femur and 14 cm wide transverse to the leg on my initial visit. I discussed the value of XR [x-ray] imaging to rule out any type of fracture. The patient refused having the leg imaged at this time. I spoke with nursing and ordered to keep the leg elevated, and to apply an ice pack. I promised to return in about an hour to re-evaluate the hematoma and developing situation. I re-examined the patient at 15:30. The patient was in no acute distress, but clearly uncomfortable and appeared frustrated. My examination revealed expansion of the hematoma now to 21 cm long x 18 cm wide. Given my concern r/t [related to] his chronic anticoagulation and hematoma development, and subsequent blood loss, I strongly encouraged the patient to consider being sent out via EMS [emergency medical services] to the ED [emergency department] for emergent evaluation +/- x-ray imaging and blood testing. He agreed to going out. On 8/21/25 at 10 a.m., the DON was again asked about the hospital records and stated they were working to obtain them. The surveyor asked the medical director if he had access to the records and he said he did not, that perhaps the resident or his spouse could access the records. On 8/21/25 at 10:45 a.m., the survey team met with the facility administrator, DON, and corporate staff to review the above findings. They reported they had no further information to provide. The assistant director of nursing confirmed they had reached out to the hospital to obtain copies of the records from where R17 had been sent to the hospital on 7/29/25. When asked if they had reached out to the hospital prior to that day, when the surveyor started asking for the documents, the assistant director of nursing stated, not that I am aware of. All of the administrative staff in attendance confirmed that the expectation would have been for the hospital records to be contained within R17's clinical record. On 8/21/25, during a meeting with the facility administrator, director of nursing, medical director, and corporate staff, the above concerns were discussed. No additional information was provided.

Based on observations, resident interview, staff interview, clinical record review, and facility documentation review the facility staff failed to administer oxygen per physician's orders, and to date and label oxygen tubing and humidifier bottle for one resident, Resident #10 (R10) out of a survey sample of 18 residents.The findings included:R10 was not being administered her ordered oxygen, and the oxygen tubing and humidifier bottle were not labeled with a date of placement.On 8/19/25 at 11:10 a.m., an observation of R10 revealed that oxygen was not being administered as ordered. The oxygen concentrator was observed in the resident's room with the humidifier bottle sitting on the floor. There was no oxygen tubing connected to the concentrator. During the observation, R10's spouse was present in the room, stated that the resident had not had the oxygen on since the previous day when it was removed and the oxygen tubing was taken out of the room. A subsequent observation of R10 on 8/19/25 at 2:45 p.m., again revealed that oxygen was not being administered per the physician's order.On 8/19/25 at 2:45 p.m., an interview was conducted with the unit one manager, licensed practical nurse, LPN#2 (LPN2). LPN2 was asked to review R10's oxygen order and stated that the order was for two liters per nasal cannula, continuous. LPN2 then entered R10's room and was observed looking at the oxygen concentrator. The concentrator had tubing and humidifier bottle present; however, the tubing was stored in a bag and there were no dates or labels on the tubing or the humidifier bottle. At the time of the observation, R10 was still not receiving oxygen as ordered.During this observation with LPN2 on 8/19/25 at 2:45 p.m., R10's spouse, who was in the room, told LPN2 that the tubing from the oxygen concentrator had been removed the previous day. He further stated that they were planning to keep a check on the resident's oxygen levels, and that no staff had come in to check since he had been present that morning. R10 was still not receiving oxygen per order.On 8/19/25 at 4:00 p.m., another observation showed R10 still was not receiving oxygen. At that time, LPN1 was observed checking R10's oxygen saturation, which measured 94%. Earlier that morning, the oxygen saturation had been documented at 98%. On 8/19/25, a review of R10's clinical record revealed a physician's order for oxygen to be administered vis nasal cannula continuously at tow liters. Documentation showed the order had been signed off that morning as having been administered. Review of R10's care plan reflected the same instructions for continuous oxygen at two liters via nasal cannula. On 8/20/25, a facility document was reviewed. The facility documentation titled, Oxygen Administration (all routes) Policy, read in part, .licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. On 8/20/25 at approximately 4:00 p.m., an end of the day meeting was held with the regional director of clinical services, vice president of operations and director of nursing. They were made aware of the concerns above.No additional information was provided.

Based on staff interview, and clinical record review, the facility staff failed to maintain an accurate clinical record for one resident (Resident #1, R1) in a survey sample of 3 residents. The findings included: The facility staff failed to maintain accurate documentation with regards to falls. Diagnoses for R1 included Dementia, manic depression, and fractures secondary to falls. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 6/3/24. R1 was assessed with a cognitive score of 00 indicating severely cognitively impaired. R1's clinical record was reviewed regarding a falls leading to R1 being sent to the hospital and diagnosed with two rib fractures and lacerated spleen on 12/9/23. Progress notes dated 12/9/23 documented a fall had occurred at 4:16 AM while R1 was in the hallway taking off clothing. A full assessment was completed and did not show any abnormalities or injuries. R1 was assisted back to bed. Another progress note dated 12/9/23 at 12:15 PM indicated R1 had become confused, lethargic, restless, with an unsteady gait, and was hypotensive. R1 was transferred to the hospital due to change in condition and was found to have fractures of two ribs and a lacerated spleen. Further review of R1's progress notes dated 12/22/23 as a late entry for 12/9/23 indicated R1 had a fall on 12/9/23 around 8:00 AM and was found partially under the bed, was assessed for injuries and noted a bruise to the right side of R1's head. Another progress note dated 12/22/23 and timed 12:18 PM as a late entry for 12/9/23 indicated R1 was observed with unsteady gait and having trouble holding a cup of water was at the elevator and began to fall a certified nursing assistant (CNA) and nurse tried to prevent the fall but R1's knee touched the floor. R1 was assessed and due to change in condition was sent to the hospital. On 7/30/24 at 9:45 AM license practical nurse (LPN #6) was interviewed. LPN #6 verbalized being the nurse near the elevator when R1 lost balance and tried to help the CNA prevent a fall. LPN #6 was asked about not documenting the fall on 12/9/23. LPN #6 verbalized not being assigned to R1 that day and thought that the assigned nurse to R1 would document the fall. On 7/30/24 at 10:00 AM the director of nursing (DON) was interviewed concerning the above finding. The DON verbalized R1's injuries were investigated by the facility and during the investigation it was evident that the staff knew about the falls occurring on 12/9/24 but two nurses that were involved during R1's falls did not document on the falls at that time. The DON said when it was evident that the nurses did not document at the time of the falls both nurses were inserviced and then all nursing staff were inserviced. The DON verbalized a plan of correction for this was completed at the time of the findings. The DON provided the following plan of correction: 1. On 12/21/23 All nursing staff educated on fall huddle and risk management documentation. one on one education was provided both nurses involved in fall documentation. 2. To identify like residents that have the potential to be affected the DON/designee reviewed all residents that ambulate without assist devices with high fall risk to ensure fall interventions are in place and reflected on the care plans. 3. To prevent this from happening again the DON/designee will educate CNA's and licensed staff on when residents has a fall that the fall is documented and interventions to prevent further falls are in place after every fall. 4. DON and or unit manager to monitor for ongoing compliance with documentation will be completed in morning meetings when discussing falls for three months to ensure that falls are documented in risk management and fall huddle form is completed and brought to morning meetings to ensure thorough investigation of fall and intervention was placed. An audit sheet will evidence monitoring was completed. Results will also be discussed in QAPI monthly for 3 months. 5. Date of correction 12/22/23. All inservice records were reviewed along with all forms used to monitor the plan of correction. At the time of the survey there were no current concerns regarding inaccurate records. The survey team accepted the deficiency as past non-compliance.

Based on staff interview, and clinical record review, the facility staff failed to complete an assessment after a fall for one of 3 residents. Resident #1 (R1) did not have documented assessment after a fall. The findings included: Diagnoses for R1 included Dementia, manic depression, and fractures secondary to falls. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 6/3/24. R1 was assessed with a cognitive score of 00 indicating severely cognitively impaired. R1's clinical record was reviewed regarding a falls leading to R1 being sent to the hospital and diagnosed with two rib fractures and lacerated spleen on 12/9/23. Progress notes dated 12/9/23 documented a fall had occurred at 4:16 AM while R1 was in the hallway taking off clothing. A full assessment was completed and did not show any abnormalities or injuries. R1 was assisted back to bed. Another progress note dated 12/9/23 at 12:15 PM indicated R1 had become confused, lethargic, restless, with an unsteady gait, and was hypotensive. R1 was transferred to the hospital due to change in condition and was found to have fractures of two ribs and a lacerated spleen. This progress note was prompted due to a fall occurring near the elevator at this time and R1 was observed unsteady on feet. Further review of R1's progress notes dated 12/22/23 as a late entry for 12/9/23 indicated R1 had a fall on 12/9/23 around 8:00 AM and was found partially under the bed, was assessed for injuries and noted a bruise to the right side of R1's head. Review of the clinical record did not evidence any assessments were completed at the time of the fall (8:00 AM). There was evidence that a Neuro check form had been initiated but not until 12:00 PM after the third fall. The nurse involved in the 8:00 AM fall was unable to be interviewed due to no longer working at the facility. On 7/30/24 at 10:00 AM the director of nursing (DON) was interviewed concerning the above finding. The DON verbalized R1's injuries were investigated by the facility and during the investigation it was evident that the staff knew about the falls occurring on 12/9/24 but two nurses that were involved during R1's falls did not document on the falls at that time and one of the nurses did not document any assessments after the fall. The DON said when it was evident that the nurses did not document at the time of the falls both nurses were inserviced and then all nursing staff were inserviced. The DON verbalized a plan of correction for this was completed at the time of the findings. The DON provided the following plan of correction: 1. On 12/21/23, one on one education was provided to newly hired nurse on change of condition and the process that are expected. 2. To identify like residents that have the potential to be affected the DON/designee reviewed all residents that had change in condition to ensure proper documentation. Completed on 12/21/23. 3. To prevent this from happening again the DON/designee will educate licensed nurses on assessment and notification of change in condition. 4. DON and or unit manager to monitor for ongoing compliance with documentation will be completed in morning meetings for three months to ensure SBARs and change in condition is assessed and documented. An audit sheet will evidence monitoring was completed. Results will also be discussed in QAPI monthly for 3 months. 5. Date of correction 12/22/23. All inservice records were reviewed along with all forms used to monitor the plan of correction. At the time of the survey there were no current concerns regarding change in condition assessment implementation. The survey team accepted the deficiency as past non-compliance.

Based on observation, staff interview and clinical record review, the facility staff failed to assess and implement interventions to prevent a pressure ulcer for one of twelve residents in the survey sample, Resident #4. Resident #4 developed a sacral pressure ulcer initially identified as unstageable with necrotic tissue. There was no prior assessment of impaired skin on the sacrum. A nurse with knowledge of redness on the sacrum failed to document or report the redness prior to the development of the ulcer. The findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #4 with moderately impaired cognitive skills and as requiring the extensive assistance of one person for bed mobility. Resident #4's clinical record documented the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 9/14/21 documented the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . This assessment listed the ulcer as, .in house acquired .was not present on admission .No drainage Wound Bed appearance is Necrotic No odor .Periwound appearance is Necrotic/Black . An additional nursing note on 9/14/21 documented the resident also had a state 2 sacrum pressure ulcer measuring 2 x 1 x 0 (length by width by depth in centimeters). This note documented the stage 2 ulcer as, .in house acquired .not present on admission .No Drainage Wound bed appearance is Pink No odor Periwound appearance is Pink . Treatment orders were initiated that included daily dressing changes with wound cleanser, Santyl ointment and foam dressing. The facility's wound nurse assessed the resident's sacrum ulcers on 9/14/21 and documented the following assessments. 9/14/21 - unstageable pressure ulcer measuring 2.2 cm x 1.5 cm x 0.1 cm, in house acquired, no drainage with necrotic tissue covering the wound bed 9/14/21 - stage 2 pressure ulcer measuring 2 cm x 1 cm x 0 cm, in house acquired, no drainage with pink wound bed The director of nursing (DON) documented a note dated 9/15/21 at 9:43 a.m. stating, Resident with 2 open areas on sacrum, area cleansed and covered placed on air mattress .MD to eval [evaluate] . The resident's physician assessed the resident on 9/15/21 and documented, .saw and examined the patient for a new wound on her sacrum. It was discovered today and is very superficial. It is not painful or tender. No drainage. No known trauma. It is uncomfortable for the patient to turn from side to side and she needs staff assistance to do so .There is a stage 2 sacral wound which is clean and without slough or drainage . There was no mention on this assessment of the necrotic pressure ulcer assessed by nursing on 9/14/21. The consultant wound physician assessed Resident #4 on 9/17/21. The wound physician's note dated 9/17/21 documented, .a thorough wound care assessment and evaluation was performed today. She [Resident #4] has an unstageable (due to necrosis) sacrum for at least 1 days duration. There is moderate serous exudate. There is no indication of pain . (Sic) The wound physician's assessment documented the sacral pressure ulcer measured 4 cm x 1 cm x 0.5 cm and was 100% covered with thick, adherent devitalized necrotic tissue. Prior to the assessed sacral pressure ulcer on 9/14/21, the clinical record documented weekly body audits that listed no impaired skin on the resident's sacrum. The most recent body audit prior to 9/14/21 was on 9/11/21 and documented the resident had no current skin issues and no new skin impairments. Braden pressure ulcer risk assessments were completed on 7/23/21, 7/30/21 and 8/6/21 with the resident listed as low risk for pressure ulcer development. Resident #4's plan of care prior to the sacral pressure ulcer (initiated 7/16/21) documented the resident had potential for skin breakdown. Interventions to maintain intact skin included notification to physician of changes in the skin, Braden scale per protocol, skin assessments per protocol, diet as ordered, turn and reposition as indicated and use of pressure relieving devices as indicated. On 9/21/21 at 1:50 p.m., the licensed practical nurse (LPN #3) responsible for wound care was interviewed about Resident #4's sacral pressure ulcer. LPN #3 stated nursing initially documented two pressure ulcers on the resident's sacrum starting on 9/14/21. LPN #3 stated one ulcer had necrotic tissue and was unstageable while the other open area was assessed as a stage 2 ulcer. LPN #3 stated when the wound physician assessed the resident's sacrum on 9/17/21, the physician listed the area as a cluster wound and documented the area as one pressure ulcer. LPN #3 stated she was not aware of any skin impairment to the resident's sacrum until 9/14/21. LPN #3 stated when she first assessed the pressure ulcers on 9/14/21 one of the open areas was unstageable due to necrotic tissue. On 9/21/21 at 2:20 p.m., the registered nurse (RN #1) caring for Resident #4 on 9/14/21 was interviewed. RN #1 stated on 9/14/21 a certified nurses' aide (CNA) reported to her that the resident had an open area on her sacrum. RN #1 stated she assessed the resident's sacrum on 9/14/21 and found one open area that was pink with no eschar that she listed as a stage 2 ulcer. RN #1 stated the other open area on the resident's sacrum was partially covered with eschar and was assessed as unstageable. RN #1 stated she had no reports from staff of any skin impairments for Resident #4 prior to 9/14/21. RN #1 stated she did not know why the area was not identified earlier. RN #1 stated floor nurses performed body audits once per week. On 9/21/21 at 2:25 p.m., the certified nurses' aide (CNA #1) caring for Resident #4 was interviewed. CNA #1 stated she was not caring for Resident #4 when the open area was found. CNA #1 stated she worked with the resident only occasionally and was not aware of any skin impairments prior to 9/14/21. CNA #1 described the resident as total care and stated the resident stayed mostly in bed. On 9/21/21 at 2:30 p.m., the unit manager (LPN #2) caring for Resident #4 was interviewed. LPN #2 stated a CNA reported to her on 9/14/21 that the resident had an open area on the sacrum. LPN #2 stated the registered nurse working on the unit assessed the wounds and notified the wound nurse. LPN #2 stated nobody had reported any skin impairments for Resident #4 prior to 9/14/21. LPN #2 stated Resident #4 was total care for all activities of daily living. LPN #2 stated floor nurses were responsible for completing body audits at least weekly for pressure ulcer prevention. On 9/21/21/ at 3:10 p.m., LPN #4 that completed the last body audit prior to 9/14/21 was interviewed. LPN #4 stated that on 9/11/21 the resident's sacrum was not open but red. LPN #4 stated the resident liked to stay mostly on her back and he thought the red area was from the resident being positioned on her back. LPN #4 stated he touched the red area and the area was not warm and not painful. LPN #4 stated he did not check if the red area blanched when touched, as registered nurses were required to perform that type of assessment. LPN #4 stated he did not document the redness on the body audit sheet because he thought she just needed repositioning. LPN #4 stated he did not notify the provider about the redness because he was on the night shift (11:00 p.m. to 7:00 a.m.). When asked if he reported the red area to the next shift, LPN #4 stated, No. On 9/22/21 at 7:45 a.m., with the resident's permission, LPN #3 was observed performing a dressing change to Resident #4's sacral pressure ulcer. The resident had a linear, unstageable pressure ulcer on the sacrum approximately 1.75 inches in length and 0.5 inches wide. This wound was 100% covered with black, leather-looking tissue. The skin surrounding the wound was dark pink/red. On the left buttock, adjacent to the linear necrotic wound, was an irregular shaped open area (approximately 3/4 inch in diameter) with a pink/red wound bed. There was a small amount of dark brownish/red drainage on the existing dressing when removed. The resident stated the area hurts a little when the clean dressing was applied. On 9/22/21 at 11:20 a.m., the resident's physician (administration staff #3) was interviewed about the resident's acquired, unstageable pressure ulcer. The physician stated he recalled notification about a new pressure ulcer. The physician stated, What I saw when I looked at it, it was superficial. On 9/22/21 at 2:15 p.m., the unit manager (LPN #2) was interviewed again about any further information regarding Resident #4's pressure ulcer. LPN #2 sated she had nothing else. LPN #2 stated as soon as she was aware of the pressure area, the area was assessed and treated. The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury as .localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . The NPIAP defines a stage 2 pressure injury as, Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel . The NPIAP defines an unstageable pressure injury as, Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible .Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (1) This finding was reviewed with the administrator and director of nursing during a meeting on 9/22/21 at 4:15 p.m. The facility presented a quality assessment and performance improvement (QAPI) action plan that was initiated on 7/29/21 regarding inaccurate skin assessments, follow-up skin assessment not done, inaccurate wound assessments, worsening of wounds and inaccurate care plans regarding wound care. Root cause analysis was performed and action items implemented included 100% skin sweep of all residents for identification of pressure ulcers, designated nurse to round with wound physician and complete wound documentation, weekly tracking of wounds by nurse supervisor and review in weekly wound meeting. Education was provided on 8/3/21 for unit manager about the QAPI plan and their role in monitoring weekly wound/skin assessments. Education was completed on 8/8/21 for nurses on pressure ulcer documentation and accuracy of weekly skin assessments. Weekly monitoring of skin assessments/wounds was ongoing at the time of the survey with the plan correction date listed as 9/14/21. After Resident #4's pressure ulcer was identified on 9/14/21 the facility's audits revealed no further pressure ulcers. There were no other pressure ulcers in the facility at the time of the current survey. The QAPI plan was accepted as evidence of past non-compliance. This deficiency was cited as past non-compliance. (1) NPIAP Pressure Injury Stages. National Pressure Injury Advisory Panel. 9/23/21. www.npiap.org/

