Every finding on record at Montgomery Nursing & Rehab CTR

Based on observation, interview and record review, the Facility failed to provide food in a form that meets individual needs for 4 of 4 residents (R6, R52, R7, R56) reviewed for nutritional services in the sample of 26.Findings include: 1-R6's Face Sheet documents R6 was admitted to the facility on [DATE]. R6's 3/30/26 Diet Order documents R6 is on a pureed diet. On 5/5/26 at 7:10 AM, V7, Cook, placed a bowl of regular oatmeal on R6's meal tray. The oatmeal contained visible chunks of oats. 2-R52's Face Sheet documents R52 was admitted to the facility on [DATE]. R52's 4/8/19 Diet Order documents R52 is on a pureed diet. On 5/5/26 at 7:12 AM, V7 placed a bowl of regular oatmeal on R52's meal tray. 3-R7's Face Sheet documents R7 was admitted to the facility on [DATE]. R7's 8/26/25 Diet Order documents R7 is on a pureed diet. On 5/5/26 at 7:18 AM, V7 placed a bowl of regular oatmeal on R7's meal tray 4-R56's Face Sheet documents R56 was admitted to the facility on [DATE]. R56's 4/21/26 Diet Order documents R56 is on a pureed diet. On 5/5/26 at 7:20 AM, V7 placed a bowl of regular oatmeal on R56's tray. On 5/5/26 at 7:23 AM, V7 stated they normally just give regular oatmeal to residents on pureed diets and do not put it through the blender. The Facility's Pureed Breakfast Menu for 5/5/26 documents cereal should be pureed. On 5/7/26 at 1:12 PM, V2, Director of Nursing (DON), stated she expects the Facility to provide pureed foods to residents on pureed diets according to the prescribed menus. The Facility's Undated Pureed Diet Policy documents the pureed diet is for individuals who have trouble chewing or swallowing. All foods are prepared in a food processor or blender. Hot or cold items are processed until a smooth consistency is achieved.

Based on interview and record review the facility failed to ensure one (R1) resident was free of sexual abuse from one (R8) resident reviewed for abuse in the sample of 8. This past non-compliance occurred from 1/9/2026-1/13/2026. Findings include:On 3/23/2026 at 12:41 V3, Assistant Director of Nursing (ADON) stated R1 reported allegation to her spouse and R1's spouse notified the facility. V3 stated she came in to the facility on 1/9/2026 to do a skin assessment. V3 stated R1 had no injuries.On 3/23/2026 at 12:45PM V2 Director of Nursing (DON) stated she got a statement from R1. V2 stated R1 stated she was sitting on side of bed without any pants on. V2 stated R1 stated that R8 entered her room in his wheelchair and touched her privates. V2 stated R1 reported she slapped R8 and he left her room. V2 stated the camera footage was reviewed and R8 was observed entering R1's room in his wheelchair and exiting a short time later. V2 stated R8 was moved to the 400 hall which is a hall where would be more visibility due to more staff passing through V2 stated R8 was placed on a 1:1initially and then phased down to 15 minutes checks. V2 stated this behavior is out of character for R8 and stated he has never been inappropriate with female residents. V2 stated R8 had a urinary tract infection at that time. V2 stated R8 did admit to touching R1 and stated it would never happen again. V2 stated R8 is to be the first one down for bed and the last one up on days. On 3/23/2026 at12:58PM V1, administrator stated he came to the facility for abuse investigation. R1 stated, but felt would be best if V2, DON did the interview. V1 stated felt R1 may be more comfortable talking with a female. V1 stated the video footage was reviewed and did show R8 entering R1's room and exiting short time later. V1stated during interview with R8, R8 admitted he had touched R1. V1 stated the police was notified and did come to the facility. V1, informed surveyor that had interviewed residents and staff as part of investigation.The facility reported incident dated 1/9/2026 documents On 1/9/26 at 18:20 resident, R1's , husband reported to staff nurse that resident had reported an altercation that occurred around 0500 this morning. Admin (Administration) was immediately notified of allegation. Local police department was notified at 1847. MD (medical doctor) was made aware of allegation at 1900. Deputy arrived at facility at 1905 and interviewed resident and husband at that time. Full skin assessment was completed at 1922 and no new skin alterations were noted. Local PD (police department) ombudsman, attending physician and responsible party of allegation of abuse. Administrator, DON, and Deputy reviewed facility camera footage and found resident, R8, entering R1's room at approximately 0500 the morning of 1/9/26. R8 was interviewed by administrator at 1928 and admitted to entering R1'ss room without permission and touching her in the perineum, resulting in her slapping him in the face twice. R1's face sheet, undated documents a discharge date d of 2/12/2026, R1's face sheet documents a diagnosis of Hemiplegia and Hemiparesis following cerebral infarction, affecting Right dominant side, localized edema, iron deficiency anemia, Vitamin D deficiency unspecified, bipolar disorder, unspecified sequelae of nontraumatic intracerebral hemorrhage. R1's care plan dated 12/31/2025 documents R1 requires staff assistance with Activity of Daily Living (ADL) related to her weakness and impaired mobility. R1's Minimum Data Set (MDS) MDS dated [DATE] documents a Behavior Interview of Mental Status a (BIMS) of 10 . With score 8-12 moderately impaired cognition. R1's MDS documents R1 requires partial to moderate assistance-helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort for oral hygiene, toileting hygiene, bathing, dressing and