Based on staff interview, clinical record review and facility document review, the facility staff failed to implement policies and procedures to prevent the spread of scabies on one of three units in the facility and failed to identify residents affected by the outbreak on the infection control tracking log. Six individual residents (Resident (s) #78, 13, 60, 58, 65 and 104) were all treated with oral and/or topical creams for the treatment of [REDACTED]. Findings were: Resident #78 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/29/2018, assessed Resident #78 with severe cognitive impairment with a summary score of 01. On 12/11/2018 at approximately 1:15 p.m., during the initial tour of the facility Resident #78 was observed on the third floor of the facility. She was observed walking in and out of other resident rooms, friendly, shaking hands, patting individuals on the back, talking to other residents, staff and surveyors. The clinical record was reviewed at approximately 3:00 p.m. The following note dated 11/23/2018 contained the following: Late entry for 11/20 Resident treated with Ivermectin X (times) (number not documented) doses, [MEDICATION NAME] (sic) RP (responsible party) is aware of new order. Further review of the clinical record provided the following information from the progress notes: 9/28/2018 22:29 (10:29 p.m.) Resident has a pink-red circular rash all over body. +(plus/positive) pruritis (itching). Roommate being treated for [REDACTED]. 9/28/2018 22:31 (10:31 p.m.) Resident with rash allover (sic) body. + pruritis. Roommate being treated for [REDACTED]. (names) RNP (nurse practitioner) phoned. Received orders for [MEDICATION NAME], Ivermectin tablets (to be repeated in one week.) In am (a.m.) 9/29/18, all clothes and linens need to beset (sic) to the laundry for hot water/hot dryer to kill source of bites. RP notified. 9/29/2018 22:41 (10:41 p.m.)Resident with rash allover body. + pruritis. Resident was treated with [MEDICATION NAME] cream tonight and will be showered, and receive Ivermectin tablets tomorrow then will be (repeated in one week.) In am (a.m.) 9/30/18, all clothes and linens need to be sent to the (sic) for hot water/hot dryer to kill source of bites. 10/01/2018 10:38 (a.m.) Resident continues with rash on body no s/s (signs/symptoms) of discomfort no s/s of adverse reaction to the medication. The physician orders [REDACTED]. 9/28/2018 [MEDICATION NAME] Cream 5% Apply to body topically one time only for rash for 1 day. Apply topically neck to feet and beneath nails. Wash off after 8 hours. 9/28/2018 Ivermectin tablet 3 mg Give 4 tablets by mouth one time only for rash for 1 day. The physician orders [REDACTED]. 11/20/2018 Ivermectin Tablet give 12 mg by mouth one time a day every seven days related to ENCOUNTER FOR [MEDICATION NAME] MEASURES UNSPECIFIED until 11/28/2018. The facility medication reference system contained the following information regarding the prescribed medications: [REDACTED] [MEDICATION NAME] Cream 5% .Common Brand Name [MEDICATION NAME]. USES: This medication is used to treat scabies, a condition caused by tiny insects called mites that infest and irritate your skin. [MEDICATION NAME] belongs to a class of drugs known as [MEDICATION NAME]. [MEDICATION NAME] works by paralyzing and killing the mites and their eggs. Ivermectin 3 mg tablet .Common Brand Name [MEDICATION NAME]. USES: This medication is used to treat certain parasitic roundworm infections .Ivermectin belongs to a class of drugs known as antihelmintics. It works by paralyzing and killing parasites. OTHER USES: This section contains uses of this drug that are not listed in the approved professional labeling for the drug but that may be prescribed by your health care professional This drug may also be used for other parasitic infections, including lice and scabies. Resident #78's roommate was identified as Resident #13. Resident #13 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: [MEDICAL CONDITION], unspecified dementia, hypertension and major [MEDICAL CONDITION]. The most recent MDS was a quarterly assessment with an ARD of 09/07/2018. Resident #13 was assessed as being severely impaired in her cognitive status with a summary score of 04. The progress notes section of the clinical record were reviewed on 12/11/2018 at approximately 3:30 p.m., and contained the following: 09/27/2018 23:50 (11:50 p.m.) Resident c/o (complaining of) severe itching. Bite marks on arms, legs, back, buttocks. Stated she saw small black bugs biting her. Nurse phoned [NAME] (on call) MD for (name of physician). [MEDICATION NAME] lotion ordered for 9/28/2018. ? (question) need to order Ivermectin for systemic treatment. ? Linens and clothing needs to go to laundry and be washed in hot water. Medicated for [MEDICATION NAME] at HS (hour of sleep). 9/27/2018 22:47 (10:47 p.m.) [MEDICATION NAME] Tablet 25 mg Give 25 mg by mouth every 06 hours as needed for pruritis 25-50 mg po (by mouth) PRN Administration was: Effective. 09/28/2018 10:17 (a.m.) Resident's bed linen and clothing was sent to laundry no itching or scratching observed by I the writer. 09/28/2018 10:59 (a.m.) Resident has order Ivermectin 3 mg tab give 4 mg tabs then repeat in one week RP notified. 09/28/2018 22:25 (10:25 p.m.) [MEDICATION NAME] cream applied: neck to feer (sic), including fingernails anf (sic) toe nails at 2030 (8:30 p.m.). Due for a shower in 8 hours at 0430 (4:30 a.m.). Ivermectin received this eve. Will be given 9/29/18. 09/30/2018 10:19 (a.m.) Ivermectin given per orders. No observations of itching/scratching this am. Faint red patchy areas to arms and torso, scabbing noted. 09/30/2018 22:17 (10:17 p.m.) Res tolerating new med. Ivermectin well and no s/sx of adverse reactions noted .She continues dry, scabby, bumps type rash to face, hands, bilateral UE/LE (upper extremities/lower extremities), torso, back areas. Res noted with scratch marks from her itching self . 10/01/2018 10:35 (a.m.) Resident continues with dry bumps on arms back ABD (abdomen) area resident cued not to scratch areas Resident denies any discomfort. 10/01/2018 22:48 (10:48 p.m.) Resident continues to have an extensive pruritic rash all over her body. Needs to be seen by MD. 10/01/2018 23:05 (11:05 p.m.) SBAR (Situation/Background/Assessment/Request) S: Change in condition .extensive round pruritic rash all over her body. Has had [MEDICATION NAME] cream and Ivermectin tablets . A: Itching rash scabies or other infestation . Skin Checks for Resident #13 were reviewed in the clinical record. The bi-weekly skin check dated 9/28/2018 contained the following information: Scabies treatment in place. The physician orders [REDACTED]. 9/28/2018 [MEDICATION NAME] Cream 5% Apply to body topically one time only for rash for 1 day. Apply topically neck to feet, under finger nails and toe nails at bedtime. Wash off after 8 hours. 9/28/2018 Ivermectin tablet 3 mg Give 4 tablets by mouth one time only for itching for 1 day. The physician orders [REDACTED]. 11/20/2018 Ivermectin Tablet give 18 mg by mouth one time a day every seven days related to ENCOUNTER FOR [MEDICATION NAME] MEASURES UNSPECIFIED until 11/28/2018. On 12/11/2018 at approximately 4:15 p.m., the DON (director of nursing) was asked about the treatment provided to Resident #78 and #13 on the third floor. She was asked to provide any information that was available regarding the original treatment of [REDACTED]. At approximately 4;40 p.m., the DON came to the conference room. She stated, We got a call from the health department in (MONTH) around the 13th .a resident had transferred out to a facility in (place) and had a rash .the resident was being treated for [REDACTED].then we talked again around (MONTH) 20 just to follow-up .I told her we had two more people (Resident #58 and Resident #65) who had gotten rashes and were being treated with the Ivermectin .we never did a scraping to confirm that it was scabies .she said that if anyone else broke out she would recommend that we do a BIT (burrow ink test) and she told me how to do it. The DON was asked what a BIT test was and how it was done. She stated, Well you take a marker and put a mark on the bumps and then wipe it off .if it's scabies then the ink goes down under the skin, into their burrows .On that very day that I talked to her (health department nurse) we had another resident (Resident #104) get a rash on her left arm so (name of unit manager) and I did the BIT test and it was positive .we notified (name of medical director) and we treated the whole floor at that point. The DON was asked if she had let the nurse at the health department know about the positive test. She stated, Yes, I believe so. The DON was asked if she had any tracking as to who the residents were who had a rash or any documentation regarding her conversation with the health department. She stated, No, just my notes .we also did skin sweeps and we inserviced the staff on the policy. She presented an inservice record and the facility policy titled: Scabies. The policy contained the following information: It is the policy of the facility to teat resident infected with and sensitized to Sarcopetes scabiel (scabies) and to prevent the spread of scabies to other residents and staff .General Guidelines: Scabies is an itching skin irritation caused by microscopic human itch mite, which burrows into the skin's upper layers and eventually causes itching, tiny irregular red lines just above the skin and an allergic rash .Incubation period can be 2-6 weeks before onset of itching for persons with no previous exposure .Symptoms sometimes include severe itching which worsens at night .Scabies is spread by skin to skin contact with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture. [DIAGNOSES REDACTED]. Failure to identify scraping as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites may cause multiple [MEDICAL CONDITION]. Often [DIAGNOSES REDACTED]. Affected residents should remain on Contact Precautions until twenty four (24) hours after treatment. Family and friends of residents who have had close contact should be notified and given instruction .A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, daily assessments should be made until the case has resolved .PRE_TREATMENT PR[NAME]EDURE: While the resident is being treated remove four (4) sets of clothing from the resident's room. bag the clothing in a bag and send the bag to the laundry for processing. Place all remaining clothing of the infected resident into a bag. Seal the bag and label Do Not Open Until (date 14 days from storage date). STEPS IN THE PR[NAME]EDURE: Implement Contact Isolation. Should scrapings be ordered, obtain before treatment (Note: Negative scraping do not exclude the diagnosis. Treatment should be administered if symptoms are present) .Continue Contact Precautions until twenty -four (24) hours after treatment . The policy also contained guidelines for departmental responsibilities and environmental services. Guidelines for cleaning the environment included but were not limited to: Clean lobbies, lounges, etc before resident bathing and treatment times so that treated residents do not use unclean areas, Vacuum furniture made of fabric in the resident's room. Wrap furniture in plastic and store for two (2) weeks) The policy was reviewed and the DON was asked if any of the residents had been put on Contact Isolation/Precautions. She stated, In (MONTH) when we treated the whole unit, we isolated all the residents to the floor we didn't let them leave the floor we didn't isolate them to their room just to the unit .we tried to keep the same staff going in and out. She was asked if the other residents that were identified and treated in (MONTH) prior to the positive BIT test, had been isolated. She stated, No. She was asked if either Resident #78 or Resident #13 had been isolated during their treatment in September. She stated, No, we didn't. She was asked if the furniture had been wrapped in plastic after cleaning either in (MONTH) or November. She stated, No, we didn't do that either. On 12/11/2018 at approximately 5:44 p.m. the medical director was interviewed about scabies and the treatment used. He stated that he hesitated to use the topical creams on residents with dementia. He stated, You have to paint them from head to toe and then shower them off after so many hours .it can be traumatic for them. He stated that he was aware of the resident who had been transferred to a different facility and had spoken with the family. He was asked if since Resident #78 was a wanderer on the unit should the entire unit have been treated at that time. He stated, It's hard to isolate someone like that .what maybe could have been done for the 24 hours after her treatment would be maybe one to one or put gloves on her, like a reverse precaution thing .I don't know if that would have worked but it could have been tried. On 12/12/2018 the clinical records of Resident #58, Resident #60 and Resident #104 were reviewed. The following information was obtained. Resident #60 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The most recent MDS was a quarterly assessment with an ARD of 10/16/2018. Resident #60 was assessed as being severely impaired with a cognitive summary score of 0. Review of the progress notes contained the following: 11/18/2018 13:18 (1:18 p.m.) Resident observed to have rash/scabs covering entire body. Resident picking and scratching at skin . 11/18/2018 20:07 (8:07 p.m.) Resident skin assessed. He is covered all over with red marks. Orders in computer to treat for scabies. Linen collected, double bagged and placed in bathroom until taken to laundry. Review of the MAR (medication administration record) for (MONTH) contained the following: Ivermectin Tablet 3 mg Give 1 tablet by mouth one time only related to ENCOUNTER FOR OTHER PR[NAME]EDURES FOR PURPOSES OTHER THAN REMEDYING HEALTH STATED for one day repeat does in 1 week. The medication was given on 11/20/2018 and 11/26/2018. Resident #58's record was reviewed. She was admitted on [DATE] with the following diagnoses, but not limited to: Dementia, hypertension, diabetes mellitus and major [MEDICAL CONDITION]. Her most recent MDS was a quarterly assessment with an ARD of 10/12/2018. Her cognitive status was assessed as having difficulty with both long and short term memory and severe impairment in daily decision making skills. Her progress notes contained the following information: 11/18/2018 15:06 (3:06 p.m.) SBAR S: change in condition .red bumps/rash to multiple areas on skin .A: .Skin changes: Itching Rash to have scabies on multiple areas to skin . 11/18/2018 21:33 (9:33 p.m.) Resident has been visiting with family today .continues with rash on body, started on Ivermectin . Resident #104 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Unspecified Dementia, diabetes mellitus, fronto-temporal dementia, and anxiety. The most recent MDS was a quarterly assessment with an ARD of 11/9/2018. Resident #104 was assessed as having a cognitive summary score of 01, indicating severe impairment with her cognitive status. The progress notes were reviewed and contained the following: 11/20/2018 10:22 (a.m.) SBAR Change in Condition: Rash A: Skin changes: Rash to have rash on back legs, arms .R: Order obtained for Ivermectin 3 mg 11/20/2018 11:17 (a.m.) Resident linen and clothing double bagged and sent to laundry. There was no documentation in the clinical record regarding the BIT test conducted on Resident #104. Skin sweeps conducted on the third floor from (MONTH) to (MONTH) were requested from the DON on 12/12/2018. Review of the skin sweeps identified a sixth resident treated with a rash and treatment, Resident #60. Review of the clinical record revealed the following: 11/09/2018 18:15 (6:15 p.m.) .Resident with bite marks on back and rt (right) lateral buttock + pruritis. Has scratched 4 areas of open skin on rt lateral posterior buttock .orders received for treatment of [REDACTED]. The MAR indicated [REDACTED]. Apply X 1 at HS. Shower and rinse cream off 8 hours later. The medication was signed off as given on 11/12/2018. The Director of Housekeeping and Laundry was interviewed on 12/12/2018 at 10:57 a.m. He stated that in (MONTH) all of the rooms on third floor were treated because of scabies. He stated the curtains, walls, resident clothing, common areas, etc. were all cleaned with bleach. We started on the far side of the room at the ceiling and worked our way down . He presented a calendar of which rooms were cleaned and the order they were cleaned. He stated, We started on (MONTH) 19th and had them all done by the 21st .We did the same thing in the same order a week later stating on (MONTH) 26 .we wiped down the chairs and cleaned the lobby the same way. He stated the residents clothing was bagged, washed, stored for one week. He was asked about any cleaning done in September. He stated, We cleaned one room like that Room (number) .we cleaned all the common areas too, but we just deep cleaned that one room. The unit manager was interviewed on 12/12/2018 at approximately 11:30 a.m. She was asked what precautions had been taken in (MONTH) and (MONTH) when the treatment for [REDACTED]. She stated, With (name of Resident #78) you really can't isolate her .she is a wanderer .we tried to redirect her .then in (MONTH) we isolated the whole unit and tried to keep everyone up here. On 12/12/2018 at approximately 1:45 p.m. the DON and the corporate nurse consultant were asked if there was any additional documentation. Concerns were voiced regarding the number of residents treated on the third floor for scabies and the facility not following the policy to isolate the residents initially involved (Resident #78 and 13). The Corporate nurse consultant stated, The cases weren't identified until (MONTH) and we treated and isolated the unit. The corporate nurse consultant was informed that review of the clinical records and facility documentation revealed that at least six cases were treated before the unit was isolated. This did not include the resident that was transferred out to another facility. She stated, I wasn't aware we had that many. On 12/12/2018 at approximately 2:00 p.m., the nurse at the local health department was contacted regarding her involvement and conversation with the DON in November. She stated she was the epidemiologist nurse for the area. She stated she remembered speaking with the DON regarding the resident that was transferred but she would need to review her notes and call this surveyor back. The infection control tracking manual was reviewed on 12/13/2018 at approximately 8:00 a.m. There was no tracking or documentation in the manual regarding the treatment of [REDACTED]. The DON was interviewed and asked about the documentation. She stated, Yes, it should have been documented and tracked in there .I didn't do it. A form in the infection log titled .CDC Criteria for Signs/Symptoms of .Scabies was shown to the DON. The form contained the following: Scabies Both Criteria 1 and 2 Must be Satisfied 1). A maculopaular and/or itching rash; 2). At least one (1) of the following scabies subcriteria (circle all that apply) a. Physician diagnosis; b. Laboratory Confirmation (scraping or biopsy); c. Epidemiological linkage to a case of scabies with laboratory confirmation. The DON was asked if the facility was suppose to be using the form. She stated, I don't think so .let me check. She returned and stated, Yes, we should have used that. A meeting was held with the DON, the administrator and the corporate nurse consultant on 12/13/2018 at approximately 10:00 a.m. The above information was discussed and the facility staff was notified that possible harm had been identified. The facility staff was asked to present any additionally documentation that may be available. The DON came to the conference room at approximately 12:30 and stated, We don't have anything additional to give you. No further information was obtained prior to the exit conference on 12/13/2018. After exit from the facility a call was received from the nurse at the health department. She stated, I am sorry I am just getting back to you . I needed to review my notes .I am the epidemiologist for the area and I've never had a state surveyor call me before .this is what I remember and have in my notes .I spoke with the DON on 11/14/2018 regarding the resident who transferred out .I asked her if there had been any cases of scabies there or residents with rashes .She told me they had not had a problem at the facility. I asked her to keep in touch with me and to let me know if there were any residents with rashes and if there were any positive cases, since it take someone who has never been infected before up to six weeks to get a rash and exhibit symptoms. The nurse was asked if they had been notified of a positive BIT test at the facility with resulting treatment of [REDACTED].we like to be involved when something like that occurs, especially on a dementia unit .we may or may not have recommended the whole unit be treated .I wish she had contacted me .I actually have it on my calendar to contact her six weeks from when we first talked to see if she had any more problems. No further information was obtained.

Based on Resident interview, staff interview, facility document review, and in the coarse of a complaint investigation, the facility failed to provide appropriate and sufficient services for the treatment and care of an indwelling catheter resulting in harm for one of 35 Resident's in the survey sample, Resident #100. Resident #100's catheter was pulled out causing trauma to the penis and he was admitted to the hospital. The Findings Include: Resident #100 was admitted to the facility on [DATE] with the most readmission on 10/30/18. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 11/6/18. Resident #100 was assessed as being cognitively intact with a score of 15 of 15. Section G of the MDS coded Resident #100 as total dependence with one person assist for bed mobility. [DIAGNOSES REDACTED]. Resident #100's medical chart was reviewed on 12/12/18. A Change in Condition Evaluation dated 8/10/18 by the facility documented that Resident #100 was actively bleeding, had blood in urine and a Summarized Observation and Evaluation that read: Resident foley pulled out during care by CNA (certified nursing assistant), bleeding over 100 cc (cubic centimeters) in urine bag, unable to determine if urine is flowing. Resident #100 was sent out to the hospital. Review of Resident #100's hospital records documented (via a Hospital Discharge Summary, dated 9/4/18) that Resident #100 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. On 12/12/18 10:07 AM Resident #100 was interviewed regarding the incident. Resident #100 verbalized that a CNA had came into the room to turn Resident #100 (as he, Resident #100 is quadriplegic and cannot turn himself). During being turned the CNA did not move the catheter bag from one side of the bed to the other and as a result the Foley catheter tubing was pulled out of the penis with the balloon still inflated. The CNA seen what had happened and went and got the nurse. Resident #100 verbalized that he was unable to feel that the Foley was being pulled due to his [MEDICAL CONDITION], but seen a lot of blood. Resident #100 was asked if a catheter anchor (a device used to secure the tubing of the catheter to the leg to prevent the tubing from being pulled from the bladder through the penis) was in place at the time of being turned. Resident #100 verbalized that there was no anchor in place and went onto verbalize that the facility had started putting an anchor in place after coming back from hospital. A facility incident report was provided for review. A hand written note by the CNA dated 8/10/18 said while during rounds with (Resident's name) catheter came out of (Resident's name) penis. As soon I notice (SIC) , I reported to charge nurse (signed by CNA) and dated 8/14/18. There was no other information regarding an investigation or other interviews. The CNA and nurse on duty was unable to be interviewed during this investigation. The nurse no longer works at the facility and the CNA was not available. On 12/12/18 10:49 AM the ADON (assistant director of nursing) was interviewed concerning the finding. The ADON verbalized the incident happened when Resident #100 was being turned and the CNA did not move the Foley bag to the other side of the bed before being turned causing tension on the tubing and pulling out from the penis. Resident #100's care plan was reviewed along with physician orders, nurses notes, skin assessments, and treatment administration record from a time period of (MONTH) 1st (YEAR) through (MONTH) 10th (YEAR) (the day Resident #100 was sent to the hospital). There was no evidence that a catheter anchor was ordered, care planned, or placed for Resident #100. Resident #100's care plan for indwelling catheter was updated on 10/18/18 to include an intervention for an anchor to Resident #100's Foley catheter. also an order [REDACTED].) ensure foley secured to leg ( .) On 12/12/18 02:52 PM Resident #100 physician (other staff, OS #1) was interviewed. OS #1 was asked about information in regards to Foley coming out. OS #1 verbalized he had not read any of the incident report and was unable to answer why the catheter came out. OS #1 verbalized that he doesn't disagree with hospital diagnoses. When asked about a catheter anchor, OS #1 verbalized that an anchor would have helped prevent the tubing being pulled out, but could not say it would be a fail safe. When asked about ordering an anchor for a catheter OS #1 verbalized he doesn't typically order a anchor so if one was ordered, it must have been ordered because a nurse asked for one, verbalizing that an anchor would be more of a nursing intervention and can be done without an order. On 12/13/18 08:01 AM registered nurse (RN #1) MDS coordinator was interviewed concerning the updated care plan to include a Foley anchor. RN #1 verbalized that the care plan was updated to ensure the Foley catheter would be secure in place and prevent the tubing being pulled out. A facility policy and procedure was asked for and received for indwelling catheter placement and care. The policy was titled Catheterization Competency and read in part Tape the catheter or apply a Velcro leg strap. Never leave the room until the catheter is secured. The mechanical irritation caused by catheter movement can cause urethral and meatal tearing, accidental removal, and serious complications. ( .) The catheter in the male is secured to either the upper thigh (with leg strap)or the abdomen (with tape). On 12/13/18 09:55 AM the above finding was brought to the attention of the director of nursing (DON) and administrator and was asked to provide any evidence to support an anchor being in place at the time of the incident or any evidence that would support the CNA moving the Foley bag prior to turning Resident #100 (as not to cause tension on the Foley tubing). The facility staff did not elaborate. No other information was provided prior to exit conference on 12/13/18. This is a complaint deficiency.

Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide treatment and services for the prevention of pressure ulcers for two of 24 residents, Resident #14 and Resident # 4. 1. The facility failed to prevent a facility acquired medical device related pressure ulcer for one of 24 residents, Resident #14. An unknown staff member placed a dressing over a wound on Resident #14's left leg stump. The dressing remained in place for an unknown length of time and when removed on 09/06/2017 the wound was an unstageable pressure ulcer . The most recent weekly skin observation sheet was dated 08/27/2017 and indicated no new skin issues. This resulted in harm. 2. The facility staff failed to provide weekly skin assessments for Resident # 4 for four weeks. Findings were: 1. The facility failed to prevent a facility acquired medical device related pressure ulcer for one of 24 residents, Resident #14. An unknown staff member placed a dressing over a wound on Resident #14's left leg stump. The dressing remained in place for an unknown length of time and when removed on 09/06/2017 the wound was an unstageable pressure ulcer . The most recent weekly skin observation sheet was dated 08/27/2017 and indicated no new skin issues. This resulted in harm. Resident #14 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 07/27/2017. Resident #14 was assessed as having a cognitive summary score of 04, indicating severe impairment with his cognitive status. However, Resident #14 answered the survey team's questions appropriately during a resident interview and during verbal interaction with the survey team members. Resident #14 was very hard of hearing and while this hindered his ability to understand, if spoken to directly and into his ear he answered and carried on a conversation with no difficulty. Resident #14 was interviewed by a member of the survey team on 09/05/2017 at approximately 2:30 p.m. During the interview he pulled up his left pants leg to show the surveyor a dressing on his left leg stump. He stated that he had been asking for three weeks to go to the leg doctor' .that his prosthetic leg had rubbed a spot on his stump. On 09/06/2017 at approximately 8:00 a.m., Resident #14's clinical record was reviewed. Observed on the electronic physician orders was an order for [REDACTED]. Review of the progress note section did not provide a corresponding note for either of those dates regarding any skin issues. Weekly Skin Observation assessments were observed in the electronic record with the last recorded assessment being 08/27/2017. Under the section OBSERVATIONS, the following information was documented: Does the resident have any skin issues?. The question was answered No. There were no Weekly Skin Observation assessments completed for the body audits conducted in September. At approximately, 9:00 a.m., RN (registered nurse) #4 who was one of the wound nurses at the facility was in the conference room to speak with a member of the survey team. She was asked if she was doing dressing changes for (Name of Resident #14). She stated that she was not doing any dressing changes with him and was not aware that he had a wound. This surveyor went to the unit where Resident #14 resided on 09/06/2017 at approximately 9:15 a.m. Resident #14 was asked if he had a dressing on one of his legs. Resident #14 stated, Yeah, and pulled up his pants leg on his left leg stump. Observed was a square border gauze dressing. An area of drainage was observed on the bandage. There was no date, time or initials to indicate when the dressing had been applied or who had applied it. Resident #14 was asked who put the dressing on his leg and how long it had been there. He stated, It's been on there for three days .one of the girls here put it on there, I don't remember which one .it's came from trying to wear my legs you want to see it? I'll take it (the dressing) off of there. Resident #14 was asked to leave the dressing in place until this surveyor could get a staff person in the room to assist him. This surveyor went out into the hallway and asked RN # 7 if she knew anything about a dressing on Resident #14's leg. She stated, I've worked here since last Thursday .this is the first time I have been on this hall, I don't know anything about these residents, I am just giving medications. This surveyor then went to the other side of the unit. RN # 3 was observed in an office with his cell phone in hand. He came out to speak with this surveyor. He was asked if he knew anything about Resident #14. He stated that he did not work that end of the hall. He was asked who the unit manager was. He stated We don't have a unit manager so (Name of the Director of Nursing) is who we go to. This surveyor went to the DON's office. The DON was asked who could discuss the dressing on Resident #14's leg. She directed this surveyor to RN #2, who was the other wound nurse at the facility. RN #2 was busy with another resident. At approximately 10:00 a.m., this surveyor met RN #2 in the hallway. RN #2 was asked if she knew anything about a dressing over a wound on Resident #14's leg. She stated, I just heard about that. This surveyor, RN #2 and the medical director went to Resident #14's room. The dressing had been removed from his left leg stump. The wound was covered with a scab. The medical director, lifted the scab up stating, This is a mobile scab. The wound nurse was asked to measure the wound. She measured the area underneath the scab and stated, It is 1.2 X 1 X .2 She was asked what the yellow area covering the bottom of the wound was. She stated, That's slough. The edges of the wound were rolled and bright pink in color. The wound nurse was asked what she would stage the wound as. She stated, A three. The medical director stated, I would call it a stage 2 or a Stage 3 .it's about the depth. The medical director asked Resident #14 how long the dressing had been in place. He stated, Three days . The medical director asked Resident #14 if he knew what day it was or the date. Resident #14 stated, It's Wednesday isn't it .either September 6th or 7th. The clinical record was reviewed and a note written on 09/06/2017 at 13:24 (1:24 p.m.) written by RN #2 was observed which read: Resident found with open area to front of LLE (Left lower extremity). Resident was assessed by MD and nurse. Resident has stag (sic) II pressure ulcer to that area. MD gave treatment order for daily dressing change (cleanse area with wound cleanser, apply hydrogel and cover with border gauze q (every) day shift and PRN (as needed)). MD gave consult referral to resident to follow up with amputation clinic at (name of office) for evaluation and treatment of [REDACTED]. A copy of the facility reference and guidelines for the staging of pressure ulcers was requested and received. According to the document provided, Wound Classification Guide-2016 NPUAP (National Pressure Ulcer Advisory Panel) a stage II Pressure ulcer is described as: The wound bed is viable, pink or red, moist .Granulation tissue, slough and eschar are not present. A stage III pressure ulcer is described as: .granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. An unstageable pressure ulcer is described as: Extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If the slough or eschar is removed, a Stage III or Stage IV pressure injury will be revealed. During an end of the day meeting on 09/06/2017, the staging of Resident #14's pressure ulcer was discussed with RN #2, the administrator and the DON. RN #2 stated, The doctor called it a 2 so that's what I wrote. RN #2 was asked based on the facility guidelines what would she stage the pressure ulcer as. She stated, A three or unstageable. RN #2 was asked if she would discuss the wound with the medical director and let this surveyor know the following morning what had been decided regarding the staging of the wound. RN #2 agreed. On 09/07/2017 at approximately 8:00 a.m., the administrator was in the conference room speaking with the survey team. She was asked if RN #2 was ready to speak with this surveyor regarding the staging of Resident #14's pressure ulcer. The administrator stated, Oh, yesterday was her last day .she doesn't work here anymore .we can call her if you want to talk to her. This surveyor voiced concern that RN #2 was suppose to discuss Resident #14's pressure wound that morning. The administrator stated, Oh she talked to (name of physician) about it last night .we are sending him (Resident #14) to the wound clinic today. The medical director came to the conference room to speak with the surveyors at approximately 10:00 a.m. Resident #14's pressure ulcer was discussed. He stated that a wound specialist was coming in to look at the wound and would determine how it should be staged but he (medical director) felt it should be classified as unstageable. At approximately 12:15 p.m., the wound specialist arrived at the facility. This surveyor accompanied him to Resident #14's room. He removed the bandage and stated, It's unstageable .you cant stage that. He lifted up the scab that was present and pulled it off. He stated, I'm just [MEDICATION NAME] this a little. He then looked at the underlying wound. He stated, It's all about the base .the base of this wound is covered with slough .there is some granulation tissue but it is mainly slough .we don't know what is under there .it's unstageable and if we had to give it a stage it would minimally be a three this is a medical device related pressure ulcer that has come from his prosthetic legs. The above information was discussed with the administrator,the administrator in training (AIT), the DON, and other facility staff during an end of the day meeting on 09/07/2017. Concerns of were voiced that the wound had been covered without treatment orders by someone in the facility, not reported to the physician, and when discovered by the survey team was determined to be unstageable by the wound specialist. The DON was asked what her expectation would be if a pressure ulcer was identified by staff. She stated, The doctor should be notified and orders obtained for treatment. The facility staff were informed that due to the severity of the pressure ulcer at the time of discovery, the lack of weekly skin observation assessments and the initiation of treatment by an unknown staff member without orders, the survey team had identified harm. On 09/11/2017, at approximately 9:00 a.m., the Administrator and the AIT came to the conference room to present additional information to the survey team. Included in the information were facility policies for wound care, Dressing, Dry/Clean and Skin and Wound Care Program. The Dressing, Dry/Clean policy contained the following instruction: Verify that there is a physician's order for this procedure. The Skin and Wound Care Program policy contained the following statement: The licensed nurse will assess skin weekly and report concerns to the Director of Nursing and the Physician. The administrator and the AIT were asked if any documentation associated with the skin audits checked off as completed on 09/01/2017 and 09/02/2017 had been located. The administrator stated, Not at this time. A copy of all progress notes and orders from 09/07/2017 through 09/11/2017 were requested. Review of the presented documentation from 09/07/2017 through 09/11/2017 contained a note from the wound specialist. The note contained the following information: KEY FINDINGS: L (left) stump with 1.5 X .5 full thickness wound which debrided easily to a yellow/pink granulated bed 20/80% slough. No evidence of infection. ASSESSMENT AND PLAN: 1) Medical device related pressure injury unstageable. Start [MEDICATION NAME] gel to area daily with border gauze. Resident should not wear prosthesis until wound closure. 2) Debility - -Continue LTC (long term care). Have prosthetics and orthotics come in here to evaluated fitment of shrinker/device. No further information was presented prior to the exit conference on 09/11/2017. This is a complaint deficiency. 2. Resident #4 (R 4) did not have completed wound assessments for four weeks. Findings include: R 4 was admitted to the facility on [DATE] with a readmission on 9/1/17 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 5/26/17. R 4 was assessed as being severely cognitively impaired. R 4's electronic record was reviewed on 9/5/17 and evidenced, via weekly wound care notes (dated 7/14/17 and 7/20/17) that R 4 had stage two pressure ulcers on the sacrum and left heel that were being treated. There were no documentation or evidence that weekly wound assessments were being done after 7/20/17 through 8/21/17 (yielding 4 missed assessments) when R 4 had been discharged to the hospital. R 4 was readmitted with the same pressure ulcers on 9/1/17. On 9/6/17 at 9:00 a.m. an interview with the acting facility wound nurse took place (registered nurse RN #4). RN #4 verbalized that she works part time and the days RN #4 works are Saturday, Sunday, Tuesday, and Wednesday. RN #4 verbalized that she wasn't familiar with the electronic record and was unable to document any assessments, but another wound nurse documents the wound assessments in the electronic record. RN #4 was asked if she had any paper documentation that the assessments were done. RN 4 verbalized that she did not because the other wound nurse was supposed to document the assessments. On 9/6/17 at 9:20 RN #2 (wound nurse) was interviewed regarding the missing wound assessments. RN #2 verbalized that she had went on leave for two weeks beginning 7/22/17 and when she came back she (RN #2) was placed in a different roll as a unit manager and not the wound nurse, leaving only the part time wound nurse to complete assessments. On 9/6/17 at 4:30 p.m. the above finding was presented to the administrator and director of nursing. On 9/7/17 at 8:30 a.m. the administrator verbalized that she was unable to provide weekly wound assessments. No other information was provided prior to exit conference on 9/11/17. This is a complaint deficiency.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of a change in condition for one of 24 residents, Resident #14. This resulted in harm. An unknown staff member identified a wound on Resident #14's left leg stump, and placed a dressing over the wound without a physician's orders [REDACTED]. The dressing remained in place for an unknown length of time and when removed on 09/06/2017 the wound was an unstageable pressure ulcer. Findings were: Resident #14 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 07/27/2017. Resident #14 was assessed as having a cognitive summary score of 04, indicating severe impairment with his cognitive status. However, Resident #14 answered the survey team's questions appropriately during a resident interview and during verbal interaction with the survey team members. Resident #14 was very hard of hearing and while this hindered his ability to understand, if spoken to directly and into his ear he answered and carried on a conversation with no difficulty. Resident #14 was interviewed by a member of the survey team on 09/05/2017 at approximately 2:30 p.m. During the interview he pulled up his left pants leg to show the surveyor a dressing on his left leg stump. He stated that he had been asking for three weeks to go to the leg doctor' .that his prosthetic leg had rubbed a spot on his stump. On 09/06/2017 at approximately 8:00 a.m., Resident #14's clinical record was reviewed. There were no entries in the clinical record regarding a wound for Resident #14. At approximately, 9:00 a.m., RN (registered nurse) #4 who was one of the wound nurses at the facility was in the conference room to speak with a member of the survey team. She was asked if she was doing dressing changes for (Name of Resident #14). She stated that she was not doing any dressing changes with him and was not aware that he had a wound. This surveyor went to the unit where Resident #14 resided. Resident #14 was asked if he had a dressing on one of his legs. Resident #14 stated, Yeah, and pulled up his pants leg on his left leg stump. Observed was a square border gauze dressing. An area of drainage was observed on the bandage. The was no date, time or initials to indicate when the dressing had been applied or who had applied it. Resident #14 was asked who put the dressing on his leg and how long it had been there. He stated, It's been on there for three days . one of the girls here put it on there, I don't remember which one . it's came from trying to wear my legs . you want to see it? I'll take it (the dressing) off of there. Resident #14 was asked to leave the dressing in place until this surveyor could get a staff person in the room to assist him. This surveyor went out into the hallway and asked RN # 7 if she knew anything about a dressing on Resident #14's leg. She stated, I've worked here since last Thursday . this is the first time I have been on this hall, I don't know anything about these residents, I am just giving medications. This surveyor then went to the other side of the unit. RN # 3 was observed in an office with his cell phone in hand. He came out to speak with this surveyor. He was asked if he knew anything about Resident #14. He stated that he did not work that end of the hall. He was asked who the unit manager was. He stated We don't have a unit manager so (Name of the Director of Nursing) is who we go to. This surveyor went to the DON's office. The DON was asked who could discuss the dressing on Resident #14's leg. She directed this surveyor to RN #2, who was the other wound nurse at the facility. RN #2 was busy with another resident. At approximately 10:00 a.m., this surveyor met RN #2 in the hallway. RN #2 was asked if she knew anything about a dressing over a wound on Resident #14's leg. She stated, I just heard about that. This surveyor, RN #2 and the medical director went to Resident #14's room. The dressing had been removed from his left leg stump. The wound was covered with a scab. The medical director, lifted the scab up stating, This is a mobile scab. The wound nurse was asked to measure the wound. She measured the area underneath the scab and stated, It is 1.2 X 1 X .2 She was asked what the yellow area covering the bottom of the wound was. She stated, That's slough. The edges of the wound were rolled and bright pink in color. The wound nurse was asked what she would stage the wound as. She stated, A three. The medical director stated, I would call it a stage 2 or a Stage 3 .it's about the depth. The physician was asked if he had been made notified of the wound prior to that morning (09/06/2017). He stated, No. He was asked if he would expect to be notified when an open wound was discovered on a resident. He stated, Yes. The above information was discussed with the administrator, the administrator in training (AIT), the DON, and other facility staff during an end of the day meeting on 09/07/2017. The DON was asked what her expectation would be if a pressure ulcer was identified by staff. She stated, The doctor should be notified and orders obtained for treatment. A copy of any facility policy/protocol for physician notification was requested. On 09/11/2017, at approximately 9:00 a.m., the Administrator and the AIT came to the conference room to present additional information to the survey team. Included in the information was a facility policy for Change in Condition. The policy contained the following instruction: In order to maintain the resident's safety, a resident's change in condition will be collected and reported in a timely manner .The nursing staff will contact the Physician about significant changes in condition . The administrator asked if the policy presented is what should have been followed when the wound on Resident #14's left leg stump was originally identified by facility staff and covered without an order. She stated, Yes. No further information was presented prior to the exit conference on 09/11/2017.

Based on clinical record review and staff interview, the facility staff failed to ensure acceptable nutritional parameters for two of 24 residents in the survey sample (Residents # 9 and # 22), resulting in harm and failed to ensure a therapeutic diet was provided as ordered by the physician for one of 24 residents, Resident # 2. 1. The facility failed to address the Resident # 9's continued weight loss of greater than 10% over six consecutive 180 day periods between 9/4/17 and 10/3/16. The facility failed to address the resident's continued weight loss ranging from 10.7% over 180 days to 19.6% over 180 days, resulting in harm. 2. The facility staff failed to ensure interventions recommended by the Dietitian were implemented for Resident # 22, as written and failed to implement additional interventions to prevent a weight loss of 31.7 pounds (20.7%) in 6 months resulting in harm 3. Resident #2, with history of poor intake and high sodium and potassium levels, was not provided a low potassium diet as ordered by the physician. The findings include: 1. The facility failed to address the Resident # 9's continued weight loss of greater than 10% over six consecutive 180 day periods between 9/4/17 and 10/3/16. The facility failed to address the resident's continued weight loss ranging from 10.7% over 180 days to 19.6% over 180 days, resulting in harm. Resident # 9 in the survey sample, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/30/17, and the most recent Quarterly MDS, with an ARD of 7/30/17, the resident was assessed under Section C (Cognitive Patterns) as having short and long term memory problems with severely impaired daily decision making skills. Under Section G (Functional Status) on the Annual and Quarterly MDS's, the resident was assessed as totally dependent with one person physical assist for eating, indicating Resident # 9 was unable to feed herself and needed to be fed by staff. Review of the weight record in Resident # 9's Electronic Health Record revealed the following weight history: The resident's weight on 4/3/17 was 154 pounds, and on 10/3/16 her weight was 191.6 pounds, for a loss of 37.6 pounds, or 19.6% in 180 days. The resident's weight on 5/1/17 was 148.8 pounds, and on 11/1/16 her weight was 184.2 pounds, for a loss of 35.4 pounds, or 19.2% in 180 days. The resident's weight on 6/1/17 was 146.8 pounds, and on 12/6/16 her weight was 176.8 pounds, for a loss of 30 pounds, or 16.9% in 180 days. The resident's weight on 7/3/17 was 145 pounds, and on 1/2/17 her weight was 165 pounds, for a loss of 20 pounds, or 12.1 % in 180 days. The resident's weight on 8/1/17 was 144.6 pounds, and on 2/1/17 her weight was 162 pounds, for a loss of 17.4 pounds, or 10.7 % in 180 days. The resident's weight on 9/4/17 was 142.2 pounds, and on 3/1/17 her weight was 163 pounds, for a loss of 20.8 pounds, or 12.7 % in 180 days. The physician progress notes [REDACTED]. No recent behaviors, now bed bound, poor eye contact .Looks thinner to me .requires to be fed. At 8:50 a.m. on 9/7/17, the facility's RD (Registered Dietician) was interviewed by telephone. The RD stated he started as the RD for the facility in mid-July (2017). Regarding Resident # 9, the RD said, Her monthly weights are stabilizing. I saw no need to put in any interventions. The resident's continued weight loss of greater than 10% over six consecutive 180 day periods between 9/4/17 and 10/3/16, and her use of a Magic Cup four times a day since 10/24/16 was discussed. When asked, based on that information, if new interventions should have been initiated, the RD said, We should have, based on that information. During a meeting at 4:30 p.m. on 9/7/17, that included the Administrator in Training, the Administrator in Training Mentor, the Director of Nursing, and the survey team, Resident # 9's continued weight loss and the lack of new interventions was discussed. 2. The facility staff failed to ensure interventions recommended by the Dietitian were implemented for Resident # 22, as written and failed to implement additional interventions to prevent a weight loss of 31.7 pounds (20.7%) in 6 months resulting in harm Resident # 22 had a documented weight loss of 31.7 lbs (pounds) in 6 months, without appropriate interventions to maintain an acceptable weight for the resident. Findings include: Resident # 22 was admitted to the facility originally on 4/12/16, with the most current readmission on 3/21/17. The resident was again discharged on [DATE] and returned late on 9/6/17. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was a significant change assessment dated [DATE], this MDS assessed the resident with a cognitive score of '13', indicating the resident was cognitively intact for daily decision making skills. The resident was also assessed as extensive assistance from staff for most all ADL's (activities of daily living) except for eating, which was supervision with one person assist. The resident also triggered for the CAAS (care area assessment summary) section of this MDS for nutrition. The resident's height and weight was recorded on this MDS as 64' inches tall and weighing 150 lbs. A comparison MDS was reviewed. A quarterly assessment dated [DATE] documented the resident as having a cognitive score of '10', indicating moderate impairment in daily decision making skills and as requiring extensive to total assistance from staff for most ADL's, including eating which was now extensive assistance with one person assist. The resident's height and weight were recorded on this MDS as 64' inches tall and weighing 126 lbs. A difference of 24 lbs between the two MDS assessments, in a 3 month period. Resident # 22's weight records were then reviewed and revealed the following weights. 2/1/17-152.6 4/3/17-141.2 5/3/17-134.3 6/1/17-126.3 7/8/17-123.0 8/1/17-120.9 A total weight loss of 31.7 lbs (20.7%) in 6 months. Resident # 22's CCP (comprehensive care plan) was then reviewed. The CCP documented, .ADL .eating: The resident requires assistance by staff to eat (3/30/17) .Nutritional .monitor/document/report as needed signs and symptoms of dysphasia (difficulty swallowing) pocketing, choking coughing, drooling, holding food in mouth, refusing to eat .weight loss .> (greater than) 10% in 6 months .provide and serve diet supplements as ordered .med pass per order (revision on 6/30/17) .RD to evaluation and make diet change recommendations .weigh as indicated . Resident # 22's progress notes were documented were reviewed. A nutritional/dietary note dated 5/12/17 documented: .134.3 .11.99% X 90 day weight loss .Recommend: House supplement/med pass 120 cc TID (three times daily). continue to monitor . A nutrition/dietary note dated 7/7/17 documented: .123.3 .19.49% loss x 6 months .Med pass 120 cc BID (twice daily) started 5/14/17 .appetite good weight loss has slowed over the last month. Recommend increasing Med Pass to TID and will continue to monitor . A nutritional/dietary note dated 8/11/17 documented: .120.9 .Med Pass 120 cc started on 5/14/17, recommendation to increase to TID made on 7/7/17, increased to TID on 8/9/17 .will continue to monitor weights as received .no new interventions at this time . Resident # 22's POS (physician's orders [REDACTED]. Resident # 22's did not have any nutritional evaluations and/or assessments that could be located in the clinical record. On 9/7/17 at approximately 2:00 p.m., the administrator, DON (director of nursing) and AA were made aware of concerns regarding Resident # 22's weight loss and the fact that the Dietitian recommended in 5/12/17 for the resident to receive 120 cc of supplement three times a day, which was started on 5/14/17 and only given twice a day-not three times a day as recommended, and then on 7/7/17 the supplement was again recommended to be increased to at 120 cc three time a day and that was not initiated until 8/9/17. The staff were asked for assistance in determining why the resident did not get the supplements as recommended. On 09/11/17 at approximately 9:00 a.m., the resident's clinical record was again reviewed and documented a 'significant nutritional therapy evaluation' dated 9/11/17 and documented, which was in progress. The evaluation did not have any pertinent data entered related to the resident's nutritional status or state, the evaluation was basically blank. No further information and/or documentation was presented prior to the exit conference on 9/11/17 at 2:45 p.m., to clarify or explain why the resident did not get the recommended supplement to prevent weight loss in May and then again in July, and why no other interventions were implemented to prevent a significant weight loss for Resident # 22. 3. Resident #2, with history of poor intake and high sodium and potassium levels, was not provided a low potassium diet as ordered by the physician. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #2 with severely impaired cognitive skills and body weight of 107 pounds. Resident #2's admission history and physical dated 7/14/17 documented the resident had poor intake and had [DIAGNOSES REDACTED]. fluid daily for management of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #2's clinical record documented a physician's orders [REDACTED]. A telephone physician's orders [REDACTED]. Resident #2's diet requisition form dated 7/14/17 documented a regular pureed diet. The diet slip made no mention of the order for a low potassium diet. The resident's plan of care (revised 8/8/17) documented the resident had potential for impaired nutrition due to dementia and underweight body mass index and refusals to eat meals. Interventions to maintain weight and prevent weight loss included, Nutritional supplement as ordered d/t (due to) underweight .Observe daily po (oral) and fluid intake .Provide diet as ordered .Resident has been refusing meals at times, Encourage assist with meals . On 9/5/17 at 2:30 p.m. the registered nurse (RN #3) caring for Resident #2 was interviewed about the ordered low potassium diet. RN #3 stated he was not aware of a low potassium diet. RN #3 stated the resident may have been discharged and readmitted with a new diet order. The clinical record documented no re-admissions to the facility and no further diet orders since 7/14/17. On 9/5/17 at 3:50 p.m. the dietary manager was interviewed about Resident #2's physician ordered low potassium diet. The dietary manager stated the resident had not received a low potassium diet since admission. The dietary manager stated the last diet communication form sent to the kitchen was dated 7/14/17 and listed a regular pureed diet with no mention of low potassium. The dietary manager stated the low potassium order was not sent or communicated to the kitchen. The dietary manager stated high potassium foods were avoided for residents with orders for a low potassium diet. The dietary manager stated the registered dietitian was on vacation but he would attempt to contact him regarding Resident #2. On 9/5/17 at 4:40 p.m. the dietary manager stated he contacted the facility's registered dietitian by telephone about Resident #2's diet. The dietary manager stated the RD had no knowledge of any recommendation or orders for a low potassium diet for Resident #2. These findings were reviewed with the administrator and director of nursing during a meeting on 9/5/17 at 5:00 p.m.

Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to supervise a leave of absence for one of 24 residents in the survey sample, which resulted in harm (Resident #3) and failed to ensure one of 24 residents was safe for the use side rails (Resident #2) and failed to answer call bells in a timely manner per the group meeting. 1. The facility staff failed to ensure that Resident #3 had a current physician's order to leave the facility on a leave of absence and failed to locate the resident, when the resident was away from the facility for an extended amount of time, as a result the resident left the facility and did not return. The resident was found the next day (approximately 13.5 hours later) under a bridge by EMS (emergency medical services) with loss of consciousness. The resident was taken to the emergency department and subsequently admitted for 4 days. 2. Resident #2 was found on the floor with her head wedged between the bed rail and the air mattress. The resident had no prior assessment for safe use of the bed rails and no physician's order for the use of a specialty air mattress. The resident suffered pain and bruising to her neck and back from the entrapment and was sent to the hospital for evaluation. 3. During the Group Meeting, residents complained of a lack of call bell response. Findings include: 1. The facility staff failed to ensure that Resident #3 had a current physician's order to leave the facility on a leave of absence and failed to locate the resident, when the resident was away from the facility for an extended amount of time, as a result the resident left the facility and did not return. The resident was found the next day (approximately 13.5 hours later) under a bridge by EMS (emergency medical services) with loss of consciousness. The resident was taken to the emergency department and subsequently admitted for 4 days. Resident #3 was originally admitted to the facility on [DATE], with a current readmission on 08/07/17. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) assessment with CAAS (care area assessment summary) was a significant change assessment dated [DATE]. This MDS assessed the resident as having a cognitive score of '12', indicating resident had moderate impairment in daily decision making skills. The resident was also assessed as requiring limited assistance from one staff person for transfers, ambulation and bathing. The resident's was assessed as using a walker and w/c (wheelchair) for mobility. The resident was assessed on this MDS to have cellulitis with infection and a surgical wound present. Additionally it was documented on this MDS, that the resident received insulin injections in the previous 7 day look back period and also received IV ABX (intravenous antibiotics) during the 7 day look back period. The resident also triggered for cognition, ADL's (activities of daily living) and falls in the CAAS section of this MDS. A 14 day admission MDS assessment was reviewed for comparison, dated 08/21/17. This MDS assessed the resident to have a cognitive score of '13', indicating the resident was cognitively intact for decision making skills. The resident was assessed as requiring supervision with setup for transfers and ambulation. The resident was assessed as using a walker for mobility. The resident was also assessed as receiving IV ABX and insulin during the previous 7 day look back. Resident #3 was named in a complaint. The complaint alleged in the intake information that APS (adult protective services) reported that they (APS) received a call from the hospital ED (emergency department) that Resident #3 was found under a bridge with loss of consciousness and highly intoxicated on 8/4/17. It was reported that the resident signed himself out of the facility on 08/03/17 at approximately 4:30 p.m. The hospital ED called the facility to inform the facility that the resident had been admitted to the hospital. APS documented concerns regarding the resident's complex medical history and that the fact that the resident had a PICC (peripherally inserted central catheter) in place and had left the building for an extended amount of time and no steps were taken by facility to attempt to locate the resident when he did not return in a reasonable amount of time. During a complaint investigation on 09/5/17 through 09/07/17, Resident #3's clinical record was reviewed. The ED (emergency department) provider notes for Resident #3 were reviewed for 8/4/17, timed for 6:15 a.m. documented, ' .found altered by ems (emergency medical services) under a bridge, unknown down time or last seen normal, elevated blood sugar by fingerstick .history of alcohol abuse, cardiac arrest .seizure .he was non-responsive but able to talk upon EMS arrival (to hospital) .per (name of long term care facility) patient signed himself out at 4:30 p.m.(08/03/17) .(history) was admitted to gerontology for osteo[DIAGNOSES REDACTED] due to diabetic foot ulcer from 7/3/17-7/7/17 .6 weeks of IV vancomycin, ceftriaxone and oral flagyl .PICC was placed in left basillic vein for IV antibiotics .(current) glucose 641 .ethanol 222 .' It was documented that the resident received 10 units of IV insulin, IV fluids, insulin infusion protocol initiated and the MICU (medical intensive care unit) was consulted. The resident was admitted to the MICU, the current PICC line was removed on admission due to being completely not functioning and was cultured with no growth at time of discharge on 8/7/17. A new PICC line was placed on 8/7/17 prior to discharge. Resident #3's current POS (physician's order sheet) was reviewed. The POS included an order for [REDACTED].May go out on pass: Yes ( ) No ( ) With meds ( ) without meds ( ) May have annual flu vaccine: Yes (X) No ( ) May have pneumococcal vaccine: Yes (X) No ( ) PPD: Yes (X) No ( ) . The date for this order was dated 7/11/17 and was listed as an 'Active' order. The area to be marked (by an X) to indicate if the resident was able to go out on pass was blank, therefore the resident did not have a current physician's order for the resident to be able to leave the facility with or without medications. The resident did not have a current active physician's order to go out on pass with or without medications. Resident #3's CCP (comprehensive care plan) prior to 8/3/17 (the day the resident signed himself out of the facility) was reviewed and documented, ' .4/4/17 .activity .he is a smoker and socializes in the gazebo .5/11/17 .instruct resident about smoking risks and hazards and about smoking cessation, instruct resident about the facility smoking policy, locations, times, safety concerns, notify charge nurse immediately if it is suspected resident has violated facility smoking policy, the resident requires SUPERVISION while smoking .encourage resident to maintain communication with his family, SW (social worker) and his relationships with his peers in the facility .7/11/17 .IV medications .administer antibiotic via PICC .' There was no information and/or documentation in the resident's CCP regarding the resident having permission and/or a physician's order to leave the facility with or without supervision, there was no information about the resident signing himself out of the facility for any type of LOA, for a pass, or for leaving the grounds of the facility without supervision. The resident's current CCP after 8/3/17 was reviewed and documented, ' .4/5/17 he is a smoker and socializes in the gazebo .05/11/17 .instruct resident about smoking risks and hazards and about smoking cessation, instruct resident about the facility smoking policy, locations, times, safety concerns, notify charge nurse immediately if it is suspected resident has violated facility smoking policy, the resident requires SUPERVISION while smoking .8/9/17 resident refused to go to appointment out of facility .8/9/17 .behavioral symptoms, non-compliance with signing self out of building with PICC line .allow me to verbalize my feelings about the situation, educate me on risk of my non-compliance explain risk of signing self out while having IV access device (PICC) .notify my representative, physician/nurse practitioner of any hazardous items/unsafe practices as needed .observe me for any unsafe practices/behaviors and provide education/supervision as needed related to risk versus benefits .' There was no information and/or documentation in the resident's CCP regarding the resident having permission and/or a physician's order for leaving the facility with or without supervision, there were not interventions regarding the resident signing himself out of the facility for any type of LOA, for a pass, or for leaving the grounds of the facility without supervision. A 'Wander Evaluation' was then reviewed dated 5/4/17, which documented that the resident was cognitively impaired with poor decision-making skills (intermittent confusion, inattention, poor decisions, etc.), and that the resident had a [DIAGNOSES REDACTED]. It was also documented that the 'interventions' to be utilized would consist of exit/stairwell alarms. In the summary section of this evaluation it was documented that the resident 'is not an elopement or wander risk . ambulated independently with his walker . wears glasses .has occasional inattention . has anxiety and major depression disorders .' No other wander evaluation had been completed on Resident #3 since 5/4/17. No other assessments and/or evaluations could be located within the clinical record to evidence that Resident #3 was assessed by facility staff, as being a safe candidate to sign himself out of the facility at anytime with or without supervision. Progress (nursing) notes were reviewed from August 1, 2017 through August 10, 2017. On 08/02/16 at 3:28 a.m., it was documented that the resident 'continues on abx via picc (peripherally inserted central catheter) .purple port flushes well, but red port is occluded .' 08/02/17 at 2:02 p.m., it was documented, ' .antibiotic iv for wound L (left) foot cellulitis resident ambulates on off unit using walker .' 08/02/17 at 6:31 p.m., it was documented, ' .continues on IV .for wound infection .' 08/03/17 at 2:31 a.m., it was documented, ' .continues on IV .for infection and surgical removal of left great toe .' A 'late entry' nursing note dated 8/3/17 10:19 a.m. (created on 8/14/17 at 10:26 p.m.) documented, ' .located under a bridge, and later went to the hospital. SS (social services) created an APS referral as the facility staff feels he is a danger to himself as a reflection of his choices while signed out of the facility.' This note was created 11 days after the resident left the facility and 7 days after the resident was readmitted . A nursing note dated 8/4/17 and timed 7:08 a.m., documented, 'Reesident (sic) sign self out on 8/3/17 at 4:30 p.m. and did not return. at this time (name of hospital) called to ask if resident stay here (sic) and was told yes, Nurse stated he was found under bridge and brough (sic) to ER (emergency room ) Social worker states walker is with him and they will try to clear clog picc line ER (sic) .' A 'late entry' nursing note dated 8/7/17 6:03 p.m. (created on 8/16/17 1:37 a.m.) documented, ' .was admitted on [DATE] via stretcher .continue IV antibiotics wound care management of diabetes education of health state .see admission/readmission evaluation for additional information .' A 'late entry' nursing note dated 8/8/17 and timed 10:26 a.m. (created on 8/14/17 and timed 10:27 a.m.) documented, ' .returned to the facility yesterday, and the APS referral was submitted to APS on today as the staff feels his recent choices while signed out could make him a danger to himself.' The resident's admission evaluation dated 8/7/17 and timed 6:03 p.m. (signed as completed on 8/16/17) documented, ' .alcohol use: yes, tobacco use: yes .IV .PICC .' On 9/5/17 at 5:00 p.m., the AA (acting administrator) was asked for a policy on residents signing themselves out of the facility. On 9/6/17 at approximately 8:20 a.m., Resident #3 was interviewed in his room regarding the incident on 8/3/17, when he signed himself out of the facility. Resident #3 stated that he thought he signed himself, but couldn't remember for sure on 8/3/17. The resident stated that he had 'to get away for a little while' and stated that he was extremely depressed during that time. The resident stated that his mother had passed away, as well as an uncle that he was very close to and he was really depressed. The resident did not provide dates of the loss of his mother and/or uncle. The resident asked if he had told anyone he was depressed. The resident stated, Yes and stated that he had been speaking with the SW (social worker) # 13 and that he did not like it here and wanted to try to get his own place or move to assisted living and that the SW # 13 'won't try to help me find a place.' The resident stated that he is a diabetic and isn't in the best health and that when he left he was so depressed and drank 4 pints of Vodka and went to a bridge he used to visit when he was a child, again stating he just needed to get away from it all. On 9/6/17 at approximately 10:40 a.m., the AA and DON (director of nursing) were made aware of concerns regarding Resident #3 and that this information was not reported to the state agency, an investigation on Resident #3 regarding the above was then requested, again a policy on resident's signing out of the facility was requested. At approximately 3:45 p.m., the AA (acting administrator) stated, ' .we would not have reported to state, he is alert and oriented and goes out on LOA (leave of absence), goes out quite often, he was homeless . The AA stated at that time, the facility does not have a policy on leave of absence or a policy on residents signing themselves out of the facility and stated that the facility reported it to APS. The AA then stated that there may something in the admission packet about residents signing themselves out of the facility. The admission packet was reviewed by the survey team and did not provide any information regarding residents signing themselves out of the facility for a LOA and/or a pass. A policy was presented on 'conducting a thorough investigation', which documented, 'When an actual and/or potential care and service failure occurs involving a resident, it is necessary for facility administration to initiate an investigation to determine the facts and then act upon or respond accordingly to the findings. Examples of issues that would require investigation .falls with injury or non-injury, allegations of abuse .elopement A policy was presented on 'reporting abuse to state agencies and other entities' documented, 'All suspected violations and all substantiated incidents of abuse will be immediately reported .the facility administrator or his/her designee will promptly notify the following persons or agencies .a. The state licensing/certification agency responsible for surveying/licensing the facility . On 9/6/17 at 4:50 p.m., again concerns were raised by the survey team to the administrator, AA (assistant administrator), and DON regarding Resident #3 leaving the facility without being assessed as safe to sign out and that the resident was away from the facility and there was no evidence at all that staff attempted to locate the resident who had been away form the facility for approximately 13.5 hours. The facility staff were additionally made aware that there was no information in the admission packet regarding residents signing themselves out of the facility. The facility staff were also made aware that the sign out sheet that Resident #3 signed actually had another resident's name on top (a name similar to Resident #3) and that the sign out sheet clearly documented an area for 'signing (back) in' to the facility with a date, time and a signature of facility representative, that was completely blank. No evidence was found that the facility attempted to locate the resident during the extended amount of leave from the facility. The facility had no policy and/or procedures to identify when a resident was gone from the facility for an extended amount of time or a policy and/or procedure to direct actions of staff in an event of this type. The facility staff did not assess the resident to determine if the resident was safe to leave the facility on a LOA and/or pass and the resident did not have a physician's order for the resident to leave the facility with or without supervision. No further information and/or documentation was presented prior to the exit conference on 9/11/17 at 2:45 p.m. The is a complaint deficiency. 2. Resident #2 was found on the floor with her head wedged between the bed rail and the air mattress. The resident had no prior assessment for safe use of the bed rails and no physician's order for the use of a specialty air mattress. The resident suffered pain and bruising to her neck and back from the entrapment. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #2 with severely impaired cognitive skills. Resident #2's clinical record documented a nursing note dated 7/17/17 at 3:05 a.m. stating, Resident was observed with her bottom sitting on the floor and her head in between the bed rail and the air mattress. Resident stated she was trying to get up out of the bed. No c/o (complaints of) pain . The physician was notified of the resident's entrapment on 7/17/17 and ordered the resident to go the emergency room for evaluation and treatment. The emergency room discharge summary dated 7/17/17 documented, Patient coming from nursing home, found half way out of bed with legs on the ground by neck and head caught within the railings. Complaining of anterior neck pain. Denies L(NAME) (loss of consciousness) . Pt's (patient's) pain is moderate throbbing, without radiation and unchanged from onset. Worse with palpatiojn (palpation), not worse with movement. No associated swelling or shortness of breath, no dysphagia .No evidence of acute cervical spine fracture .minor trauma to anterior right neck, no expanding mass, minimally tender .Imaging reveals no acute injury .A [DIAGNOSES REDACTED]. The resident returned to the facility from the emergency roiagnom on [DATE]. A nursing note dated 7/17/17 at 5:24 p.m. documented, .returned from ED (emergency department) . with no new orders .Resident observed with bruise to back. Resident reports that she hit her back when she attempted to walk and fell to floor from bed. Resident was in pain .order obtained for Tylenol 325 mg (milligrams) two tablets by mouth q. (every) 6 hours. Resident reports pain management is effective . The clinical record documented no prior assessment for safe use of bed rails or a physician's order for the specialty air mattress prior to the entrapment incident on 7/17/17. There was no evidence of informed consent from Resident #2's responsible party (RP) or review with the RP of benefits and/or risks of side rail use prior to the entrapment. The resident's admission assessment dated [DATE] documented the resident was alert and oriented to person but not place, time or situation and was at risk for falls. This assessment documented the resident was independent with walking using an ambulation device and required total assistance of one person for safe transfers. This admission assessment documented side rails were not in use by the resident at the time of admission. The resident's plan of care prior to the fall (dated 7/17/17) listed the resident was at risk for falls. Interventions to prevent falls included low bed position, alternate periods of activity with rest, participate in activities, call light within reach and a clutter free environment. There was no mention of side rail use or a specialty air mattress prior to the entrapment incident on 7/17/17. There was no facility investigation of Resident #2's entrapment on 7/17/17. The facility's incident form documented the resident had an unwitnessed fall on 7/17/17 at 3:00 a.m. and was found with the side rails in the up position but made no mention the resident was found with her head wedged between the bed rail and the air mattress. The incident form did not include the length of the rails in use at the time or the area of the bed where the resident was wedged. On 9/5/17 at 2:30 p.m. the registered nurse (RN #3) caring for Resident #2 was interviewed about the entrapment incident of 7/17/17 and the resident's assessment for bed rail use and the air mattress. RN #3 stated he was not aware the resident had been wedged in between the side rails and the mattress. RN #3 reviewed the clinical record and stated he did not see an assessment for side rail use or an order for [REDACTED].#3 stated he thought side rail assessments were done upon admission for all residents. On 9/5/17 at 4:20 p.m. the staff development coordinator (RN #2) at the time of the Resident #2's entrapment was interviewed about any prior assessment and/or order for the side rails or the air mattress. RN #2 stated Resident #2 had no prior assessment for safe use of side rails. RN #2 stated she was not sure why the resident had a specialty air mattress in use. On 9/5/17 at 4:25 p.m. the director of nursing (DON) was interviewed about Resident #2's entrapment. The DON stated the use of a specialty air mattress required a physician's order prior to use. The DON stated assessment for safe use of bed rails was supposed to be done on admission or re-admission to the facility. The DON stated she was not aware of how or why the resident had side rails in use with the air mattress. On 9/6/17 at 9:10 a.m. the administrator was interviewed about Resident #2's entrapment and lack of a prior assessment for side rail use or order for the specialty mattress. The administrator stated the use of side rails was supposed to be triggered based upon the admission assessment. The administrator stated, We (facility) don't have a policy about assessment for side rails. The administrator stated there was no side rail assessment for Resident #2 prior to the entrapment incident on 7/17/17. The administrator stated she was new and did not have access to all the policies but would continue looking for a side rail policy. On 9/6/17 at 2:10 p.m. the administrator stated she found a facility policy about side rails. The policy was titled Side Rails and had no effective or review dates listed. This policy stated, Residents will be evaluated for indication of use of side rails by licensed nurse to determine if side rail is necessary to promote resident independence or safety on implementation and at least quarterly basis thereafter. Resident should be assessed to determine if side rails pose risk of restraint. Resident/responsible party should be provided education regarding risk versus benefit of use of side rails. On 9/7/17 at 9:10 a.m. the corporate admissions director was interviewed about any information concerning the source of Resident #2's specialty air mattress. On 9/7/17 at 11:00 a.m. the corporate admission director stated the resident was admitted with poor intake and potential for skin breakdown. The corporate admissions director stated the resident had a specialty mattress at the hospital so admissions thought it would be best for her to have one in the facility. The corporate admissions director stated the facility admissions director had initiated the paperwork to order for the mattress from their supplier based on her hospital history. The corporate admissions director stated there was no physician's order found for Resident #2's air mattress. On 9/11/17 at 9:10 a.m. the administrator stated, An assumption had been made that she (Resident #2) had a MD (physician) order for the air mattress. The administrator stated she did not find an order for [REDACTED]. The facility presented the air mattress manufacturer's product information guide related to the specialty air mattress in use with Resident #2 at the time of entrapment on 7/17/17. The air mattress product information guide documented warnings and danger of entrapment risks with use of the air mattress. Page 17 of the air mattress product information guide documented, Danger: Evaluate Gaps .The mattress is designed to fit on a standard bed frame. The risk of entrapment can arise when the equipment is placed on bed frames that leave gaps of even a few inches between the mattress and the head panel, and bed or side rails. The equipment is NOT to be used when such gaps are present. There was no evidence of a side rail assessment, no physician's order for the specialty air mattress and no evidence of gap measurements or any interventions to ensure Resident #2's bed environment was safe prior to the entrapment incident on 7/17/17. These findings were reviewed with the administrator and director of nursing during meetings on 9/5/17 at 4:25 p.m. and on 9/6/17 at 4:45 p.m. This was a complaint deficiency. 3. During the Group Meeting, residents complained of a lack of call bell response. At 9:30 a.m. on 9/6/17, a Group Meeting was conducted with six alert and oriented facility residents. Prior to the meeting, the Resident Council Minutes for the most recent three council meetings were reviewed. Under Old Business, the August 30, 2017 minutes included the following, Call bells at times still problem. Call bells not being answered timely. During the meeting, the residents all agreed that call bell response was a problem. I ring the call bell and they come in, ask me what I want, and then they never come back, one resident said. Another resident stated, They don't follow-up on requests. Call bell response is very slow. If you need help when they (CNA's) (Certified Nursing Assistants) are passing trays, you will wait a long time, or they will never come back.