personal hygiene. Eating supervision or touch assisting. R8's undated face sheet documents R8 has a diagnosis of unspecified Dementia moderate, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety, Acute kidney failure.R8's MDS dated [DATE] documents BIMS 3 with severely impaired cognition. R8's MDS documents personal hygiene, toileting hygiene, bathing, and personal hygiene R8 requires substantial /maximal assist -helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Dressing partial to moderate assistance- helper does less than half care Eating supervision or touch assistance. The facility Abuse and Prevention Program dated, revised 9/29/2022 documents abuse is the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm The facility Resident Rights dated revised 8/2022 documents Freedom from abuse and neglect, and exploitation; the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents' medical symptoms'.Prior to the survey dated the facility took the following actions to correct the non-compliance: R1 no longer resides at the facilityEducation on abuse prevention policy with emphasis on residents with sexual behaviors and awareness of at-risk residents provided 1/9/2026.Education on resident supervision policy with emphasis on wandering residents/ residents with sexually inappropriate behaviors and at-risk residents provided to staff 1/9/2026All abuse/ neglect risk observations updated with completion 1/13/2026Victims room change to area located on all female unit completed 1/13/2026.Behavior tracking of sexual behaviors was reviewed and revised for all residents who exhibit behaviorsCare plans for residents with sexual behavior reviewed and revised as necessary.Director of Nursing (DON)/ Designee will audit facility activity reports daily for any residents who exhibit sexual behaviors 5 times weekly x 4 weeks, then 3x weely for 4 [NAME].Administrator/ Designee will conduct random staff and resident interviews 3x weekly x 4 weeks focusing on any reports of potential abuse.

Based on observation, interview, and record review, the facility failed to properly store medication and label multi dose insulin vials and pens. This has the potential to effect all residents residing in the facility. Findings include: On 3/24/2025 at 11:12 AM the facility's 500 Hall Medication Cart was inspected. The medication cart contained the following: 1. An opened and unlabeled multi dose Lispro insulin vial. The multi-dose vial did not have a resident identifier or open date. On 3/24/2025 at 11:13 AM V20, Licensed Practical Nurse (LPN), verified that the vial was open, partially used, undated and not labeled. V20 stated that the vial should be labeled with the resident's name and open date. V20 stated that the vial belonged to R31. On 3/26/2025 at 1:56 PM V7, LPN, stated that the multi-dose vials that are not labeled are stock. V7 stated that when using the multi-dose vial it is labeled with the resident's name and open date. V7 stated that R31's insulin was discontinued October 2024. A review of R31's medical record Physician Order Sheet (POS) document no current Lispro order for R31. On 3/24/2025 at 11:15 AM the 100 Hall Medication Cart was inspected. The medication cart contained the following: 2. R29's opened, partially used, and undated multi-dose Lantus vial. 3. 1 opened, partially used, unlabeled and undated multi dose Basaglar Pen. On 3/24/2025 at 11:17 AM V22, Registered Nurse (RN), stated that the medication was open, partially used and should have a date on it. 4. On 3/24/2025 at 12:48 PM observed a clear medicine cup with a large white pill and an oblong red, white, and blue pill on a food tray in the hallway on a cart. On 3/24/2025 at 12:50 PM V6, LPN, identified the pills as R8's Tylenol 500 MG (milligram) capsule and half tablet of potassium 20 meq (milliequivalent). V6 stated that R8 must have spit it out. On 3/26/2025 at 2:00 PM V23, LPN, stated that when opening a new multi dose vial or pen an open date is written on the vial, pen and box with the expiration date. V23 stated that if there isn't a name then one is written on at that time. On 3/27/2025 at 10:00 AM V3, Assistant Director of Nursing, stated that when the staff remove a stock multi-dose vial or pen the nurse is to place the resident name and the date open. V3 stated that this date is important because it tells the nurse when the medication expires. V3 stated that once the insulin is out of the refrigerator it has a 30 day life and the written date alerts the nurse to the expiration date. V3 stated that when the nurse passes the medication they are to stay and make sure the medication is taken. V3 stated that the medication is not to be left at the bedside or on meal tray. The Resident's Census and Conditions of Resident, CMS 671, dated 3/24/2025, documents that the facility has 78 residents living in the facility. The facility's MAC Rx of Missouri Pharmacy Policies and Procedures Manual, ID1 Storage of Medications, dated 05/01/2018, documents Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: Expiration Dating D. Drugs re-packaged by the pharmacy staff will generally carry an expiration date as follows: (Note: the pharmacist determines the exact date based upon a number of factors as well as applicable law or regulation) 2) Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: In a multi-dose injectable vial, An ophthalmic medication, An item for which the manufacturer has specified a usable life after opening. E. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating (See FORMS: MEDICATIONS WITH SHORTENED EXPIRATION DATES). F. The nurse will check the expiration date of each medication before administering.