Based on staff interview, family interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow professional standards of nursing for one of 16 residents, Resident #116. The facility staff failed to thoroughly assess Resident #116 following a period of weakness during a shower on December 19, 2016. Facility documentation and staff interviews differed on what actually occurred in the shower room. Per facility documentation, Resident #116 was lowered to the floor during her shower. Per staff interview, the resident became weak and unresponsive and was transferred from the shower chair to the wheelchair and then taken to the nurse. Per a family interview, Resident #116 repeatedly stated Don't touch my leg during a visit on the evening (Following her shower) of December 19, 2016, which was reported to the nursing staff. The nurse's notes from December 19, 2016, recorded Resident #116 complaining of hurting all over and receiving medication for pain. An assessment including range of motion was not done. Per facility documentation and staff (CNA-certified nursing assistant) interview, Resident #116 complained of pain upon movement on December 21, 2016 and was unable to stand. This was reported to the staff nurse. The nurse did not document an assessment for Resident #116 on 12/21/2016. On December 22, 2016, the same CNA cared for Resident #116 and stated the pain was worse for the resident and she reported it to a different staff nurse. Resident #116 was assessed and sent to a local hospital. She was diagnosed with [REDACTED]. The facility staff failed to assess Resident #116 for a significant change in condition with resulting harm. This is a complaint deficiency. Findings were: Resident #116 was added to the survey sample as a closed record in response to a complaint investigation. The facility had submitted an FRI (facility reported incident) to both the OLC (Office of Licensure and Certification) and APS (Adult Protective Services). The FRI included information that on the morning of 12/22/2016, Resident #116 was found to have pain with movement to her right leg/hip. She was sent out to the local hospital where a right [MEDICAL CONDITION] was diagnosed . The facility determined that the resident transferred herself and fell without staff being aware. There was no evidence of abuse or neglect. On 03/08/2017 additional information was reported to the APS office and subsequently submitted to OLC. The additional information was submitted by a family member via a complaint portal for APS. The additional information included the following: (Name of Resident #116) fell at (name of facility) and later passed away. On December 19th 2016 around 5:00pm or 5:30 pm my grandmother (Name) (88) fell while taking a shower unassisted at (facility name and address). Personnel had cleaned her up from the fall when my cousin arrived (cousin name) and placed her back in bed. It was a male nurse or aid and she was his patient for the night. My cousin asked if she should go to the hospital, he stated 'No she was just shaken up. My grandmother was complaining about her hip. After several days laying in bed and pain, she was finally transported to (hospital) .my grandmother had fractured her right hip .she had surgery to repair her hip .she passed away on 29 [DATE] (12/29/2016) due to complications from Pneumonia, [MEDICAL CONDITION] and Ground level fall per her death certificate. The additional information submitted to APS via the portal was submitted to OLC and the complaint was generated. Resident #116 was originally admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) with an assessment reference date of 11/25/2016, assessed Resident #116 as having a cognitive summary score of 02, indicating severe impairment with her cognitive status. Section G, Functional Status, assessed Resident #116 as a 3/3 (Physical help in part of bathing activity/Two + persons physical assist) for bathing (G0120). The clinical record was reviewed on 04/05/2016 beginning at 9:15 a.m. The nurse's note section was reviewed. On 12/19/2016 the following notes were written: 2 pm Resident had moderate amount yellowish liquid vomit this afternoon, X (times) 1 occurrence. Bowel sounds presents (sic), abdomen soft nondistended. Ate lunch w/o (without) difficulty. Large BM (bowel movement) yesterday. 1630 (4:30 p.m.) Resident taken to shower. Staff member reported that resident became weak after shower and bowel movement on floor. Resident became unresponsive with foaming sputum from mouth. Resident taken to room and layed down in bed, Resident become (sic) responsive and talking- V.S. (vital signs) T 97.1 p 65 Resp 24 B/p 106/84. Resident had vomiting on previous shift and vital signs normal. Appetite good @ this time. + (positive) bowel sounds in all 4 quads. 1800 (6:00 p.m.) Resident had projectile vomiting X 1 with yellow bile and particles of food. No further vomiting @ this time. Resident given medications and is resting at this time. Medicated X 2 for pain this evening as resident stated she was hurting all over. Also observed in the nurse's note section was an SBAR (Situation, Background ,Appearance, Review and Notify) form dated 12/19/2016. The form was divided into sections and questions were available for staff to answer. The unit manager of the floor where Resident #116 resided, LPN (licensed practical nurse) # 2 completed the form. Questions determined to be applicable to the situation are listed below with the staff answers underlined: SITUATION The change in condition, symptoms, or signs observed and evaluated is/are n/v (nausea/vomiting), Fall This started on 12/19/16 This condition, Symptom or sign has occurred before: No (checked as the answer) Other relevant information Lowered to floor while in shower with staff BACKGROUND Primary [DIAGNOSES REDACTED]. Allergies and vital signs were also recorded. Resident Evaluation Mental Status Evaluation (compared to baseline; check all changes that you observe) No change was checked. Functional Status (compared to baseline; check all changes that you observe) Falls (one or more) Weakness (general) were checked. Behavioral Evaluation No changes observed was checked. Respiratory Evaluation No changes observed was checked. Cardiovascular Evaluation No changes observed was checked. Abdominal/GI Evaluation date of last BM 12/19/16 GU/Urine Evaluation No changes observed was checked. Skin Evaluation No changes observed was checked. Pain Evaluation: Not clinically applicable to the change in condition being reported was checked. Does the Resident have pain? No was checked. Neurological Evaluation No changes observed was checked. APPEARANCE Summarize your observations and evaluation N/V Weakness Lowered to Floor by staff in shower room REVIEW AND NOTIFY Primary Care Clinical Notified (Physician Name) Date 12/19/16 Time 6pm Nursing Notes (for additional information on the Change in Condition) Resident had episode of N/V. Was in the shower room became weak staff lowered her to the floor, Resident taken to her room Given a cup of water. Resident became responsive and is at her baseline. The CNA documentation in the clinical record regarding ADL (activities of daily living) care was reviewed. On 12/19/2016 Resident #116 was coded: D SH 1, meaning shower, Dependent, and one person help which was not consistent with the MDS assessment of 3/3 (Physical help in part of bathing activity/Two + persons physical assist). The medication administration record for 12/19/2016 was reviewed. Resident #116 had orders for [MEDICATION NAME] Tablet 5-325 Give 1 tablet by mouth two times a day related to PAIN, UNSPECIFIED .and Give 1 tablet by mouth every 6 hours as needed for pain. Resident #116 received a PRN (as needed dose) dose of [MEDICATION NAME] on 12/19/2016 at 4:00 p.m., There was not an assessment of the pain scale or pain level was documented on the MAR or the nurse's notes for the PRN administration. The nurse's entry on the back of the MAR was 12/19/2016 1600 (4:00 p.m.) [MEDICATION NAME] 5/325 po (by mouth) all over pain' and the nurse's initials. Resident #116 also received her regularly scheduled dose of [MEDICATION NAME] at 2100 (9:00 p.m.). Other pain medication for Resident #116 was a scheduled dose of Tylenol Tablet 325 mg, Give 2 tablet (650 mg), by mouth two times a day related to PAIN, Unspecified . Resident #116 also received the scheduled Tylenol at 1700 (5:00 p.m.) on 12/19/2016. The MAR contained a question Is this resident in pain? 0 = No Pain; 1-3 = mild; 4-6 = Moderate; 7-10 = Severe every shift Follow MD orders Pain levels for Resident #116 were documented as 0 every day and every shift. Additional Nurse's notes reviewed in the clinical record listed by date were: 12/20/2016 0630 (6:30 a.m.) No vomiting this shift. Resident at baseline. Res rested comfortably during night. No c/o (complaints of) pain or discomfort @ this time. + bowel sounds all 4 quads. Took a.m. med without difficulty. 12/21/2016 0600 (6:00 a.m.) Res vomited X 1 yellow bile with loose stools X 2. Bowel sounds all 4 quads . 12/22/2016 0630 Res with no vomiting (sic) or stools this shift. Rested comfortably with eyes closed. No s/s (signs symptoms) of pain or discomfort. 0830 (8:30 a.m.) Resident in bed, assisted to sitting position to eat breakfast, resident attempted to eat but vomited (sic) small amount of yellow liquid. Attempted to drink water and vomited (sic) a moderate amount of brownish liquid. Poor skin turgor & dry lips noted. Skin color pale. Responds to verbal & tactile stimuli. Notified NP, received order to give [MEDICATION NAME] (antinausea medication) 25 mg/1 ml, give 1 ml IM (intramuscularly) X 1 dose now. Injection given without difficulty. Appears to be in pain with movement will attempt po (by mouth) pain medications as ordered. Abdomen soft, nondistended. Appears to be in pain with movement/rotation of right leg and hip. NP (nurse practitioner) notified and will come see resident . Orders were obtained for mobile xrays for bilateral hips, pelvis and right leg but were canceled as resident was sent to the emergency room where she was subsequently admitted for a right [MEDICAL CONDITION]. The facility investigation/information regarding the above was requested and received. Included in the information was an INVESTIGATION ACTION PLAN. Information contained included but was not limited to: PROBLEM REPORTED: Staff observed resident with change in behavior and pain to Right leg/pelvis when touched. What actually occurred? resident was observed making facial grimaces when being positioned in bed. How did the event likely occur? Resident was lowered to floor on 12/19/16 by staff. Also gets OOB (out of bed) unassisted ambulates without assist. Why did the event occur? Resident became weak while in shower lowered to floor by staff. OOB unassisted ambulates without assist. Resident sent to ER. Included in the facility investigation were interviews with staff who cared for Resident #116 on 12/20-22/2016. There were no interviews with the nurse who cared for Resident #116 after she was lowered to the floor in the shower room or the CNA who had given her the shower on 12/19/2016. This surveyor contacted LPN #6 via telephone on 04/05/2017 at 11:20 a.m. LPN #6 had cared for Resident #116 on 12/19/2016 following the shower incident. He was asked to walk this surveyor through the events of the evening. He stated that Resident #116 had a vagal nerve response in the shower. He was asked if the CNA had told him that the resident had been lowered to the floor. He stated, I don't remember being told she was lowered to the floor .the CNA said she just went out, like she fainted and had a BM .I made a note. He was asked to describe what he saw when the resident was brought out of the shower room. He stated, She was pale, she wasn't walking, she was in the shower chair, she was awake.LPN #6 was asked if he remembered speaking with Resident #116's family that evening and saying the resident was Shaken up. He stated, I didn't say shaken up, I told them that she had a vagal nerve response and fainted in the shower. He stated that he did not remember who the CNA was that had given Resident #116 a shower that night. He also stated that Resident #116 did not get out of the bed anymore that night, but they did sit her up for dinner. He was asked if he had seen the resident up walking after that night. He stated, I was on leave after that, I don't know if I worked with her again. The APS office was then contacted and the telephone number of the family member listed as seeing the resident on 12/19/2016 was obtained. The family member was contacted on 04/05/2017 at approximately 12:00 noon. She was asked about her visit on 12/19/2016 with Resident #116. She stated, I got there that evening and her male nurse, he had a bun in his hair and a mole on his face (LPN #6) told me that (name of Resident #116) had fallen in the shower and had messed all over herself and that she was upset I went in the room and (name of Resident #116) said 'Don't touch my leg' .I went out and told the male nurse that I had been talking to .he said she was just upset about the fall .he didn't even come in there .(name of Resident #116) had on a diaper and a pajama top .she kept saying 'Don't touch my leg. I asked the male nurse if she needed to go to the hospital and he said no, she's just upset about the fall .I wish I had called the rescue squad myself .I'll live with that the rest of my life. The telephone number of the CNA (CNA #6) who had given Resident #116 a shower on 12/19/2016 was requested from the DON. The DON brought the information to this surveyor at 12:15 and stated, This is the CNA who bathed the resident on 12/19/2016 .I just talked to her and she said that the resident didn't faint but became weak. She transferred her from the shower chair to the wheelchair and took her to the nurse .she said she didn't lower her to the floor she just moved her from showerchair to wheelchair .that's a change of plane, but I consider that a fall .I didn't get a statement from her or the nurse regarding the incident on 12/19/16 .I was thinking that on December 22 she was having pain .I don't think I was here on December 19 and I wasn't linking the two. (Name of the unit manager (LPN #2)) didn't do an incident report on the shower incident. CNA #6 was contacted by this surveyor at 12:35 p.m. She was asked to walk this surveyor through the events of 12/19/2016. She stated, I noticed she was feeling weak, like she was going to faint .her head went back, I was calling her name but she didn't respond .she looked like she was looking at me but she wasn't talking .she had a small BM .I moved her from the shower chair to the wheelchair, I didn't lower her to the floor. CNA #6 was asked how she transferred the resident. She stated, I stood her up and transferred her. CNA #6 was asked if Resident #116 was responsive at the time of the transfer. She stated, No .I stood her up and transferred her and then I took her to the nurse. We took her to her room and lifted her to the bed. CNA #6 was asked why they lifted the resident at that time. She stated, I don't know we just did and then I left. The unit manager, LPN #2 came to the conference room at approximately 12:45 and stated, I can't find an incident report from the shower incident on 12/19/2016 .I looked in the (name of new system and name of the old system), I cant find it. LPN #2 was asked if the witness statements would still be available if they had been obtained. She stated, Yes, I'll ask (name of DON). Review of the witness statements written on 12/22/2016, the day Resident #116 was sent to the hospital were reviewed. One statement written on 12/22/2016 by CNA #5 contained the following information: I (name) was giving (resident name) a bath yesterday (12/21/2016), so I stood her up to wash her. And I noticed she was not standing too well. SO I put her back in bed. And she started complaining about her leg was hurting, and everytime I tried (sic) to tun her over to change she hollowed (sic) out in pain. So I reported it the (name of LPN #6) the charge nurse. She gave her pain medication. The second time I got her (LPN #6) to come in and checked (sic) her leg out. And she said that she (Resident #116) had been having problems with her leg and that it had already been charted. CNA #6 was interviewed at 1:15 p.m. on 04/05/2017. She was asked if she remembered bathing (name of Resident #116) and her having pain. She stated, Oh yes I remember. I went in to do her bath. When I stood her up beside the bed she wasn't very steady .she couldn't stand at all. She had arthritis but this was very different I went and told (name of LPN #6) about it. She came in the room and stretched out (Name of Resident #116) leg and she hollered out in pain . CNA #6 was asked which leg it was .she stated, Let me see the bed was facing this way and it was the leg to the wall, so it was her right leg .anyway I think (name of the nurse) thought it was her arthritis so she didn't do anything that day .but I came back in the next day (12/22/2016) and she was worse. I told (name of nurse working that day) and she came in and looked at (name of Resident #116} .She (nurse) knew something wasn't right and (name of Resident #116 went to the hospital .her hip was broke .I miss her. LPN #6 was interviewed on 04/05/2016 at 3:45 p.m. She was asked about the above information. She stated The CNA came and told me the resident was having pain .I went in and assessed her. I moved her legs but I don't remember he hollering out in pain .the resident had issues with leg pain I would think I wrote a note about it even if the was nothing out of the ordinary going on she was in the bed, I know I assessed her, including range of motion .it wasn't out of the ordinary for her to have pain everyday. The MAR (medication administration record) was reviewed with LPN #6. It was noted that the pain scale for Resident #116 was coded as 0 everyday, every shift, including 12/21/2016. She stated, The pain scale is in relation to her scheduled dose of [MEDICATION NAME] .if she is having pain we don't chart that .we give her the [MEDICATION NAME] that is scheduled twice a day. If it is effective then we write down a 0 that she isn't having pain because the scheduled dose works. LPN #6 was asked if there would be a note anywhere other than the clinical record as no note had been observed from her on 12/21/2016. She stated, No. The DON was interviewed on 04/05/2017 regarding the above information. She was asked if there were any policies in the facility regarding assessments for a change in resident condition. She stated that if a CNA identified a change they filled out a Stop and Watch Early Warning Tool for the nurse or told her verbally. She stated that since CNA #5 had spoken to LPN #6 directly on 12/21/2016 the form wouldn't have been done. She stated there was no policy regarding assessment for a change in condition of a resident. The DON was asked what her expectation was for assessing Resident #116 following the shower incident on 12/19/2016 and the report to the nurse on 12/21/2016. She stated, I would expect to see a documented complete assessment, including vital signs, and range of motion, and physician notification. The Lippincott Manual of Nursing Practice 10th edition on page 6 defines the nursing process as a deliberate, problem-solving approach to meeting the health care and nursing needs of patients. It involves assessment (data collection), nursing diagnosis, planning, implementation, and evaluation, with subsequent modifications used as feedback mechanisms to promote the resolution of the nursing diagnosis. Page 16 of this reference states, Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Page 17 of this reference states departure from standards of care includes, Failure to monitor or observe a patient's clinical status adequately .Failure to monitor or observe a change in a patient's clinical status .Failure to communicate or document a significant change in a patient's condition to appropriate professional . (1) A meeting was held with the DON and the administrator at approximately 4:00 p.m. on 04/05/2017. The conversation with LPN #6 was discussed with the DON and the DON was asked if the information regarding how the pain scale was coded was correct. The DON stated, There will be inservicing on that .they shouldn't write a zero if the resident is having pain .that will not be an option when we change to (name of computer system). The survey team voiced concerns of possible harm due to the lack of assessment done by the nursing staff for the shower incident on 12/19/2016 and CNA's report to the nurse on 12/21/2016 of Resident #116 having increased pain. Resident #116 was not thoroughly assessed until 12/22/2016 at which time it was determined that the resident should be sent to the emergency room . She was diagnosed with [REDACTED]. No further information was obtained from the facility staff prior to the exit conference on 04/05/2017. This is a complaint deficiency. (1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014.

Based on staff interview, clinical record review and facility document review, the facility staff failed to notify the physician in a significant change of condition for one of 5 residents in the survey sample (Resident # 2), which resulted in harm. The facility staff failed to notify the physician of a significant physical and mental status change for Resident # 2; the resident was sent to a regularly scheduled infusion appointment, arrived at the appointment essentially unresponsive, where life saving measures were implemented. The resident was then taken to the emergency department and later admitted to the MICU (medical intensive care unit); the resident subsequently expired two days later. Findings include: Resident # 2 was admitted to the facility originally on [DATE], with the most current readmission on [DATE]. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. The resident was also assessed as requiring extensive to total assistance from at one to two staff members for most ADL's (activities of daily living). An admission MDS assessment, dated [DATE] was reviewed for comparison. This MDS assessed the resident as having a cognitive score of 14, again indicating the resident was cognitively intact. The resident triggered in the CAAS (care area assessment summary) section of this MDS for, but not limited to: ADL's and urinary. During a complaint investigation on [DATE], Resident # 2's closed clinical record was reviewed. Resident was originally admitted to the facility on [DATE]. The resident was discharged from the facility and admitted to the hospital on [DATE] for [MEDICAL CONDITION] and relative [MEDICAL CONDITION]. The resident was readmitted back to the long term care facility on [DATE]. A BIMS (brief interview for mental status) form dated [DATE], documented that the resident had a cognitive score of 15, indicating the resident was cognitively intact in decision making skills. Nursing notes were reviewed. A nursing note dated [DATE] and timed 8:45 a.m. documented, Resident noted to have an altered mental status change. Resident slow to respond and lethargic. Resident was able to follow some commands very slowly. This nurse spoke with (name of person) (identified as O (Other) # 2) at (initials of infusion center) in relation to resident condition. O#2 will make infusion center aware. Resident out of facility at 8:40 a.m. via priority in poor condition .signature of LPN (Licensed Practical Nurse) # 3. No information was found in the nursing notes and/or in the clinical record to indicate that LPN # 3 had notified the physician of Resident # 2's significant change in condition. No vital signs documented, no assessment information for the resident and no evidence of notification were found in the clinical record. Resident # 2's physician's orders were then reviewed, no physician's orders were found during this time frame. One physician's progress note was found, dated [DATE]. No other information regarding Resident # 2's significant mental status change on the morning of [DATE] could be found. The hospital discharge summary dated [DATE] (the date the resident expired at the hospital), documented, .per (name of long term care facility) where she lives, she went to bed last night in her normal state of health. This morning on awakening she was found to be lethargic and following commands, but doing so slowly .Septic shock ,[DATE] (secondary to) GNR (gram-negative rod) bacteremia . LPN # 3 was interviewed on [DATE] at 2:40 p.m. regarding Resident # 2 and her condition on [DATE]. LPN # 3 stated that the resident had appointments with the infusion center every other day and she had an appointment that morning (Friday February 17, 2017). The LPN further stated that she had came in that morning and got report from the night shift nurse (LPN # 5), the night shift nurse told her (LPN # 3) that the resident was slow to respond and lethargic and had asked LPN # 3 to go assess the resident. The LPN stated that she went to the room and checked on the resident and confirmed that the resident had a mental status change from her normal self and was slow to respond and lethargic. The LPN stated that the resident was not able to give any details or anything specific, basically yes no answers to questions, but was very slow. The LPN stated that this was not Resident # 2's usual self, because she could normally converse and let you know what was going on with her, she was able to make her needs known. The LPN was asked if she got a set of vital signs on the resident. The LPN stated, I didn't put them in my note, but I'm sure I did. The LPN was asked, where would those be documented. The LPN stated again that she did not document them in her note. The LPN stated that she probably just had them written down on a piece of paper. The LPN was asked if the vital signs were normal or abnormal. LPN # 3 stated that she could not remember. LPN # 3 was asked if the night nurse assessed the resident. LPN # 3 stated that she did not know if the night shift nurse assessed the resident. LPN #3 was asked if she notified the physician. The LPN stated that she did not, the night shift nurse had notified the NP and that the NP was there at the facility that day and the NP said it was ok for her (resident) to go to her appointment, it was early in the morning. The LPN stated that the NP was aware before she (LPN # 3) had even got to the facility and didn't know if the nurse had assessed the resident or not. The LPN stated that there is a 24 hours report book and she was not sure what was in the book for that day. The LPN again stated that the night shift nurse spoke with the NP. LPN #3 was again asked why the resident was sent to the infusion center and not to the emergency room without physician notification. The LPN stated that the resident had an appointment that morning and that she called O (other) #2 at the infusion center and told O#2 to inform the infusion center of the resident's condition, so they would know when the resident arrived. The LPN was asked what O#2's last name was. The LPN did not know. The LPN was asked of O#2's title, was the person a medical professional or an operator. LPN # 3 stated that she did not know, she did not get the last name or the person's title. LPN # 3 was again asked why she sent the resident to the infusion center instead of the emergency room . LPN # 3 stated, The NP told me it was ok (for resident) to go to the appointment. The LPN was asked if an order was received for that. The LPN stated that she did not know. The LPN was asked if the NP wrote a note. The LPN stated again that she did not know. The LPN was asked who was the NP that told her to send the resident to the infusion center appointment and the LPN identified the NP as NP # 1. The LPN was asked what time did she speak with NP #1. The LPN stated that she didn't remember. LPN # 3 was asked if the transporters taking Resident # 2 to her appointment seemed concerned in the resident's condition. The LPN stated that they didn't seem concerned and if they did they did not express that to her. LPN # 3 stated that at approximately 11:00 a.m. that morning she got a call from the infusion center (individual was not identified) and they (infusion center) had asked who the LPN had spoke with that morning and the LPN told them O#2 and further stated that she (woman at infusion center) acted as though she did not know who O#2 was. The LPN was asked if she obtained a blood sugar reading on Resident # 2. LPN # 3 stated that she did not and stated that the resident was not listed as a diabetic for us (the facility). The LPN was informed that the resident had a [DIAGNOSES REDACTED]. NP #1 was interviewed on [DATE] at 8:20 a.m. The NP stated that he had only seen the resident 2 or 3 times while she was here at the facility and further stated twice in January and once in February that the resident was actually seen by the NP. The NP stated that he last seen this resident on [DATE] and wrote a progress note at that time. The NP stated that he did not see the resident on [DATE], that the resident was already gone to the appointment when he arrived at the facility and he had not received any calls from the facility with concerns regarding Resident # 2 at anytime. The NP was asked if he was made aware of any concerns regarding Resident # 2, once he arrived at the facility that morning. The NP stated, No, I did not. The NP stated that I would have had a note if I had seen her and I had a list of 15 patients to see that day and she wasn't on the list, so I didn't see her, as far as I knew she went out to her regular appointment as usual, no concerns. The NP stated there is a communication book if a resident has issues, they should have documented that she was altered. The NP stated that he received no notification that anything was wrong on the 17th or he would have seen her and based on that assessment triaged with the physician if needed. The NP stated that the staff call me first and if needed, he (NP) will call the physician. The NP was asked if had spoke with LPN # 3 that morning and told her (LPN # 3) to go ahead and send the resident to the infusion appointment. The NP stated, I have no recollection of that, I would have remembered that. The NP stated that he was unaware that any of this was going on. The NP stated that it would have been appropriate for staff to notify me (NP) and further stated, I can't treat what I don't know. An attempt to contact the night shift nurse (LPN # 5) for interview was made several times without success. The infusion center was contacted on [DATE] at 9:20 a.m. in an attempt to identify O#2. O#2 was found to be an operator for the infusion center. O#2 stated that all calls come through the call center and if immediate assistance is needed the physician is paged for the person calling. O#2 stated that he recalled LPN # 3 calling that morning an informing him of the resident being lethargic and not her normal state. O#2 stated that LPN # 3 had called approximately 8:30 a.m. and he entered the information into an email, while on the phone with LPN # 3 and sent that information to the infusion center. O#2 gave his title as an access associate, not a medical professional. O#2 stated that he did not know what the turn around was on emails, as far as how long it would take for someone to check that email and that it could essentially still be sitting there. O#2 could not provide an exact time when the email was sent, but estimated it to be at approximately 8:35 a.m. The 24 hour report book was reviewed on [DATE] at 12:50 p.m. The book documented an entry by LPN # 3 on [DATE] for 'dayshift', which documented the resident was with AMS, lethargic and slow to respond and that the resident had an appointment at the infusion center at 9:15 a.m. that morning and that O # 2 had been called and given a message on the resident's condition. The 24 hour report book had an area to check if the physician and/or family were notified, neither were marked to evidence that the anyone was notified of Resident # 2's change in condition. The DON (director of nursing) was asked for a policy on physician notification and the SBAR (situation/background/appearance/review and notify) form used by nurses on [DATE]. A policy titled, Change in Condition was presented and reviewed and documented, .to maintain the resident's safety, a resident's change in condition will be collected and reported in a timely manner .when a change in condition occurs, the nurse shall collect and document/report the following baseline information as needed: .vital signs .neurological status .level of consciousness .cognitive and emotional status .onset, duration, severity .all active [DIAGNOSES REDACTED].the nurse will contact the physician about a significant change in condition . The SBAR form documents, .Before calling the physician/NP/PA(physician's assistant)/other health care professional: Evaluate the resident: Complete relevant aspects of the SBAR form below Check Vital Signs: BP, pulse and/or apical heart rate, temperature, respiratory rate, O2 saturation, and finger stick glucose for diabetics; Review record: Recent progress notes, labs, medications, other orders; .have relevant information available when reporting . The remainder of the form had areas for detailed information to be filled in or checked off and included, but was not limited to: symptoms, diagnoses, mental status evaluation, functional status, behavior status, respiratory status, cardiovascular status, abdominal/GI evaluation, urinary, skin, pain, and neurological status. This type of form could not be located for Resident # 2. The DON and administrator were made aware of the serious concerns regarding Resident # 2's change of condition, without physician notification. The DON agreed with concerns regarding the physician not being notified. No evidence could be located or presented to evidence that Resident # 2's physician was notified and/or made aware of the resident's condition, as a result the resident was transported to a routine visit, where the resident was found essentially unresponsive, where life saving measures were initiated, the resident subsequently expired two days later at the MICU (medical intensive care unit) at the hospital. This is a complaint deficiency.

Based on staff interview, family interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow professional standards of nursing for one of 16 residents, Resident #116. The facility staff failed to thoroughly assess Resident #116 following a period of weakness during a shower on December 19, 2016. Facility documentation and staff interviews differed on what actually occurred in the shower room. Per facility documentation, Resident #116 was lowered to the floor during her shower. Per staff interview, the resident became weak and unresponsive and was transferred from the shower chair to the wheelchair and then taken to the nurse. Per a family interview, Resident #116 repeatedly stated Don't touch my leg during a visit on the evening (Following her shower) of December 19, 2016, which was reported to the nursing staff. The nurse's notes from December 19, 2016, recorded Resident #116 complaining of hurting all over and receiving medication for pain. An assessment including range of motion was not done. Per facility documentation and staff (CNA-certified nursing assistant) interview, Resident #116 complained of pain upon movement on December 21, 2016 and was unable to stand. This was reported to the staff nurse. The nurse did not document an assessment for Resident #116 on 12/21/2016. On December 22, 2016, the same CNA cared for Resident #116 and stated the pain was worse for the resident and she reported it to a different staff nurse. Resident #116 was assessed and sent to a local hospital. She was diagnosed with [REDACTED]. The facility staff failed to assess Resident #116 for a significant change in condition with resulting harm. This is a complaint deficiency. Findings were: Resident #116 was added to the survey sample as a closed record in response to a complaint investigation. The facility had submitted an FRI (facility reported incident) to both the OLC (Office of Licensure and Certification) and APS (Adult Protective Services). The FRI included information that on the morning of 12/22/2016, Resident #116 was found to have pain with movement to her right leg/hip. She was sent out to the local hospital where a right [MEDICAL CONDITION] was diagnosed . The facility determined that the resident transferred herself and fell without staff being aware. There was no evidence of abuse or neglect. On 03/08/2017 additional information was reported to the APS office and subsequently submitted to OLC. The additional information was submitted by a family member via a complaint portal for APS. The additional information included the following: (Name of Resident #116) fell at (name of facility) and later passed away. On December 19th 2016 around 5:00pm or 5:30 pm my grandmother (Name) (88) fell while taking a shower unassisted at (facility name and address). Personnel had cleaned her up from the fall when my cousin arrived (cousin name) and placed her back in bed. It was a male nurse or aid and she was his patient for the night. My cousin asked if she should go to the hospital, he stated 'No she was just shaken up. My grandmother was complaining about her hip. After several days laying in bed and pain, she was finally transported to (hospital) .my grandmother had fractured her right hip .she had surgery to repair her hip .she passed away on 29 [DATE] (12/29/2016) due to complications from Pneumonia, [MEDICAL CONDITION] and Ground level fall per her death certificate. The additional information submitted to APS via the portal was submitted to OLC and the complaint was generated. Resident #116 was originally admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) with an assessment reference date of 11/25/2016, assessed Resident #116 as having a cognitive summary score of 02, indicating severe impairment with her cognitive status. Section G, Functional Status, assessed Resident #116 as a 3/3 (Physical help in part of bathing activity/Two + persons physical assist) for bathing (G0120). The clinical record was reviewed on 04/05/2016 beginning at 9:15 a.m. The nurse's note section was reviewed. On 12/19/2016 the following notes were written: 2 pm Resident had moderate amount yellowish liquid vomit this afternoon, X (times) 1 occurrence. Bowel sounds presents (sic), abdomen soft nondistended. Ate lunch w/o (without) difficulty. Large BM (bowel movement) yesterday. 1630 (4:30 p.m.) Resident taken to shower. Staff member reported that resident became weak after shower and bowel movement on floor. Resident became unresponsive with foaming sputum from mouth. Resident taken to room and layed down in bed, Resident become (sic) responsive and talking- V.S. (vital signs) T 97.1 p 65 Resp 24 B/p 106/84. Resident had vomiting on previous shift and vital signs normal. Appetite good @ this time. + (positive) bowel sounds in all 4 quads. 1800 (6:00 p.m.) Resident had projectile vomiting X 1 with yellow bile and particles of food. No further vomiting @ this time. Resident given medications and is resting at this time. Medicated X 2 for pain this evening as resident stated she was hurting all over. Also observed in the nurse's note section was an SBAR (Situation, Background ,Appearance, Review and Notify) form dated 12/19/2016. The form was divided into sections and questions were available for staff to answer. The unit manager of the floor where Resident #116 resided, LPN (licensed practical nurse) # 2 completed the form. Questions determined to be applicable to the situation are listed below with the staff answers underlined: SITUATION The change in condition, symptoms, or signs observed and evaluated is/are n/v (nausea/vomiting), Fall This started on 12/19/16 This condition, Symptom or sign has occurred before: No (checked as the answer) Other relevant information Lowered to floor while in shower with staff BACKGROUND Primary [DIAGNOSES REDACTED]. Allergies and vital signs were also recorded. Resident Evaluation Mental Status Evaluation (compared to baseline; check all changes that you observe) No change was checked. Functional Status (compared to baseline; check all changes that you observe) Falls (one or more) Weakness (general) were checked. Behavioral Evaluation No changes observed was checked. Respiratory Evaluation No changes observed was checked. Cardiovascular Evaluation No changes observed was checked. Abdominal/GI Evaluation date of last BM 12/19/16 GU/Urine Evaluation No changes observed was checked. Skin Evaluation No changes observed was checked. Pain Evaluation: Not clinically applicable to the change in condition being reported was checked. Does the Resident have pain? No was checked. Neurological Evaluation No changes observed was checked. APPEARANCE Summarize your observations and evaluation N/V Weakness Lowered to Floor by staff in shower room REVIEW AND NOTIFY Primary Care Clinical Notified (Physician Name) Date 12/19/16 Time 6pm Nursing Notes (for additional information on the Change in Condition) Resident had episode of N/V. Was in the shower room became weak staff lowered her to the floor, Resident taken to her room Given a cup of water. Resident became responsive and is at her baseline. The CNA documentation in the clinical record regarding ADL (activities of daily living) care was reviewed. On 12/19/2016 Resident #116 was coded: D SH 1, meaning shower, Dependent, and one person help which was not consistent with the MDS assessment of 3/3 (Physical help in part of bathing activity/Two + persons physical assist). The medication administration record for 12/19/2016 was reviewed. Resident #116 had orders for [MEDICATION NAME] Tablet 5-325 Give 1 tablet by mouth two times a day related to PAIN, UNSPECIFIED .and Give 1 tablet by mouth every 6 hours as needed for pain. Resident #116 received a PRN (as needed dose) dose of [MEDICATION NAME] on 12/19/2016 at 4:00 p.m., There was not an assessment of the pain scale or pain level was documented on the MAR or the nurse's notes for the PRN administration. The nurse's entry on the back of the MAR was 12/19/2016 1600 (4:00 p.m.) [MEDICATION NAME] 5/325 po (by mouth) all over pain' and the nurse's initials. Resident #116 also received her regularly scheduled dose of [MEDICATION NAME] at 2100 (9:00 p.m.). Other pain medication for Resident #116 was a scheduled dose of Tylenol Tablet 325 mg, Give 2 tablet (650 mg), by mouth two times a day related to PAIN, Unspecified . Resident #116 also received the scheduled Tylenol at 1700 (5:00 p.m.) on 12/19/2016. The MAR contained a question Is this resident in pain? 0 = No Pain; 1-3 = mild; 4-6 = Moderate; 7-10 = Severe every shift Follow MD orders Pain levels for Resident #116 were documented as 0 every day and every shift. Additional Nurse's notes reviewed in the clinical record listed by date were: 12/20/2016 0630 (6:30 a.m.) No vomiting this shift. Resident at baseline. Res rested comfortably during night. No c/o (complaints of) pain or discomfort @ this time. + bowel sounds all 4 quads. Took a.m. med without difficulty. 12/21/2016 0600 (6:00 a.m.) Res vomited X 1 yellow bile with loose stools X 2. Bowel sounds all 4 quads . 12/22/2016 0630 Res with no vomiting (sic) or stools this shift. Rested comfortably with eyes closed. No s/s (signs symptoms) of pain or discomfort. 0830 (8:30 a.m.) Resident in bed, assisted to sitting position to eat breakfast, resident attempted to eat but vomited (sic) small amount of yellow liquid. Attempted to drink water and vomited (sic) a moderate amount of brownish liquid. Poor skin turgor & dry lips noted. Skin color pale. Responds to verbal & tactile stimuli. Notified NP, received order to give [MEDICATION NAME] (antinausea medication) 25 mg/1 ml, give 1 ml IM (intramuscularly) X 1 dose now. Injection given without difficulty. Appears to be in pain with movement will attempt po (by mouth) pain medications as ordered. Abdomen soft, nondistended. Appears to be in pain with movement/rotation of right leg and hip. NP (nurse practitioner) notified and will come see resident . Orders were obtained for mobile xrays for bilateral hips, pelvis and right leg but were canceled as resident was sent to the emergency room where she was subsequently admitted for a right [MEDICAL CONDITION]. The facility investigation/information regarding the above was requested and received. Included in the information was an INVESTIGATION ACTION PLAN. Information contained included but was not limited to: PROBLEM REPORTED: Staff observed resident with change in behavior and pain to Right leg/pelvis when touched. What actually occurred? resident was observed making facial grimaces when being positioned in bed. How did the event likely occur? Resident was lowered to floor on 12/19/16 by staff. Also gets OOB (out of bed) unassisted ambulates without assist. Why did the event occur? Resident became weak while in shower lowered to floor by staff. OOB unassisted ambulates without assist. Resident sent to ER. Included in the facility investigation were interviews with staff who cared for Resident #116 on 12/20-22/2016. There were no interviews with the nurse who cared for Resident #116 after she was lowered to the floor in the shower room or the CNA who had given her the shower on 12/19/2016. This surveyor contacted LPN #6 via telephone on 04/05/2017 at 11:20 a.m. LPN #6 had cared for Resident #116 on 12/19/2016 following the shower incident. He was asked to walk this surveyor through the events of the evening. He stated that Resident #116 had a vagal nerve response in the shower. He was asked if the CNA had told him that the resident had been lowered to the floor. He stated, I don't remember being told she was lowered to the floor .the CNA said she just went out, like she fainted and had a BM .I made a note. He was asked to describe what he saw when the resident was brought out of the shower room. He stated, She was pale, she wasn't walking, she was in the shower chair, she was awake.LPN #6 was asked if he remembered speaking with Resident #116's family that evening and saying the resident was Shaken up. He stated, I didn't say shaken up, I told them that she had a vagal nerve response and fainted in the shower. He stated that he did not remember who the CNA was that had given Resident #116 a shower that night. He also stated that Resident #116 did not get out of the bed anymore that night, but they did sit her up for dinner. He was asked if he had seen the resident up walking after that night. He stated, I was on leave after that, I don't know if I worked with her again. The APS office was then contacted and the telephone number of the family member listed as seeing the resident on 12/19/2016 was obtained. The family member was contacted on 04/05/2017 at approximately 12:00 noon. She was asked about her visit on 12/19/2016 with Resident #116. She stated, I got there that evening and her male nurse, he had a bun in his hair and a mole on his face (LPN #6) told me that (name of Resident #116) had fallen in the shower and had messed all over herself and that she was upset I went in the room and (name of Resident #116) said 'Don't touch my leg' .I went out and told the male nurse that I had been talking to .he said she was just upset about the fall .he didn't even come in there .(name of Resident #116) had on a diaper and a pajama top .she kept saying 'Don't touch my leg. I asked the male nurse if she needed to go to the hospital and he said no, she's just upset about the fall .I wish I had called the rescue squad myself .I'll live with that the rest of my life. The telephone number of the CNA (CNA #6) who had given Resident #116 a shower on 12/19/2016 was requested from the DON. The DON brought the information to this surveyor at 12:15 and stated, This is the CNA who bathed the resident on 12/19/2016 .I just talked to her and she said that the resident didn't faint but became weak. She transferred her from the shower chair to the wheelchair and took her to the nurse .she said she didn't lower her to the floor she just moved her from showerchair to wheelchair .that's a change of plane, but I consider that a fall .I didn't get a statement from her or the nurse regarding the incident on 12/19/16 .I was thinking that on December 22 she was having pain .I don't think I was here on December 19 and I wasn't linking the two. (Name of the unit manager (LPN #2)) didn't do an incident report on the shower incident. CNA #6 was contacted by this surveyor at 12:35 p.m. She was asked to walk this surveyor through the events of 12/19/2016. She stated, I noticed she was feeling weak, like she was going to faint .her head went back, I was calling her name but she didn't respond .she looked like she was looking at me but she wasn't talking .she had a small BM .I moved her from the shower chair to the wheelchair, I didn't lower her to the floor. CNA #6 was asked how she transferred the resident. She stated, I stood her up and transferred her. CNA #6 was asked if Resident #116 was responsive at the time of the transfer. She stated, No .I stood her up and transferred her and then I took her to the nurse. We took her to her room and lifted her to the bed. CNA #6 was asked why they lifted the resident at that time. She stated, I don't know we just did and then I left. The unit manager, LPN #2 came to the conference room at approximately 12:45 and stated, I can't find an incident report from the shower incident on 12/19/2016 .I looked in the (name of new system and name of the old system), I cant find it. LPN #2 was asked if the witness statements would still be available if they had been obtained. She stated, Yes, I'll ask (name of DON). Review of the witness statements written on 12/22/2016, the day Resident #116 was sent to the hospital were reviewed. One statement written on 12/22/2016 by CNA #5 contained the following information: I (name) was giving (resident name) a bath yesterday (12/21/2016), so I stood her up to wash her. And I noticed she was not standing too well. SO I put her back in bed. And she started complaining about her leg was hurting, and everytime I tried (sic) to tun her over to change she hollowed (sic) out in pain. So I reported it the (name of LPN #6) the charge nurse. She gave her pain medication. The second time I got her (LPN #6) to come in and checked (sic) her leg out. And she said that she (Resident #116) had been having problems with her leg and that it had already been charted. CNA #6 was interviewed at 1:15 p.m. on 04/05/2017. She was asked if she remembered bathing (name of Resident #116) and her having pain. She stated, Oh yes I remember. I went in to do her bath. When I stood her up beside the bed she wasn't very steady .she couldn't stand at all. She had arthritis but this was very different I went and told (name of LPN #6) about it. She came in the room and stretched out (Name of Resident #116) leg and she hollered out in pain . CNA #6 was asked which leg it was .she stated, Let me see the bed was facing this way and it was the leg to the wall, so it was her right leg .anyway I think (name of the nurse) thought it was her arthritis so she didn't do anything that day .but I came back in the next day (12/22/2016) and she was worse. I told (name of nurse working that day) and she came in and looked at (name of Resident #116} .She (nurse) knew something wasn't right and (name of Resident #116 went to the hospital .her hip was broke .I miss her. LPN #6 was interviewed on 04/05/2016 at 3:45 p.m. She was asked about the above information. She stated The CNA came and told me the resident was having pain .I went in and assessed her. I moved her legs but I don't remember he hollering out in pain .the resident had issues with leg pain I would think I wrote a note about it even if the was nothing out of the ordinary going on she was in the bed, I know I assessed her, including range of motion .it wasn't out of the ordinary for her to have pain everyday. The MAR (medication administration record) was reviewed with LPN #6. It was noted that the pain scale for Resident #116 was coded as 0 everyday, every shift, including 12/21/2016. She stated, The pain scale is in relation to her scheduled dose of [MEDICATION NAME] .if she is having pain we don't chart that .we give her the [MEDICATION NAME] that is scheduled twice a day. If it is effective then we write down a 0 that she isn't having pain because the scheduled dose works. LPN #6 was asked if there would be a note anywhere other than the clinical record as no note had been observed from her on 12/21/2016. She stated, No. The DON was interviewed on 04/05/2017 regarding the above information. She was asked if there were any policies in the facility regarding assessments for a change in resident condition. She stated that if a CNA identified a change they filled out a Stop and Watch Early Warning Tool for the nurse or told her verbally. She stated that since CNA #5 had spoken to LPN #6 directly on 12/21/2016 the form wouldn't have been done. She stated there was no policy regarding assessment for a change in condition of a resident. The DON was asked what her expectation was for assessing Resident #116 following the shower incident on 12/19/2016 and the report to the nurse on 12/21/2016. She stated, I would expect to see a documented complete assessment, including vital signs, and range of motion, and physician notification. The Lippincott Manual of Nursing Practice 10th edition on page 6 defines the nursing process as a deliberate, problem-solving approach to meeting the health care and nursing needs of patients. It involves assessment (data collection), nursing diagnosis, planning, implementation, and evaluation, with subsequent modifications used as feedback mechanisms to promote the resolution of the nursing diagnosis. Page 16 of this reference states, Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Page 17 of this reference states departure from standards of care includes, Failure to monitor or observe a patient's clinical status adequately .Failure to monitor or observe a change in a patient's clinical status .Failure to communicate or document a significant change in a patient's condition to appropriate professional . (1) A meeting was held with the DON and the administrator at approximately 4:00 p.m. on 04/05/2017. The conversation with LPN #6 was discussed with the DON and the DON was asked if the information regarding how the pain scale was coded was correct. The DON stated, There will be inservicing on that .they shouldn't write a zero if the resident is having pain .that will not be an option when we change to (name of computer system). The survey team voiced concerns of possible harm due to the lack of assessment done by the nursing staff for the shower incident on 12/19/2016 and CNA's report to the nurse on 12/21/2016 of Resident #116 having increased pain. Resident #116 was not thoroughly assessed until 12/22/2016 at which time it was determined that the resident should be sent to the emergency room . She was diagnosed with [REDACTED]. No further information was obtained from the facility staff prior to the exit conference on 04/05/2017. This is a complaint deficiency. (1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014.