Based on observation, interview and record review the Facility failed to follow their Enhanced Barrier Precautions (EBP) policy by not posting signage or utilizing Personal Protective Equipment (PPE) when caring for residents with qualifying criteria for 4 of 4 residents (R33, R74, R75, and R230) reviewed for Transmission Based Precautions (TBP) in the sample of 40. Findings include: 1. On 3/24/2025 at 10:10 AM, R75 was observed in a low bed with a catheter bag attached. The catheter bag was rested on the floor. There was no signage or Personal Protective Equipment outside R75's room or near the vicinity of R75's room. On 3/24/2025 at 3:18 PM, V20, Licensed Practical Nurse (LPN) stated R75 had a catheter but she removed it because he was pulling at it. V20 stated R75 still has a nephrostomy tube that gets flushed every day by the nurses. R75's Progress Notes dated 3/23/2025 at 10:27 AM documents R75's nephrostomy tube and catheter were in place. R75's Progress Notes dated 3/23/2025 at 1:58 PM documents R75's nephrostomy tube and catheter were draining urine and catheter care was provided by staff. R75's Care Plan dated 3/10/2025 documents R75 has a indwelling catheter and nephrostomy in place, putting him at risk for complications. R75's Care Plan further documents, as well as, ensure the bag and tubing are off the floor at all times. R75's Physician's Orders dated 3/11/2024 documents, Flush nephrostomy drainage tube with 10 CC (Milliliters) N/S (Normal Saline) every 12 hours. On 3/26/2025 at 10:00 AM, V7, LPN brought the treatment cart inside R75's room, performed hand hygiene and applied gloves. V7 did not don a gown. V7 then proceeded to flush R75's nephrostomy tube and empty the urine from the bag. V7 then attached the bag to the bed. The urinary bag was touching the floor. 2. The Facility Matrix provided on 3/25/2025 documents R74 has Intravenous Therapy (IV) R74's Face sheet undated, provided on 3/26/2025, documents R74 has a diagnosis of Bacteremia (infection in the blood). R74's Care Plan dated 2/20/2025 documents R74 currently has a PICC line to her left upper arm for antibiotic treatment related to bacteremia. It continues to document to administer medication per orders. On 3/24/2025 at approximately 10 AM, R74 was observed in her room. There was a bag of medicine observed connected to an IV pole. At this time R74 stated she was receiving antibiotic medications through her IV site but was not sure why. There was no signage on R74's door to indicated enhanced barrier precautions should be utilized nor or any PPE located nearby. On 3/25/2025 at 8:10 AM, V5, Registered Nurse (RN) entered R74's room, donned gloves, but no gown, and connected R74's IV antibiotic medication to R74's peripherally inserted central catheter (PICC) 3. The Facility Matrix provided on 3/25/2025 documents R230 receives dialysis. On 3/24/2024 at 9:50 AM, there was no signage on R230's door to indicate EBPs were to be utilized, nor was there any PPE readily available. R230's Face sheet dated 3/26/2025 documents R230 has a Gastostomy Tube (G-tube) and is dependent on renal dialysis. R230's Care Plan dated 3/18/2025 documents R230 currently has a feeding tube in place. It further documents R230 has a pressure area to his coccyx (backside) and receives dialysis. R230's Physician's Orders dated 3/18/2025 documents R230 receives dialysis three times a week. On 3/24/2025 at 4:00 PM, V6, Licensed Practical Nurse (LPN) entered R230's room to administer his tube feeding. V6 donned gloves, but no gown. V6 connected the tube feeding to R230's G-tube and began the feeding. On 3/26/2025 at 1:50 PM, V3, Assistant Director of Nursing (ADON) stated she is in charge of infection control. When asked if a resident who receives a feeding via G-tube should be on EBP, V3 stated, That's a really good question. We don't get a lot of G-tubes. I know chronic wounds should be, but I'm not sure what the time frame is to determine if it's a chronic wound. (R74) had the IV Monday and Tuesday and (R75's) catheter was 'pulled' on Monday (3/24/2024) afternoon. He should have been on EBP because I know (catheters) should. On 