Based on staff interview, clinical record review and facility document review, the facility staff failed to complete a thorough assessment and provide necessary care and services to maintain the highest practicable well being for one of 5 residents in the survey sample (Resident # 2), which resulted in harm. The facility staff failed complete a thorough and accurate assessment for Resident # 2 for a significant change in condition, resulting in harm. The resident was found to have a significant change in physical and mental status, was sent to a regularly scheduled infusion appointment, the resident arrived essentially unresponsive, was sent to hospital and subsequently expired two days later. Findings include: Resident # 2 was admitted to the facility originally on [DATE], with the most current readmission on [DATE]. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. The resident was also assessed as requiring extensive to total assistance from at one to two staff members for most ADL's (activities of daily living). An admission MDS assessment, dated [DATE] was reviewed for comparison. This MDS assessed the resident as having a cognitive score of 14, again indicating the resident was cognitively intact. The resident triggered in the CAAS (care area assessment summary) section of this MDS for, but not limited to: ADL's and urinary. During a complaint investigation on [DATE], Resident # 2's closed clinical record was reviewed. Resident # 2 was admitted originally on [DATE] and discharged to the hospital on [DATE] for [MEDICAL CONDITION] and relative [MEDICAL CONDITION]. The resident was readmitted back to the long term care facility on [DATE]. admission orders [REDACTED]. A BIMS (brief interview for mental status) form dated [DATE], documented that the resident had a cognitive score of 15, indicating the resident was cognitively intact in decision making skills. Nursing notes were reviewed. A nursing note dated [DATE] and timed 8:45 a.m. documented, Resident noted to have an altered mental status change. Resident slow to respond and lethargic. Resident was able to follow some commands very slowly. This nurse spoke with (name of person) (identified as O (Other) # 2) at (initials of infusion center) in relation to resident condition. O#2 will make infusion center aware. Resident out of facility at 8:40 a.m. via priority in poor condition .signature of LPN (Licensed Practical Nurse) # 3. No information was found in the nursing notes and/or in the clinical record to indicate that LPN # 3 had notified the physician of Resident # 2's significant change in condition. No vital signs could be located, no assessment information for the resident and no evidence of notification to the physician could be located. Resident # 2's physician's orders were then reviewed, no physician's orders were found during this time frame. One physician's progress note was found, dated [DATE]. No other information regarding Resident # 2's significant mental status change on the morning of [DATE] could be found. Hospital records were obtained and reviewed at this time. The ED (emergency department) records were reviewed. The ED records dated [DATE] and timed 10:04 a.m. (approximately 1 hour and 25 minutes after the resident left the facility) documented, .Altered mental status [DIAGNOSES REDACTED] (low blood sugar) .history of GI bleed .DM who presents to the ED via tx (treatment) [MEDICAL CONDITION] center (medic 5) with complaints of altered mental status and [DIAGNOSES REDACTED]. Per EMS (emergency medical services), (name of resident) arrived at [MEDICAL CONDITION] center today for an infusion and was found lethargic, altered, and semi-unresponsive, with a blood sugar of 16. After receiving 1 amp of D50 ([MEDICATION NAME]) EMS reports that her blood sugar is now 97 and she is more responsive but still lethargic. The patient's last blood pressure was ,[DATE] .unable to perform ROS (review of systems) mental status change .urinalysis .color red .leukocyte esterase large .bacteria many .CT of head .no acute intracranial abnormalities .CT of abdomen .No evidence of hemorrhage .XR (xray) chest .bibasilar atelectasis and small bilateral pleural effusion .could represent pneumonia .ED course: .presenting from infusion center for [DIAGNOSES REDACTED], [MEDICAL CONDITION], AMS (altered mental status). [MEDICAL CONDITION] (high heart rate) .respiratory distress .possible contributing septic shock .The patients treatment in critical care status was because the patient had acute altered mental status, was hypotensive, was hypoxic, was in acute [MEDICAL CONDITION] and was septic. The care provided during this time included providing blood product administration, fluid administration, oxygen therapy and pressor medication . The hospital discharge summary dated [DATE] (the date the resident expired at the hospital), documented, .per (name of long term care facility) where she lives, she went to bed last night ([DATE]) in her normal state of health. This morning ([DATE]) on awakening she was found to be lethargic and following commands, but doing so slowly .Septic shock ,[DATE] (secondary to) GNR (gram-negative rod) bacteremia . LPN # 3 was interviewed on [DATE] at 2:40 p.m. regarding Resident # 2 and her condition on [DATE]. LPN # 3 stated that the resident had appointments with the infusion center every other day and she had an appointment that morning (Friday February 17, 2017). The LPN further stated that she had came in that morning and got report from the night shift nurse (LPN # 5), the night shift nurse told her (LPN # 3) that the resident was slow to respond and lethargic and had asked LPN # 3 to go assess the resident. The LPN stated that she went to the room and checked on the resident and confirmed that the resident had a mental status change from her normal self and was slow to respond and lethargic. The LPN stated that the resident was not able to give any details or anything specific, basically yes no answers to questions, but was very slow. The LPN stated that this was not Resident # 2's usual self, because she could normally converse and let you know what was going on with her, she was able to make her needs known. The LPN was asked if she got a set of vital signs on the resident. The LPN stated, I didn't put them in my note, but I'm sure I did. The LPN was asked, where would those be documented. The LPN stated again that she did not document them in her note. The LPN stated that she probably just had them written down on a piece of paper. The LPN was asked if she remembered whether the vital signs were normal or abnormal. LPN # 3 stated that she could not remember. LPN # 3 was asked if the night nurse(LPN # 5) assessed the resident. LPN # 3 did not know if the night shift nurse assessed or not. The LPN was asked if she notified the physician. The LPN stated that she did not, the night shift nurse had notified the NP and that the NP was there at the facility that day and the NP said it was ok for her (resident) to go to her appointment, it was early in the morning. The LPN stated that the NP was aware before she (LPN # 3) had even got to the facility and did not know if the nurse had assessed the resident or not. The LPN stated that there is a 24 hour report book and she was not sure what was in the book for that day. The LPN again stated that the night shift nurse spoke with the NP. The LPN was again asked why the resident was sent to the infusion center and not to the emergency room without physician notification. The LPN stated that the resident had an appointment that morning and that she called O#2 at the infusion center and told O#2 to inform the infusion center of the resident's condition, so they would know when the resident arrived. The LPN was asked what O#2's last name was. The LPN did not know. The LPN was asked what was O#2's title, was he a medical professional or an operator. LPN # 3 stated that she did not know. LPN # 3 was again asked why she sent the resident to the infusion center instead of the emergency room . LPN # 3 stated, The NP told me it was ok (for resident) to go to the appointment. The LPN was asked if an order was received for that. The LPN stated that she did not know. The LPN was asked if the NP wrote a note. The LPN stated again that she did not know. The LPN was asked who was the NP that told her to send the resident to the infusion center appointment and the LPN identified the NP as NP # 1. The LPN asked what time did she speak with NP #1. The LPN stated that she didn't remember. LPN # 3 was asked if the transporters taking Resident # 2 to her appointment seemed concerned. The LPN stated that they didn't seem concerned and if they did they did not express that to her. LPN # 3 stated that at approximately 11:00 a.m. that morning she got a call from the infusion center and they (infusion center) had asked who the LPN had spoke with that morning and the LPN told them O#2 and further stated that she (woman at infusion center) acted as though she didn't know who O#2 was. The LPN was asked if she obtained a blood sugar reading on Resident # 2. LPN # 3 stated that she did not and stated that the resident was not listed as a diabetic for us. NP #1 was interviewed on [DATE] at 8:20 a.m. The NP stated that he had only seen the resident 2 or 3 times while she was here at the facility and further stated twice in January and once in February. The NP stated that he last seen this resident on [DATE] and wrote a progress note at that time. The NP stated that he did not see the resident on [DATE], that the resident was already gone to the appointment when he arrived at the facility and had not received any calls from the facility with concerns regarding Resident # 2 at anytime. The NP was asked if he was made aware of any concerns once he arrived at the facility that morning. The NP stated, No, I did not. The NP stated that, I'd had a note if I had seen her and I had a list of 15 patients to see that day and she wasn't on the list, so I didn't see her. The NP stated there is a communication book if a resident has issues, they should have documented that she was altered. The NP stated that he received no notification that anything was wrong on the 17th or he would have seen her and based on that assessment triaged with the physician if needed. The NP stated that the staff call me first and if needed, he (NP) will call the physician. The NP was made aware that there was little documentation and no assessment information on the resident such as vital signs. The NP stated, .if she'd had vital signs that would have been good. The NP further stated that an initial set of vital signs determines what you do, they didn't have any. The NP stated that the resident's blood sugars had been running normal and stated that the facility was checking them periodically. No evidence of blood sugar checks could be located for Resident # 2 for this admission ([DATE]) to the facility. The NP stated that the resident's condition would have qualified for an assessment. The NP was asked if had spoke with LPN # 3 that morning and told her to go ahead and send the resident to the infusion appointment. The NP stated, I have no recollection of that, I would have remembered that. The NP stated that he was unaware that any of this was going on. The NP stated that it would have been appropriate for staff to notify me (NP) and further stated, I can't treat what I don't know. The infusion center was contacted on [DATE] at 9:20 a.m. in an attempt to identify O#2. O#2 was found to be call center operator for the infusion center. O#2 stated that all calls come through the call center and if immediate assistance is needed the physician is paged for the person calling. O#2 stated that he recalled LPN # 3 calling that morning an informing him of the resident being lethargic and not her normal state. O#2 stated that LPN # 3 had called approximately 8:30 a.m. and he entered the information into an email, while on the phone with LPN # 3 and sent that information to the infusion center. O#2 gave his title as an access associate, not a medical professional. O#2 stated that he did not know what the turn around was on emails, as far as how long it would take for someone to check that email and that it could essentially still be sitting there. O#2 could not provide an exact time when the email was sent, but estimated it to be at approximately 8:35 a.m. The 24 hour report book was reviewed on [DATE] at 12:50 p.m. The book documented an entry by LPN # 3 on [DATE] for 'dayshift', which documented the resident was with AMS (Altered Mental Status), lethargic and slow to respond and that the resident had an appointment at the infusion center at 9:15 a.m. that morning and that O # 2 had been called and given a message on the resident's condition. The 24 hour report book had an area to check if the physician and/or family were notified, neither were marked to evidence that the anyone was notified of Resident # 2's change in condition. An attempt to contact the night shift nurse (LPN # 5) for interview was made several times without success. CNA # 1 (certified nursing assistant), the CNA that worked the night before the 17th was interviewed and stated that she could not remember clearly, but did not recall the resident being sick or different. The day shift CNA # 2 from the day before ([DATE]) was interviewed and stated that she did not notice anything unusual that the resident was acting normal to her. OS (other staff) # 3, also known as the COTA (certified occupational assistant) was interviewed on [DATE] at 2:20 p.m. The COTA stated that he remembered that day, [DATE] and he had came to work with Resident # 2 around '7:30 ish' and noticed immediately that the resident was not her normal self, closing her eyes, not as coherent, and even when the resident is tired she would normally be conversing and she wasn't that morning. The COTA stated that he went into the hall and looked for Resident # 2's nurse (LPN # 5/night nurse) and could not find her, but did find the night shift nurse for the other hall (identified as LPN # 4). The COTA stated that they both went into the resident's room and did an O2 (oxygen) saturation on the resident and that it was not registering and her heart rate was up between ,[DATE] on the pulse ox. The COTA then stated that he left to go treat another resident and was giving the nurse time to do what she needed to do with the resident and then he returned about 8:00 or 8:15 to attempt to work (therapy) with the resident again. The COTA stated that at about that same time transport was coming to pick the resident up for her infusion appointment and he helped the transporters get the patient onto the stretcher, at that time LPN # 3 and LPN # 4 were in the room at the same time and they were conversing back and forth about whether the resident should go to the emergency room or on to the appointment. The COTA stated that he did not know and did not hear discussion of an assessment being done, of the physician being notified or anything about any other vital signs being obtained, he knew for sure about the pulse ox at approximately 7:35 because he was there with LPN # 4, shortly after 7:30 a.m. Resident # 2's CCP (comprehensive care plan) was reviewed and documented the following, .Full code .my family and staff are made aware of my FULL CODE status the resident will remain free from UTI (urinary tract infection) related to incontinence .assist with bed pan as needed .assist with peri care personal hygiene as needed .Monitor/document for s/sx (signs and symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns The DON (director of nursing) was asked for a policy on physician notification and the SBAR (situation/background/appearance/review and notify) form that nurse's use on [DATE]. A policy titled, Change in Condition was presented and reviewed and documented, .to maintain the resident's safety, a resident's change in condition will be collected and reported in a timely manner .when a change in condition occurs, the nurse shall collect and document/report the following baseline information as needed: .vital signs .neurological status .level of consciousness .cognitive and emotional status .onset, duration, severity .all active [DIAGNOSES REDACTED].the nurse will contact the physician about a significant change in condition . The SBAR form documents, .Before calling the physician/NP/PA(physician's assistant)/other health care professional: Evaluate the resident: Complete relevant aspects of the SBAR form below Check Vital Signs: BP, pulse and/or apical heart rate, temperature, respiratory rate, O2 saturation, and finger stick glucose for diabetics; Review record: Recent progress notes, labs, medications, other orders; .have relevant information available when reporting . The remainder of the form had areas for detailed information to be filled in or checked off and included, but was not limited to: symptoms, diagnoses, mental status evaluation, functional status, behavior status, respiratory status, cardiovascular status, abdominal/GI evaluation, urinary, skin, pain, and neurological status. This type of form could not be located for Resident # 2. A meeting was conducted with the survey team, the DON and administrator on [DATE] at approximately 3:00 p.m. The DON and administrator were made aware of the serious concerns regarding Resident # 2's change of condition and that there was not assessment information for the resident, and the resident's physician was not notified. No evidence could be located or presented to evidence that Resident # 2's physician was notified and/or made aware of the resident's condition, no evidence could be located to evidence any type of assessment was completed on this resident, as a result the resident was transported to a routine visit, where the resident was found essentially unresponsive and several life saving measures were initiated, the resident subsequently expired two days later in the MICU (medical intensive care unit) at the hospital. This is a complaint deficiency.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide footrests for Resident #8 who was known to have hemiparesis (weakness of an entire side of the body). On 4/3/2015, Resident #8 was being pushed in a wheelchair that did not have footrests. Resident #8 ' s foot dropped and as a result, the resident was ejected from her wheelchair and sustained a fractured right arm, fractured left tibia, and a subdural hematoma. This resulted in harm. Resident 8 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The current MDS (minimum data set) was a 30 day assessment dated [DATE], this MDS assessed the resident as having a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. The resident was also assessed as requiring extensive assistance with at least two staff members for bed mobility and as requiring total assistance from staff with at least two staff members for transfers. The resident's functional limitation in motion on this MDS was assessed as impairment on one side for the upper and lower extremity. A quarterly MDS was reviewed for comparison dated 02/09/15 (prior to the incident); this MDS assessed the resident as having a cognitive score of 15, indicating the resident was cognitively intact for daily decision making skills. This MDS also assessed the resident as having requiring extensive assistance from staff, with at least two staff members for transfers. A FRI (facility reported incident) involving Resident # 8 was reviewed on 08/12/15 and 08/13/15. The FRI documented: Resident was being assisted to van by transport to an outside appointment and fell out of wheelchair. Resident sent to emergency room for evaluation. Attached to the FRI was a letter to inform of the investigation, which documented: .the transportation driver.came into the building yelling for help.(name of resident) was face down on pavement.did not lose consciousness after the fall, and was able to maintain conversation while being given emotional support.returned from emergency room with fractured right arm, subarachnoid hemorrhage. On 08/12/15 at approximately 8:00 a.m., the DON (director of nursing) and the administrator were asked for the investigation and any information regarding Resident # 8's fall from the w/c on 04/03/15. At approximately 2:00 p.m., the DON presented a folder and voiced this was additional information regarding Resident # 8. The employee statements documented: On April 3 the driver was bringing (name of Resident # 8) out of the door. He was pushing her forward in her wheelchair. He started going a little faster down the hill with the rain. She put her foot down and she fell . He went back into the building to get help and more people showed up. The other employee statement documented: The driver came to get (name of Resident # 8) to take her to the van, he came back in and said can you help get (name of resident) up. I said what you mean help you (sic). He said she feel (sic) out of the chair. I said what you mean she fell (sic) out of the chair. He said her leg got caught and she fell . (name of resident) was face down at (sic) I maintain Cspine.I put blankets over (resident) because the rain was coming down hard.I went out on 4/6/15 and measure from the end of ramp.appx: 11 feet. On 08/12/15 at 3:55 p.m., the resident was interviewed in her room. The resident was sitting in her w/c with a lift pad under her, two leg rest attached to the w/c with her legs elevated, playing solitaire on her computer. The resident was asked if she could describe what happened the day of the accident on April 3, 2015. The resident stated, I didn't have my leg rest on, I should have-that was my fault. My left leg got caught under the w/c and I fell on my face. I broke my right arm and left leg.oh, yea and that (subarachnoid hemorrhage). The resident was asked if she could put the leg rests on her w/c herself, she voiced, no-nursing would do that. The resident was asked if she realized that the leg rests were not on her w/c when she was going out to the appointment, the resident voiced that she did not think of it until after she fell and that sometimes she forgets. The resident voiced that it was not anyone's fault, but her own because she was the one that forgot and further stated, You learn. The resident was asked if the transport person was pushing her too fast and the resident stated, I don't think so. The resident was asked if she was holding her feet up while the transport person was pushing her and the resident voiced, yes-but I've had a stroke and I am real weak on my left side, my leg must have got weak and dropped. At approximately 4:50 p.m., the DON and administrator were made aware of concerns regarding Resident # 8 and the above information. No further information or documentation was provided prior to the exit conference on 08/13/15 at noon.

The facility staff failed to ensure adequate supervision and assistive devices to prevent accidents for two of 28 residents in the survey sample, Resident #28 and Resident # 3. 1. The facility staff failed to properly transfer Resident # 28, as a result the resident sustained [REDACTED]. 2. Resident #3 did not have the physician ordered pad alarm on his bed or his wheelchair, the facility staff was using a tab alarm instead. The tab alarm that was being used was not properly placed on the bed frame. Findings include: 1. Resident # 28 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) with CAAS (care area assessment summary) was an annual assessment dated [DATE]. This MDS assessed the resident with a cognitive score of "6", which indicated the resident was severely impaired cognitively. The resident was also assessed on this MDS as requiring extensive to total assistance from staff for ADL's (activities of daily living) including bed mobility and transfers. Additionally, the resident was assessed as "not steady, only able to stabilize with staff assistance" for surface-to surface transfers. During a facility reported incident review on 08/28/13 at approximately 2:00 p.m., Resident # 28's clinical record was reviewed. Resident # 28 sustained bilateral (right and left leg) tibia/fibula fractures from an improper transfer on 04/20/13. A nursing note was written on 04/20/13 and timed 5:40 p.m., documented: "...informed that resident was sliding off of bed at time of transfer...Resident assessed for pain/injuries...CNA (certified nursing assistant) stated they then picked resident up off the floor and put her back to bed..." A physician's telephone order dated 04/21/13 (no time stamp) documented: "...X-ray left lower extremity tibia/fibula and ankle..." A physician's telephone order dated 04/21/13 and timed 9:30 a.m. documented: "X-ray Right tibia/fibula and ankle due to swelling and pain..." Resident # 28's bilateral fractures were revealed on X-ray on 04/21/13, which were electronically signed at 12:49 p.m. on 04/21/13. According to Resident # 28's MAR's (medication administration records) the resident was administered Tylenol 650 milligrams once during the month of April 2013. The medication was documented as administered on 04/21/13 prior to being discharged from the facility. The resident was discharged from the facility on 04/21/13 at approximately 1:30 p.m., according to nursing notes and the resident did not return to the facility. Resident # 28 was assessed and identified by facility staff as 'total lift' with the use of a "hoyer lift", that required two staff during transfers. Resident # 28's current POS (physician's orders [REDACTED]...01/03/13 ANC (ancillary) QD (every day) INFO (information) ***********FYI********** HOYER LIFT...." Resident # 28's CCP (comprehensive care plan) was reviewed and documented: "...If resident becomes agitated; take a break from the task and come back in a few minutes and re-offer...assist with positioning, toileting and peri care every 2 hours and as needed...REQUIRES EXTENSIVE TO TOTAL ASSISTANCE WITH ADL'S DUE TO DECREASED MOBILITY, WEAKNESS...HOYER LIFT W/ASSIST OF 2...Assist resident with transfers, bathing, and dressing as needed...EXTENSIVE TO TOTAL ASSIST...OBSERVE FOR SAFE POSITIONING IN BED... Resident # 28's "Daily Care Guide" was reviewed and documented: "...Assist with transfers...HOYER LIFT W/ASSIST OF 2..." Resident # 28 had a "Lift evaluation" completed on 01/19/13, which documented: "...decreased functional mobility/weakness...full lift transfer...total body lift (Hoyer)..." A "Lift evaluation" was also completed on 04/10/13, which documented: "...decreased functional ability/weakness...full lift transfer...total body lift Hoyer..." A CNA (certified nursing assistant) Care Card was reviewed for Resident # 28. The form was filled in with pencil, no date or time was found on the form to indicate when the information was documented. The CNA care card for Resident # 28 documented: "...behavior pattern: appropriate, alert to surroundings, forgetful...Transferring: assist of 2 nsg (nursing) staff, does not walk...Bathing: Lift, total assist 1 for bathing...Dressing: is total assist..." Resident # 28's ADL record was reviewed and documented that the resident required extensive assistance and was dependent upon 2 staff for bed mobility and transfers. Nursing notes were reviewed. A page of nursing notes were observed (front/back). The front page of the nursing notes was a full page of notes, dated from 04/18/13 (timed 9:15 p.m.) through 04/21/13 (timed 1:30 p.m.). The back side of the page had one nursing note (approximately a paragraph long) dated 04/21/13 (no time stamp). No other documentation was on this page of nursing notes. "04/20/13- 2:30 a.m. Remains on abt (antibiotic) -UTI (urinary tract infection) with no adverse effects observed..." "04/21/13-2:00 a.m. Resident on ABTX (antibiotics) r/t (related to) UTI..." "04/21/13- 9:30 a.m. Resident laying in bed, BLE (bilateral lower extremities) raised, BLE appear swollen, left leg with some discoloration, BLE hot to touch. When resident legs are moved resident screams out in pain. Resident states she doesn't know what cause (sic) this. MD (medical doctor) notified...X-ray left lower extremity tibia/fibula and ankle due to to swelling and pain..." At approximately 3:00 p.m., the Medical Records manager was asked for the investigation regarding Resident # 28's improper transfer. The investigation documented: "...On 04/20/13 resident was transferred to bed by staff without use of Hoyer lift. Resident slid off bed with legs crossed and was lowered to the floor by staff. X-ray obtained..." The investigation further documented that the two CNA's involved in the transfer of Resident # 28 were terminated and that the LPN (Licensed Practical Nurse) on duty of the incident was terminated as well. On 08/29/13 at approximately 11:45 a.m., the DON (director of nursing) and the administrator were made aware of the concerns related to the injuries Resident # 28 sustained, in a meeting with the survey team. The DON and administrator were additionally made aware of new findings during the current survey in the area of Quality of Care-Supervision. No further information or documentation was provided prior to the exit conference on 08/29/13. 2. Resident #3 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. His [DIAGNOSES REDACTED]. The most recent MDS (minimum data set was a quarterly assessment with an ARD (assessment reference date) of 06/10/2013. Resident #3 was assessed as having a cognitive summary score of "03" indicating he was severely impaired in his cognitive status. The clinical record was reviewed on 08/27/2013 beginning at 3:00 p.m. and continued throughout the day on 08/28/2013. During review of the clinical record the POS (physician order [REDACTED]." In the nurse's note section an entry dated 05/17/2013 read: "0400 (4:00 a.m.) Staff including myself heard a loud thud. Staff entered res (resident) room and observed res lying on floor in BR (bathroom) on his left side. Res denies hitting head but states, "I hit everything but my head." Res with no c/o (complaints)of pain at this time ..." The care plan was also reviewed. A problem listed was: "Falls: I am at high risk for falls r/t (related to) decline in health condition, recent hospitalization for AmS (altered mental status), [DIAGNOSES REDACTED]. Problem onset: 03/07/2013." Interventions listed for this problem included, but were not limited to: "Lower risk of injury by considering low bed, alarms; and 05/17/2013 Resident to have pad alarm to bed and W/C. Nurse check function and placement QS (every shift.)." On 08/27/2013 from approximately 2:00 p.m. until 3:45 p.m. Resident #3 was observed sitting up in his wheelchair in both his room and in the hallway. A tab alarm was observed attached to the back of his shirt and to the alarm box located on the back of the wheelchair. On 08/28/2013 at approximately 8:30 a.m., Resident #3 was observed lying in supine in his bed. He stated that he had just had breakfast and was "resting." No alarm box was visible on the side of his bed. LPN (licensed practical nurse) #6 was in the hallway passing out morning meds. She was asked who the CNA (certified nursing assistant) taking care of Resident #3 was. She directed this surveyor to CNA #2. CNA #2 accompanied this surveyor to Resident #3's room. She was asked where the pad alarm was for the resident. She felt under Resident #3 and stated, "I don't feel one." CNA #2 was asked if there was an alarm box anywhere on the bed. CNA #2 continued to look. She lifted the pillow under Resident #3's head and stated, "Here it is." CNA #2 was asked what type of alarm was attached to Resident #3 and she stated, "It's a tab alarm...see here it is attached to his shirt." CNA #2 was asked if the alarm boxes were normally placed under the pillows on the beds. She stated. "No, they should be down here on the bed frame...that's where I put them...it would be hard to hear it and he would have to sit up pretty far to activate the alarm like that...the other CNA must have done that." On 08/28/2013 at approximately 9:30 a.m., the MAR and TAR (medication administration record/treatment record) were reviewed for Resident #3. The entry "Pad alarm to bed and W/C at all times-nursing to check placement and function Q (every ) shift" was initialed for all shifts including the day shift for that day. LPN #6 was asked about her initials beside the entry. She stated, "I check to see if there is an alarm...not necessarily what type it is...my objective is to keep him safe. Sometimes the type of alarm gets changed because the old one stops working and it doesn't get communicated." LPN #6 accompanied this surveyor to look at the alarm. LPN #6 was asked about the placement of the alarm box. She stated, "It should be on the bed frame." LPN #6 was asked if the alarm box should be left in the bed under the pillow. She stated, ""No." The DON (director of nursing) and the administrator were notified of the above information during an meeting on 08/28/2013 at approximately 1:45 p.m. No further information was obtained prior to the exit conference on 08/29/2013. THIS IS A COMPLAINT DEFICIENCY.

Based on staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to ensure the prevention of a stage four pressure ulcer for one of 31 residents in the survey sample, Resident #24. The findings include: Resident #24 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/11 was an admission assessment. The resident was assessed as a having short and long-term memory impairments and severely impaired in decision-making skills. Under section G. Functional Status. G0110 Activities of Daily Living (ADL) Assistance: A. Bed mobility, B. Transfers, and G. Dressing, the resident was coded as 4/3 (Total dependence with two person assistance). Under section M. Skin Conditions the following items were marked for the resident: M0150. Risk of Pressure Ulcers. Is this resident at risk of developing pressure ulcers? 1. Yes...M0210. Unhealed Pressure Ulcers. Does this resident have one or more unhealed pressure ulcers at Stage 1 or higher? 1. Yes. M0300. Current number of (non-[MEDICATION NAME]) Unhealed Pressure Ulcers at each stage. A. Number of Stage 1 pressure ulcers (2). Stage 1. Intact skin with non-blanchable redness of a localized area usually over a bony prominence. B. Number of Stage 2 pressure ulcers (1). Stage 2. Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of these Stage 2 pressure ulcers that were present upon admission / entry/reentry (1). Date of oldest Stage 2 pressure ulcer (3/21/11). C. Number of Stage 3 pressure ulcers (0). Stage 3. Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. D. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry (0). Stage 4. Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. E. Number of theses unstageable pressure ulcers that were present upon admission/entry or reentry (0). Unstageable Non-removable dressing: Known but not stageable due to non-removable dressing /device. F. Unstageable-Slough and /or eschar: Known but not stageable due to coverage of a wound bed by slough and /or eschar. Number of theses unstageable pressure ulcers that were present upon admission/entry or reentry (0). G. Unstageable-Deep tissue-Suspected deep tissue injury in evolution. Number of unstageable pressure ulcers with suspected deep tissue injury in evolution (0). Under Section K Swallowing /Nutritional Status. K0200 Height and weight; Height 62 inches and Weight 137 lbs. On 8/2/12 at approximately 8:00 a.m. an admission "Pressure Ulcer Assessment" form was reviewed to include "3/21/11 Skin Integrity Breaks: Pressure areas? Yes. Location: Right heel Stage 1, Longest length 3 Longest width 4.6, Location Left heel Stage 1, Longest length 3.8 Longest width 5.1, Location Coccyx Stage 2, Longest length 2 Longest width 2. The following "Daily /Weekly/ Monthly Body Audit and Hydration Report was reviewed to include: "3/21/11 Skin is warm and dry to touch. Area to coccyx medseptic applied TID (three times a day) 4/1/11 Skin is warm and dry to touch. Area to the coccyx medseptic applied. 4/7/11 Resident has peg tube free from S/S (sign and symptoms) of infection, no new orders. 4/14/11 Skin is warm and dry to touch. 4/19/11 Skin is warm to touch but drsing (dressing) to R (right) hip is intact..." A "Discharge Summary," dated 3/20/11, from the hospital was reviewed in part to include: "Addendum: The patient was kept and extra night as she was thought to possibly be aspirating. Her tubes feed have been decreased slightly from optimum, and she has done well overnight. Unfortunately she has a stage 1 decubitus on her right buttocks. Therefore, we will minimize the amount of time that she is on her right side but maximize her tube feeds when she is in that position. She will get [MEDICATION NAME] one can [MEDICATION NAME] every six, and she should be on her right side for one hour during this time...She remains decubitus and strict aspiration precautions." A care plan dated 3/21/11 was reviewed to include: "Self care deficit: requires staff intervention to total care to maintain... bed mobility...Under approaches it was documented: "Resident required total assistance with bed mobility." For "Skin: High risk skin integrity r/t (related to) decreased mobility...Resident (named) was admitted with a stage 2 to her coccyx, and stage 1 to her left and right heel...Approaches: Sure prep to rt heel Q (every) day WCN (wound care nurse) D/C discontinued 4/12/11...Sure prep to lt heel Q day WCN D/C 4/12/11...Bilateral heel protectors...Skin integrity Risk: High...Monitor skin condition on a weekly basis and daily with bath...Watch for skin tears or reddening of the skin...Ensure that direct care staff are aware of skin risk...Ensure that turning and toileting/peri care is offered and done on a 2 hour rotation at a minimum..."On 4/19/12 the Care plan was updated to include: "R hip stage 4...Approaches: Air overlay mattress..." On 8/2/12 at approximately 8:05 a.m., a nursing note was reviewed in the closed clinical record to include the following: "4/19/11 0600 Resident lyeng (sic) in bed c (with) eyes closed. Peg intact flush well-tolerated [MEDICATION NAME] -total care for ADL's transferring, bed mobility. R (right) hip c (with) skin breakage, reddened area extended around area. WCN (wound care nurse) notified..." Another note was reviewed to include: 4/19/11 0730 Noted R (right) hip unstageable ulceration dark in color c (with) center redness No drainage no odor-MD (physician) aware. See new orders..." The following physician's orders [REDACTED]. (2) Wedge pillows PRN (as needed / necessary) positioning. (3) Sure prep R hip, allow to dry, apply [MEDICATION NAME] c (with) adhesive change qod (every other day). WCN (wound care nurse)...5/3/11 (1) D/C sure prep and [MEDICATION NAME] R hip (2) Cleanse R hip c (with) wound cleanser Apply Santyl Ointment [MEDICATION NAME] Active 2.2 Cover with 4x4 ABD secure with tape QD. WCN (wound care nurse)." On 8/2/12 at approximately 8:30 a.m., the wound care nurse (WCN), who was a licensed practical nurse (LPN) #8 was interviewed regarding Resident #24's pressure ulcer being found at unstageable on 4/19/11. LPN #8 stated, "Yeah, I wrote a note the next morning after I was told. It was an acquired avoidable pressure ulcer. I started the treatment as soon as I was notified." When asked about the assessments of the pressure ulcer, LPN #8 stated, "I have the weekly wound report in my office." When asked about the documentation of the progression of the pressure ulcer after treatment was initiated, LPN # 8 stated, "I have those too." This surveyor accompanied the WCN to her office to review the reports. A copy of the reports were reviewed as follows: 4/19-25 2011, Resident (named)...Date of Onset 4/19/11 9 (ACQ-acquired)...Pressure sore site and staging R hip 2x3 US (unstageable)." The "Weekly Pressure Sore Progress Report was reviewed to include: "4/19/11 R hip 2x3 cm Stage: US (unstageable) Color: dark. Progress: Acquired..." "4/26/11 R hip 2x3 cm US, Color: tan, yellow, dark. Odor: slight, Progress: same..." "5/3/11 R hip 2.4 x 3 x >0.5 cm Stage: 4, Color: tan, red, purple. Odor: slight, drainage: tan. Progress: [MEDICATION NAME]" A "Pressure Ulcer Notification" form to the physician was reviewed. The form was documented by the facility staff informing the physician that the resident had developed a pressure ulcer. There was a section for the physician to fill out after the notification was reviewed to include: "This is considered a Quality Indicator which requires a review by the facility/physician. As the physician, I have reviewed the current treatment plan. My response is as follows: 3 boxes were listed with the following information for the physician to mark, This is an unavoidable pressure ulcer due to (1) [MEDICAL CONDITION] ([MEDICAL CONDITION], (2) DM (diabetes mellitus, (3) Terminal Illness." None of the boxes were marked by the physician as the cause of the pressure ulcer. The physician's signature was noted at the bottom of the form and dated for 4/19/11. On 8/2/12 at approximately 8:45 a.m., the unit manager, LPN #3 was interviewed regarding the resident developing an unstageable pressure ulcer. LPN # 3 stated that the resident was admitted from another facility and that the resident "did not talk." LPN # 3 stated that the resident was a "new peg tube" and came to the facility with skin breakdown but "we got that healed." LPN #3 further stated that the resident was "dependent on staff for turning." LPN #3 was asked if the pressure ulcer was acquired or if the resident was admitted with it. LPN #3 stated, "I can't tell you how it happened, all of our patients are turned and cleaned. It's not something that's normal for us. We do not acquire pressure ulcers here." On 8/2/12 at approximately 9:00 a.m. LPN #8 approached LPN #3 and stated, "This was an acquired pressure ulcer that was avoidable not unavoidable. After it (the pressure ulcer) opened that's when I started [MEDICATION NAME] it." LPN #3 stated, "Oh ok." On 8/2/12 at approximately 10:38 a.m., the administrator, director of nursing and the medical director were made aware of the above findings. The medical director, after receiving clarification of what the survey team was investigating stated, "You said she had a pressure ulcer on on bottom that we were able to heal. So I can see how it happened from her (the resident) being turned from side to side, hip to hip, which made it easy for her to get the pressure ulcer on her hip due to trying to heal the other wounds." On 8/2/12 at approximately 11:55 a.m., the LPN #8, the WCN, was interviewed in the presence of the survey team regarding the staging and the size of the pressure ulcer that was found at unstageable. LPN #8 stated that after the eschar came off, "It was a stage four. I could see the depth of the wound from the side and that's the reason the depth was what it was (>0.5) and it was coded as a stage four." LPN #8 was asked if the resident had bone, muscle or tendon exposed after the eschar came off the wound bed. LPN #8 stated, "Yes, she was emancipated (sic) you could see the bone. Again, I was able to see it by looking from the side of the wound." LPN #8 was asked if she used the Pressure Ulcer Assessment Guide to stage the wound. LPN #8 stated, "We did not have one then but we have one now. I still say looking at it (the pressure ulcer guide) that it was four (the staging of the wound)." LPN #8 further stated, "You see people that get them (pressure ulcers) on their elbows or other boney areas, it doesn't take much to get to the bone because she was so small and hers was on a bony area, I could see the bone."