3/26/2025 at 2:38 PM, V3 stated, Yes, they should have been wearing gowns while providing direct care. I am going to put the sign and PPE cart out for (R75) now. 50628 4. R33's undated face sheet documented she was admitted to the facility on [DATE] with diagnoses of pressure ulcer left heel, long term use of antibiotics, foot drop left foot, and sepsis. R33's MDS dated [DATE] documented she is moderately cognitively alert, requires assistance with all activities of daily living. R33's care plan last updated 3/13/25 documented she has an unstageable pressure ulcer to her left heel and that she will wear heel boots on to offload pressure, cleanse area with wound cleanser, apply betadine to wound bed, cover with dry dressing daily and a needed. R33's physician orders dated 3/13/25 documented to cleanse left heel with wound cleanser, apply betadine to wound bed and cover with dry dressing daily. On 03/26/25 12:40 PM V3, assistant director of nursing (ADON) provided wound care to wound left heel. R33 was lying in bed. Previous dressing had gotten caught in resident's sock and she requested that staff performed wound care. Wound measured .5 cm x .5cm (centimeters) which V3 stated is significantly smaller than last week. Appropriate hand hygiene was performed. Wound was cleansed with wound cleanser and betadine was applied. Wound covered with dated, bordered gauze. Foot is elevated off the bed on a foot pillow. There were no enhanced barrier precautions sign on R33's door. The Facility's Policy dated April 1, 2024 documents, It is the policy of (Facility) to make every effort to prevent the spread of infection in the Facility. Standard Precautions require the health care worker (HCW) to estimate the degree of risk associated with a given task and plan for appropriate personal protective equipment. Enhanced Barrier Precautions is used in combination with Standard Precautions and expect the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's (Multidrug-Resistant Organisms) to staff hands and clothing. It continues to document EBP will be used for any resident who meets the following criteria: Chronic wounds such as pressure ulcers, indwelling medical devices, such as central lines, urinary catheters, and feeding tubes. It continues to documents resident who meet the above criteria, EBP are recommended while performing high contact resident activities such as changing briefs/linens, indwelling medical device care and chronic wound care. It continues, Place EBP sign at entrance to the room for the resident who meet the criteria and Staff will wear gloves and a gown for high- contact resident care activities.

Based on observation, interview and record review, the facility failed to administer a Gastrostomy Tube (G-tube) feeding according to standards of care for 1 of 1 residents (R230) reviewed for tube feedings in the sample of 40. Findings include: R230's Face sheet dated 3/26/2025 documents R230 has a Gastrostomy Tube (G-tube). R230's Care Plan dated 3/18/2025 documents R230 currently has a feeding tube in place, placing him at risk for complications, including aspiration (inhaling fluid into the lungs). R230's Physician's Orders dated 3/19/2025 documents R230 gets a tube feeding at 237 milliliters over 60 minutes four times a day via G-tube. On 3/24/2025 at 4:00 PM, V6, Licensed Practical Nurse (LPN) entered R230's room to administer his tube feeding. V6 donned gloves, but no gown. V6 connected the tube feeding to R230's G-tube and began the feeding at 237 milliliters per hour. R230 was laying flat in bed. V6 did not elevate the head of R230's bed. On 3/25/2025 at 7:58 AM, V2 Director of Nursing (DON) stated she would expect the nurse administering a tube feeding to elevate the head of the bed. V2 stated she asked V6 if she did elevate the head of R230's bed and V6 confirmed she did not. R230's Progress Notes dated 3/26/2025 documents R230 currently has aspiration pneumonia, continues the tube feedings and the head of the bed is elevated 30 degrees while infusing. The Facility's Policy does not address elevating the head of the bed prior to initiating a tube feeding.

Based on observation, record review and interview, the facility failed to provide dignity for two of six (R3 and R19) residents reviewed for dining in a sample of 40. Findings include: On 3/24/2025 at 11:00 AM, V4, Certified Nursing Assistant (CNA), was at a half round table, in the assistive dining room, where there were 3 residents that needed feeding assistance. She was standing up feeding R3 from behind the half round table. V1, Administrator, asked V4 to sit down when she was feeding the resident. V4 stated that she was too short to reach R3. V1 walked away. She continued to feed R3 standing up instead of sitting down next to her. Another CNA asked V4 to switch her tables and feed R19. V4 did so, sat down and could not reach R19 across the table so she stood up instead of sitting next to R19 and gave her bites of food. R3's Minimum Data Set (MDS), dated [DATE] documented that she was rarely or never understood and that she was dependent upon staff for eating. R3's Care Plan, dated 11/24/2020, documented, Set up tray and hand her utensil with food and encourage her to place into mouth using hand over hand and verbal cue as needed. R3's Physicians order sheet, dated 3/26/2025 documented diagnoses of Alzheimer's, Delusional disorders and Dysphagia. R19's MDS, dated [DATE] documented that she was rarely or never understood and that she required substantial to maximal assistance from staff to eat. R19's Care Plan, dated 11/13/2017, documented, (Encourage)/ Assist her to perform all (activities of daily living) to (maximum) potential. R19's Physicians order sheet, dated 3/26/2025, documented diagnoses of Dementia and Hemiplegia affecting left non-dominant side. On 03/26/2025 at 11:08 AM, V15, CNA, stated that when she is feeding someone, she will sit down and make eye contact with them. On 03/26/2025 at 11:10 AM, V16, CNA, stated that she sits down to feed residents but may have to stand up to give bites. On 03/26/2025 at 11:10 AM, V17, CNA, stated that she sometimes will have to stand up to reach a resident to feed them. When CNA was asked if she could sit next to the resident to assist with the meal, she stated that they were told they had to sit behind the table, across from the resident. On 03/26/2025 at 11:15 AM, V1, Administrator, stated that they were never instructed that they had to sit behind the table to assist a resident with a meal and that they could sit next to the resident. The facility's policy, Assisting Residents with meal, dated 6/2016, documented, 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting them with meals.

Based on observation, interview, and record review the facility failed to adequately supervise 1 of 1 resident (R5), reviewed for accidents and incidents, in a sample of 5. This failure resulted in R5 spilling coffee on herself and sustaining second degree burns. This past non-compliance occurred between 4/28/24 and 4/30/24. Findings Include: Facility reported incident, dated 4/30/2024, documented, [AGE] year-old female with Dementia, Atrial Fibrillation, Hypertension, Anxiety, Severely Cognitively Impaired. On 4/28/2024 at 10:16AM R5 was in room with breakfast tray. R5 attempted to stand and used the bedside table to stand up and the coffee that was on the breakfast tray spilled onto R5's lap. R5 was immediately assessed and R5 noted to have redness to right upper thigh. Medical Doctor, MD, and Power of Attorney, POA, were updated and R5 put on follow up to monitor area. No complaints of pain or discomfort to the site. On 4/30/2024 small clusters of blisters were noted to the right and left upper thigh. Call placed to update MD and orders given to apply Silvadene to the area three times daily. POA updated on orders as well. Environmental checks performed and care plan was updated to reflect update interventions. R5's progress notes, dated 4/28/2024 at 10:16AM, documented, (R5) spilled her coffee on her lap at breakfast, caused a raised red area measuring 9 (centimeter) x4 (centimeter) on her right upper leg. Complains of pain to touch. Cool cloth applied and R5 states it feels better. Update faxed to (Medical Doctor) and (Power of Attorney) aware. R5's progress notes, dated 4/29/2024 at 9:35AM, documented, Reddened area to upper right thigh noted from spilled coffee. No complaints of pain or discomfort. Resting in recliner, call light within reach. (R5) has not displayed any behaviors so far this shift. R5's progress notes, dated 4/30/2024 at 9:25AM, documented, Call