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to provide adequate supervision and safety interventions to prevent an accident for one of three residents in the survey sample, Resident # 2. Resident # 2 was not provided adequate supervision or safety interventions to prevent the resident from leaving the facility unassisted and acquiring an injury of unknown origin (a fractured left humerus), which resulted in surgical intervention. Findings include: Resident # 2 was admitted to the facility on [DATE]; the most current readmission was on 02/23/11. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set 3.0) quarterly assessment with an ARD (assessment reference date) of 02/02/11 assessed Resident # 2 as having a cognitive summary score of 12, which indicated "moderate impairment." Resident # 2 was also assessed as having a mood severity score of 7, which indicated "mild depression." The resident was also coded as being "unsteady, but able to stabilize without human assistance" for balance, walking (with assistive device, if used), turning around while walking, and toileting. The resident was also coded as using a walker and having lower extremity limitation on one side. This MDS did not assess wandering as a behavior that occurred during the look back period. An annual MDS assessment was observed for comparison with an ARD of 11/12/10. This assessment documented Resident # 2's cognitive summary score as 14 (indicating cognitively intact). The resident was also coded with a mood severity score of 4 (minimal depression). It was also coded that Resident # 2 had a history of [REDACTED]. The CAA (care area assessment) Summary was observed and documented that Resident # 2 triggered for: Cognitive loss/dementia, mood state, and falls. This MDS did not assess wandering as a behavior that occurred during the look back period. Two documents titled, "Risk Assessment Totals" were observed attached to the MDS dated [DATE] and 02/02/11. These document coded Resident # 2 as being a "MED" (medium) risk for falls and elopement. It was alleged through a complaint that Resident # 2 left the facility alone (unassisted) on 02/11/11 and that the resident sustained [REDACTED]. The clinical record was reviewed on 03/22/11 and revealed the following. The POS (physician's orders [REDACTED]. If missing or inoperable, replace bracelet as soon as available. Resident to be monitored q 15 minutes until bracelet in place...PT (physical therapy)...for gait training..." Also included on the POS were the following medications: [REDACTED]. A physician's telephone order written on 01/16/11 was observed and documented: "...Wanderguard applied to right wrist d/t (due to) elopement risk-check-Q (every) shift for placement..." Nursing notes revealed the following: ? 01/13/11-11:00 a.m.-"...continued to keep walking state (sic) I haven't vomited anymore was told a virus was going around and he had to stay on floor until he gets better. Kept going downstairs would not listen states administrator told him he could come downstair (sic)..." ? 01/13/11-3:40 p.m.-"...Resident was told by this writer that he had to stay upstairs because he has flu like symptoms. Resident became...angry & (and) starting to hit at staff and saying that the administrator told him he could have his snacks and go downstairs. This writer told him that he couldn't because he has flu like symptoms...called sister (Resident # 2's RP-responsible party)...(Name of sister/RP) also agreed that resident should stay upstairs and that he acts out like this when he can't have his way...Resident remained angry and got on elevator it took myself and the assist of (4) other staff to get resident off of elevator. Resident calmed down...Staff will continue to monitor residents behaviors..." ? 01/16/11 10:45 a.m.-"Wanderguard applied...d/t (due to) elopement risk..." ? 01/16/11-11:00-"...Res. (resident) non-compliant with wanderguard. Res. removed wanderguard with comb. Sister aware states "he's removed those plenty of times"...Res. yelling..."I can do anything I want to do"...Supervisor made res aware that res can not leave unit alone, must be accompanied by staff..." ? 01/23/11-11:00 a.m.-"Res...feet dragging with walker..." ? 01/23/11-4:00 p.m.-"...unsteady gait..." Nursing notes further documented: ? 01/25/11-5:30 p.m.-"N.O. (new order)...PT (physical therapy)...for gait training..." A physician's orders [REDACTED]. The TAR (treatment administration record) for January 2011 was reviewed. The TAR was signed off for the Wanderguard to wrist, staff to check placement and function with circled initials, which indicates that the treatment/service was not administered/given for some reason. The circled initials were observed from January 16th through January 31st (all three shifts). The back of the TAR was observed (an area used to document explanation/reason a particular treatment wasn't given). It was documented on 01/16 (7-3 shift) that, "Res. removed Wanderguard with comb at 11:30." On 01/17/11 (11-7 shift) it was documented, "Resident removed Wanderguard*refused to have other place." On 01/23/11 (11-7 shift) it was documented, "Resident removed wanderguard*refused to have replaced." On 01/24/11 (11-7 shift) it was documented, "Resident removed & refused to have replaced." It was documented four times (as listed above) that the resident refused to have the Wanderguard reapplied. No further documentation could be located within the clinical record to indicate that staff continued to attempt to reapply. No documentation could be located within the clinical record to indicate that the resident was no longer an elopement risk and no documentation could be located within the clinical record to evidence that other safety interventions were being used or that new interventions had been introduced after the Wanderguard was removed by the resident on 01/16/11 to prevent the resident from a potential elopement. After the physician's orders [REDACTED].# 2. On the morning of 02/11/11, Resident # 2 left the facility unassisted (without staff) through a side door located at the therapy department. The resident left the facility grounds and made his was to Commonwealth Drive (according staff, approximately 0.5 mile away). Two separate staff members observed the resident on the sidewalk (alone). At some point between the time the resident left the facility alone and was brought back by staff, the resident sustained [REDACTED]. This injury subsequently required surgical intervention. The TAR for February 2011 was then observed. The TAR was signed off with initials (not circled), indicating that the Wanderguard was in place and and that staff had checked placement/function each shift from February 11 th through February 23 rd. On the back of the TAR it was documented, "No Wanderguard" on 02/24/11 (11-7 shirt), no reason was provided. On 2/26 (11:00) it was documented, "No Wanderguard", the reason provided was: "Pt (patient) dc'D (discharged )." ? 02/11/11-9:00 a.m.-"Resident with fall this am. Resident stated he fell in doorway and left walker behind. Resident states he got his self up. Staff noted bruising to left arm...Xray order...signature of DON (director of nursing)." ? 02/11/11-1:00 p.m.-"Xray results...humerus fx (fracture)...ortho appt. Wed. 02/16/11 at 9:15...signature of DON." ? 02/11/11-2:00 p.m.-"...hx (history) of falls...stated to DON and administrator I fell by the white door, I fell by the glass door, I was 20 min. from Culpeper when I fell . Resident with unwitnessed fall...signature of DON." ? 02/11/11-3:00 p.m.-"MD (Medical Doctor) into see Resident...signature of DON." ? 02/11/11-10:00 p.m.-"Resident on q 15 min checks...sling...bruising...No attempts to elope. Wanderguard intact and functioning..." physician's orders [REDACTED]. ? 02/11/11 (no time documented): "X-ray of left arm...wanderguard applied check placement..." ? 02/11/11 (no time documented): "Wanderguard to wrist nursing to check Q shift placement..." The physician's progress note dated 02/11/11 documented: "...examined...secondary to fall..."trying to escape"...Alarm sound staff found him and escorted him back to his room...non displaced humeral fracture..." The facility investigation on Resident # 2's fall was requested. The investigation was presented in a folder with a narrative summary that was typed. The summary had a typed signature of the DON and was not dated or timed; three hand written statements (copies), and one typed statement (also a copy) from employees. Also included, was an exam order for the X-ray and the radiology report that showed a displaced humeral neck fracture and a probable radial head fracture of the left arm. The narrative summary by the DON was reviewed, the document was not dated or timed as to when it was documented. The summary documented: "This is investigation concerning (Name of Resident # 2) on 2/11/11. I spoke with LPN (Licensed Practical Nurse) # 2 Unit Manager who informed me that (Name of Resident # 2) was assisted by staff member when he was going out of the door. I spoke with MDS Coordinator who informed me that she picked resident up by apartments. The administrator and myself spoke with resident who stated he fell by the big white door and hurt his arm and then got mad and went out the door and through (sic) his walker. Resident was assessed for pain and injury. MD and family made aware of exit seeking attempt this day. New orders given...Dr...to visit with resident on 02/11/11...noted to have displaced humeral nedck (sic) fracture. We are aware that situations in residents with cognitive impairment in a nursing facility can change rapidly related to [DIAGNOSES REDACTED]. Typed signature of DON." The statements were then reviewed and revealed that: OS (Other staff) # 5 documented (on 02/12/11-no time was documented) that while documenting at the computer, received a call from 1st floor nursing station asking OS # 5 to reset the alarm. OS # 5 walked to door, glanced out of window, did not see anything usual and then reset the alarm, went back to computer. The time detail sheet for OS # 5 was reviewed and revealed that OS # 5 clocked in at 6:55 a.m. the morning of 02/12/11. OS # 6 documented (02/11/11-no time documented) that the door alarm system activated at approximately 8:35 (Therapy door), a call was placed to the therapy dept to check/secure area and deactivate alarm. OS # 6 documented uncertainty as to whether the area was checked or secured because no response was given from therapy. OS # 6 did not check/secure the area (documented in statement), only made the phone call. RN (Registered Nurse) # 1 documented that while driving (into work) she saw Resident # 2 in front of the apartments. RN # 1 drove to the facility, ran in and told receptionist to call for staff assistance. The receptionist responded to RN # 1 that staff were aware and responding. RN # 1 then got back into the vehicle, drove back down Commonwealth Drive and noticed staff already responded...I (RN # 1) pulled up to sidewalk, rolled down window to talk to him. Resident # 2 was trying to hitchhike and asked for a ride to Culpeper. RN # 1 asked the resident to get into the car to go get coat "because it was cold out." The resident got in and RN # 1 took the resident back to facility. Resident # 2 got out and walked with me (RN # 1) and other staff who were returning into the building. CNA (certified nursing assistant) # 1 documented (on 02/11/11-no time was documented) that she was getting out of her car and noticed that Resident # 2 coming out of therapy door. CNA # 1 also documented that she saw a therapist walk by and looked out the door. It was then documented that CNA # 1 asked Resident # 2 where he was going and the resident said Culpeper. CNA # 1 documented that she did not have a cell phone to call, it was in her car and that she continued to watch the resident, not getting too close because he had been cursing and was asked to be left alone. CNA # 1 watched and the resident approached the apartments and she (CNA # 1) waited by the tree as she saw RN # 1 pull up and the resident got in the vehicle with her. Interviews were conducted on 03/23/11 with facility staff regarding Resident # 2's fall and elopement that occurred on 02/11/11. An interview was conducted with OS (other staff) # 4 at approximately 10:20 a.m. regarding Resident # 4 and the events that transpired on 02/11/11. OS # 4 voiced being off work that day, but had came to the facility to meet a friend that also works at the facility. OS # 4 voiced that when leaving the facility grounds, it was noticed that a man was up the street that looked like Resident # 2 and he was hitchhiking. OS # 4 voiced that the car was turned around and went by the man to see to make sure. OS # 4 positively identified Resident # 2 and voiced that he was dirty, his pants and shirt had dirt and mud on them. OS # 4 then voiced turning around again and going to the facility to report this. Once at the facility, OS # 4 reported what had been seen to OS # 3. OS # 4 voiced that OS # 3 reported the information to Unit 3 where Resident # 2 lived. OS # 3 and OS # 4 then left the building and got in a vehicle to go get the resident. OS # 4 verbalized that when they got back to where the resident was, he was gone. OS # 4 voiced that on the way back to the facility they saw RN # 1 waving her arm out of the window "flagging" that she had him (Resident # 2). OS # 4 stated that he was seen getting out of the vehicle once back at the facility. OS # 4 further voiced that the resident was approximately "in the middle just before the intersection." The time detail log for 02/12/11 was observed for OS # 4. OS # 4 was off work this day as described in the interview. OS #3 was interviewed at approximately 10:30 a.m. and corroborated OS # 4's recollections of the events. OS # 3 did add that when the resident got out of the vehicle after being brought back by RN # 1 that the resident looked and acted disoriented and looked dirty (dirt/debris on shirt and pants) and that staff were helping to assist the resident into the building. At approximately 10:35 a.m. RN # 1 was interviewed regarding Resident # 1 leaving the facility and the fall. RN # 1 stated that she was driving into work (was not sure of exact time) and saw Resident # 2, she had already passed him and drove on to the facility to call for additional help. RN # 1 stated that the resident was near the (Name of apartments) apartments on the sidewalk and she went back, put her hazard lights on and pulled up beside him. The RN voiced that she rolled her window down and asked what he was doing. She stated that the resident was trying to hitchhike and told her he was going to Culpeper. The RN went on to say that the resident was wearing a tee shirt (no coat), looked anxious, "he was wanting to go to his sister's." RN # 1 went on to state that he had "goosebumps" and was holding his arm (the RN could not remember which arm). The RN also verbalized she was trying to persuade the resident to get into the vehicle because it was cold and that he needed a coat. The RN then stated that the resident did look dirty and was observed by her to have dirt and leaves on his shirt. The RN voiced that the resident did finally get into the vehicle and she proceed to take him back to the facility, while heading back toward the facility she (RN # 1) saw other staff and RN # 1 said that she flashed her lights and waved to let the other staff know that she had the resident. Once back at the facility, RN # 1 stated that the resident got out of the vehicle him self and that there was approximately 6 staff people outside and the resident was then assisted inside. RN # 1 stated that she did not clock in to work until after she arrived back to the facility with Resident # 2. The time detail sheet for RN # 1 was reviewed and revealed that RN # 1 clocked in at 8:51 a.m. on the morning of 02/12/11. CNA # 1 was interviewed at at 10:45 a.m. on 03/23/11. CNA # 1 was asked for details regarding Resident # 2 leaving the facility on 02/11/11 and his fall. CNA # 1 stated, "The only thing I did was sit with him one to one." CNA # 1 voiced that she could not remember what time she clocked in that morning, but voiced that she tries to get punched in before 8:15 a.m., the CNA voiced that she had already began working that morning and that she couldn't remember the exactly what she was doing, but she stated that she does restorative nursing. CNA # 1 stated that LPN # 2 (unit manager of 3rd floor) came to her and asked her to sit with Resident # 2. The CNA could not remember the exact time, but voiced that it was still early and gave an approximate time of "maybe between 8:30 and 9:00" a.m. The CNA that she was to sit with Resident # 2 to keep him occupied and that she sat with him in his room. The CNA also voiced that he complained of his arm hurting all morning and was "kind of" holding (guarding) it. The CNA stated that it was the resident's left arm (as she was remembering how the resident was lying in the bed and guarding the arm). CNA # 1 stated that when she first encountered the resident that morning, she asked, "What's going on (First Name of Resident # 2)?" She stated that the resident said he was trying to go to Culpeper and that he did tell her that he had fallen. CNA # 1 verbalized that she sat with him from the time the LPN # 2 asked and he complained all day of his arm. The CNA verified that it was the left arm, because when lunch came he was eating with his right hand. CNA # 1 also stated that the resident did have dirt on his shirt and arms, did really notice his pants, and that around lunch time was when the Xray came to look at his arm. The CNA was asked if she had any additional information/details regarding Resident # 2 leaving the facility or falling on 02/12/11, CNA # 1 again stated, "The only thing I did was sit with him one to one." The time detail sheet for CNA # 1 was reviewed and revealed that CNA # 1 clocked in to work at 8:07 a.m., on the morning of 02/11/11. Resident # 2's care plan was then reviewed and documented the following, but not limited to: "...Wandering with Potential for Injury...increase in exit seeking behaviors...replace wanderguard as able, Resident will remain safe, will not wander off unit unattended...Resident will have no falls over the next 90 days. If fall does occur, resident will be injury free (this was documented under the PROBLEM section)...Approaches: Listen to what the resident is saying, Try to divert resident's attention, Leave the resident choices, Provide reality orientation as needed, Use safety devices prn (as needed) as ordered, Do not allow the resident to come off the unit unsupervised, Fall risk assessment and review quarterly, If fall does occur, assess etiology of fall...Assess environment for potential hazards, remove and/or correct...Monitor VS (vital signs) for 24 hours after fall...Check placement of wanderguard QS (every shift) and check function QD (every day). Wanderguard to resident's wrist as ordered. Monitor skin for irritation and make appropriate interventions as needed..." Also, on this page of the care plan was a hand written entry dated 02/11/11 that documented: "Wanderguard to wrist check Q-shift & PRN (as needed) placement & function Resident removes wanderguard often." The care plan also documented: "...Dementia secondary to Brain injury with personality changes and history of agitation and combativeness (Problem area)...Approaches: ...Resident has...poor decision making skills d/t (due to) STM (short term memory) problem and mod (moderate) cog (cognitive) impairment. He requires cues and supervision by staff for daily decision making. Potential for injury secondary to falls d/t (due to) history of falls...dementia with decreased safety awareness and poor impulse control, psychotropic medication use, unsteady gait (Problem area)...Approaches: ...If fall does occur, assess etiology of fall...encourage resident to use recommended assistive devices in ambulating...Observe environment for potential fall hazards-Remove/Correct, Review falls...with interdisciplinary input for safety precautions/recommendations." Resident # 2's clinical records were obtained from the local acute care hospital where the resident received surgical intervention for the fracture to the left arm. The records documented the following: "...Left four-part proximal humerus fracture...hemiarthroplasty of the left proximal humerus...He was trying to escape and was running to the woods, slipped on ice, and fell directly onto his left shoulder..." The facility policy on elopement was then reviewed and documented: "...The care plan will address special needs for the identified "at risk for elopement" resident to help reduce the risk for elopement...Identifying systems may be...Wanderguard bracelet...staff will check each shift to see that each at risk for elopement resident has the wanderguard in place...3. Systems, as allowed by state and local authorities, will be in place to alert staff of attempts to elope (i.e. alarms, Wanderguards, special locks, etc.)...The CNA's (certified nursing assistants) will complete a visual check of residents who have changes in behavior related to exit seeking every 30 minutes and will sign off the resident's ADL (activities of daily living) flow sheet...Visual checks will continue as needed...7. If or when a resident elopes, the missing resident procedure will be implemented. 8. When the missing resident is returned, follow the missing resident return procedure." The DON and administrator were made aware of the above concerns in a meeting with the survey team on 03/23/11 at approximately 2:45 p.m. The DON and administrator were interviewed at this time regarding Resident # 2's fall and elopement from the facility. When asked, why this incident was not reported to the state agency; the DON stated that the statement from CNA # 1 documented that she (the CNA) was with him (Resident # 2) when he left. The administrator stated that, we (the facility) follow the regulations for reporting. The DON and administrator were informed that the copied statement (in the surveyor's possession) of CNA # 1 did not document that the CNA was with the resident, only that he was seen. The DON and administrator were then asked when did staff find out that the resident had left the building. The DON stated that staff found out when RN # 1 brought him back (to the facility). The DON was then asked, what other/new interventions were put in place after the resident took off the wanderguard to ensure the resident was provided adequate supervision to prevent an elopement. The DON stated, "Just monitor by staff." The administrator stated that he could only report what was reported to him. The DON and administrator were then made aware of the concerns of the lack of detailed information regarding this incident in the investigation and the inconsistencies found between the facility's investigation and the interviews conducted by the survey team. The administrator and DON were asked for assistance in providing the survey team with any additional information/documentation, such as the leave of absence log, the wanderguard book, any documented 15 minute checks or any other information that would evidence the facility provided adequate supervision to prevent the elopement and fall with injury of Resident # 2. No additional information or documentation was provided prior to the exit conference on 03/23/11.