placed to MD (physician) regarding treatment for areas to right upper/inner thigh and left inner thigh. Order received for Silvadene 85gram cream apply topically to right upper/inner thigh and left inner thigh three times daily. Call placed to POA updated and notified of new order. R5's Minimum Data Set, MDS, dated [DATE] documented that R5 was severely cognitively impaired and required set up for eating. R5's Care Plan, updated 4/25/2024, documented, (Activities of Daily Living), (R5) Requires Limited to Extensive Staff Assist with ADL's, To Extensive Staff Assist with ADL's related to her alteration in mobility/confusion (Dementia). Interventions include provide all tools/equipment needed for ADL's, setting up as necessary, but allowing and encouraging R5 to do as much as possible, providing both physical and verbal cues. R5's order sheets, dated 4/30/2024, documented, Silvadene (silver sulfadiazine) cream 1%, 1 application topical. Special instructions: Apply topically to areas on right upper/Inner thigh and left inner thigh three times daily every shift. Open ended. R5's wound notes dated 4/28/2024 documents right thigh, length 15.5 centimeters, cm, x 18cm. Partial thickness: redness, blistered, moist, painful, stable. 5/22/2024 right thigh 6.7cm x 2cm. Left thigh dated 4/30/2024 3.5cm x 3cm. 5/22/2024 left thigh resolved. On 5/23/2024 at 10:00AM, V13, Dietary Manager, stated, We always label which coffee was brewed first, so we let it cool down and serve it first. We always check the temps. Coffee pot showed label cool down first. On 5/23/2024 at 9:00AM, V2, Director of Nursing, (DON), stated, (R5) likes to sometimes eat in her room and is independent. We allowed her to eat in her room at times, but after the incident with the coffee we now require her to eat in the dining room. We reported the incident, did in-services, Quality Assurance, temperature logs, and resident interviews. On 5/23/2024 at 10:30AM, V10, Licensed Practical Nurse (LPN), provided wound care to R5. Wound to left inner thigh closed. Wound area to right inner thigh appears open with moderate amount of reddish-brown drainage to dressing. Wound care provided with no issues. V10 stated, I was not working the day R5 received the burn, but I am the one who called and got the order for treatment. On 5/23/2024 at 10:50AM, V12, Certified Nursing Assistant (CNA), stated, I was working the day (R5) spilled the coffee on her. (R5) likes to eat in her room. We gave (R5) her breakfast tray and when she pulled on the overbed table the tray with the coffee went in her lap. We cleaned her right up and that's when we saw the redness to her thighs. On 5/23/2024 at 12:00PM, V7, CNA, stated, We have been checking the temps ourselves since the incident with (R5). (R5) would not be able to know if a drink was too hot, because when she gets her food, she immediately starts eating fast. Now we are to check the temps and the drinks are to be 130 degrees or less. On 5/23/2024 at 11:55PM, V8, CNA, stated, The kitchen checks the temps on drinks. I don't think (R5) would know if something was too hot. On 5/23/2024 at 11:00AM, V14, Nurse Practitioner, stated, Residents have the right to eat in their rooms if they want that. I think it was appropriate for (R5) to eat in her room prior to the burns, but now I feel she needs to go to dining room. The facility's policy, undated, documented, Serving Hot Beverages and Soup. The Food service Department will monitor the temperature of all hot liquids being prepared to ensure that hot liquids are served at a temperature that will prevent burns if they should come into contact with skin. Prior to the Survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement meeting was held on 4/30/24. In attendance was V1, Administrator, V2, Director of Nurses, V16, Regional Director of Operations, V17, regional Director of clinical Services and V18, Regional director of Clinical Services. 2. Measures put into place/systematic changes to ensure the deficient practice does not recur: Dietary staff/clinical staff educated on temping hot liquids to 130 degrees when leaving the kitchen. Completed: 4/30/24. Audit all resident bedside tables to ensure no concern. Completed: 4/30/24 3. Plan to monitor performance to ensure solutions are sustained: Administrator/designee to audit temp logs of hot liquids leaving the kitchen to ensure they are at 130 degrees twice weekly for 1 month and share results with QA committee.

Based on observation, interview and record review, the facility failed to discard insulin pens after being in use for longer than 28 days, remove and dispose of expired medications, and not store food items in the medication refrigerator. This failure has the potential to affect all 75 residents residing in the Facility. Findings include: On 03/10/24 at 8:40 AM, The front medication room was inspected. The unlocked refrigerator, in the medication room contained the following: 1. There was a container of personal food and a 2% milk. 2. An unopened box of Tylenol suppository's 650mg (milligrams) with an expiration date of 12/2023. 3. R68's opened Lansprazole suspension 3mg/ml (milligrams/milliliter) with no open date or discard noted to the bottle. On 03/10/24 at 8:43 AM, 12, Registered Nurse (RN) stated the Lansprazole suspension should have an open date on it and there shouldn't be any food in the medication storage refrigerator. On 03/10/24 at 8:45 AM, The stock medication cabinet was inspected and contained the following: 1. Oyster Shell calcium Vitamin 250mg expiration date 06/2023. 2. Vitamin B-6 25mg expiration date 09/2023. On 03/10/24 at 8:55 AM, The front medication cart was inspected and contained the following: 1. R14's Lantus insulin multi dose vial 100/ml open date of 02/05/2024. 2. R14's Lispro insulin injection pen u100 with an open dated of 02/04/2024. 3. R39's Tresiba insulin pen with an open date of 02/07/24. On 03/10/24 at 9:05 AM, V4, Licensed Practical Nurse (LPN) stated the insulin should be discarded 28 days after opening. On 03/13/24 at 8:54 AM, V2, Director of Nursing (DON) stated she would expect the nurses to review the dates on the medications and check the dates on the insulin pens prior to administering them, and not have food in the medication fridge. The facility's policy and procedure, Storage of Medications, revision date of 05/01/2018, documents Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal if a current order exists. It further documents K. Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator. It also documents Expiration Dating E. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best sticker to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be [30] days unless the manufacturer recommends another dated or regulations/guidelines require different dating (See Forms: Medications with shortened expiration dates). F. The nurse will check the expiration date of each medication before administering. G. No expired medication will be administered to a resident. H. All expired medications will be removed from the active supply and destroyed in the facility regardless of amount remaining. The Resident Census and Condition of Residents Form 672 dated 3/10/2024 documents there are 75 residents residing in the Facility.

Based on observation, interview, and record review, the facility failed supervise and assist with meals for 1 of 1 (R45) residents reviewed for nutrition in a sample of 38. Findings include: R45's Face sheet, print date of 03/12/24, documents R45 has diagnoses of other specified eating disorder and dysphagia (difficulty swallowing), oropharyngeal phase. R45's Minimum Data set (MDS), dated [DATE], documents, R45 is severely cognitively impaired and requires partial/moderate assistance with eating. R45's Care Plan, last care conference date of 10/26/23, documents, Goal: R45 will consume 75% of all meals and will remain free from significant weight loss. Approach list but is not limited to protein supplement three times a day with med pass, fortified ice cream with lunch and dinner, routine weights, record, notify doctor (MD)/registered dietitian (RD) of any significant changes in weight, and selective menu choices. Substitutions available for food dislikes. R45's Weights for the past six months are as follows: 10/09/2023- Weight: 119.5 pounds (lbs.) 11/06/2023- Weight: 115.5 lbs. 12/04/2023- Weight: 116.0 lbs. 01/08/2024- Weight: 100.0 lbs. 01/23/2024- Weight: 100.5 lbs. 01/29/2024- Weight: 102.5 lbs. 02/05/2024- Weight: 104.5 lbs. 02/12/2024- Weight: 105.0 lbs. 02/19/2024- Weight: 105.0 lbs. 02/26/2024- Weight: 105.5 lbs. 03/04/2024- Weight: 102.0 lbs. 03/12/2024- Weight: 104.4 lbs. R45's Dietary Note, dated 01/11/2024 at 6:19 PM, documents R45 has lost a significant amount of weight over the past month. On 12/04/23 R45 weighed 116 pounds and on 01/08/24 R45 weighed 100 pounds. Her previous weights had been fairly stable. R45 had some significant health changes. She had a fall, COVID, some increased confusion, difficulty eating and swallowing, refusing to eat at times and a poor appetite. Speech Therapy was ordered for swallowing issues, she was started on Remeron on 1/3/24 and protein supplements three times a day with medication passes (12/29/23). R45 is needed assistance with meals, weights are being monitored weekly, and fortified ice cream at lunch and supper. R45's Physician's Orders, dated 01/23/2024, documents protein supplement with medication pass three times a day 7:00-10:00 AM, 11:00-1:00 PM, 3:00-6:00 PM. R45's Physician's Orders, dated 01/03/2024, documents Remeron (mirtazapine) tablet; 15 milligrams (mg); amount: 1 tablet; oral Special Instructions: administer one tablet by mouth (po) every bedtime (hs) for depression and appetite stimulant. Once A Day 7:00 PM-10:00 PM (19:00 - 22:00). On 03/10/24 at AM, R45 is sitting up in her recliner beside her bed resting with her eyes closed, her call light is observed to be within easy reach, she is dressed appropriately in clean clothes her shirt seems a bit large and baggy on her, and she appears to be thin and frail. On 03/11/24 at 10:30 AM, R45 was observed in her room. She appeared to be very thin and frail in appearance and her sweatshirt appeared to be big and baggy on her. On 03/11/24 at 11:05 AM, R45's meal was brought to her. Meal tray was uncovered, and she had baked chicken, scalloped potatoes, broccoli, cookie, ice cream, milk, water. 03/11/24 11:15 AM, R45 was given a nutritional supplement by V16, Registered Nurse (RN) at this time. On 03/11/24 at 11:30 AM, R45 ate a couple bites from her lunch tray then pushed it away from her. On 03/11/24 at 11:40 AM, R45's lunch tray was still in her room pushed away from her and she hadn't taken any further bites. Staff did not encourage her to eat, offer to assist her with her meal, or offer to go and get her something else to eat. On 03/11/24 at 11:51 AM, V15, Certified Nursing Assistant (CNA) went into R45's room and asked R45 if she was done with her tray. V15 did not encourage her to eat, did not offer to assist her with her meal, or did not offer to get her a substitution from the kitchen. V15 then removed R45's lunch tray from her room. It was observed to have the nutritional supplement still on it, and the fortified ice cream was observed to still have the lid on it. The nutritional supplement was still full when this surveyor picked it up to check and see how much had been drank by R45. On 03/12/24 at 11:32 AM, V18, CNA asked R45 if she was done eating. R45 told her she was eating a little at a time. V18 reminded R45 she had ice cream on her tray. No offer to assist R45 with her meal was made. On 03/12/24 at 11:45 AM, R45 sitting in her chair with her meal tray still in front of her. Resting her head on the back of her chair, her eyes closed, and only a few bites of food has been eaten. On 03/12/24 at 11:56 AM, V18 was observed picking up R45's tray. V18 asked R45 if she was done eating and if she was still hungry. No encouragement for her to eat or offer to assist her with her meal was made at this time. V18 left R45's supplement and water on her over the bed table for her to drink. On 03/12/24 at 12:03 PM, V18, CNA stated if she noticed someone wasn't eating, she would offer to go and get them something else to eat, she would ask someone else to go in and try to see if they could get them to eat, and let the nurse know. On 03/13/24 at 08:50 AM, V2, Director of Nursing (DON) stated she would expect the staff to find out if they liked what was on their plate, offer the alternative, have someone reproach, because sometimes if they won't eat for one person they will for someone else, supervise, give verbal cues, assist if needed, notify the nurse, and bring the resident to the dining room if they will come. On 03/13/24 at 10:52 AM, V31, Registered Dietitian stated if the resident wasn't eating she would expect the staff to give them their supplement, ice cream, and if they weren't eating and drinking those to let her know so they could change it because it would be pointless for them to continue to be given them. She said she would also expect for the staff to assist them with their meal and encourage them to eat. She said she would also have them move the resident to the dining room to eat for better supervision. The facility's policy and procedure, Weight Management Program, revision date February 2024, documents Policy: It is the policy of the facility to manage resident weight through prevention, assessment, and implementation and evaluation of interventions.

Based on observation, interview, and record review, the facility failed to ensure resident's call lights were within easy reach for 1 of 11 residents (R2) reviewed for call lights in a sample of 11. Findings include: R2's Face Sheet, print date of 09/26/23, documents R2 has diagnoses of Hemiplegia, unspecified affecting left nondominant side, Epilepsy, and Gastroesophageal reflux disease, (GERD). R2's Minimum Data Set, (MDS), dated [DATE], documents R2 is moderately cognitively impaired and requires extensive assistance, two plus person physical assist with bed mobility, transfer, dressing, toilet use, personal hygiene, and he is frequently incontinent of bowel and bladder. On 09/20/23 at 10:50 AM, R2's call light was observed to be lying on the floor beside his bed where he was unable to reach it. When this surveyor questioned R2 about his call light, he stated it's supposed to be hooked to the bed, but sometimes they will drop it on the floor, and he is unable to reach it and he must scream for someone to come in and help him. R2 stated sometimes it may take them 45 minutes to an hour to answer his call light. On 09/26/23 at 1:57 PM, V2, Director of Nursing, (DON), stated she expects the call light to always be within reach and for it to be answered as quickly as possible. The facility's policy, Answering the call light, with a revision date of July 2014, documents Purpose: The purpose of this procedure is to respond to the resident's request and needs. It further documents General guidelines 5. When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to maintain the resident's environment in a clean and sanitary condition for 1 of 11 residents (R2) in a sample of 11. Findings include: R2's Face Sheet, print date of 09/26/23, documents R2 has diagnoses of Hemiplegia, unspecified affecting left nondominant side, Epilepsy, and Gastroesophageal reflux disease (GERD). R2's Minimum Data Set, (MDS), dated [DATE], documents R2 is moderately cognitively impaired and requires extensive assistance, two plus person physical assist with bed mobility, transfer, dressing, toilet use, personal hygiene, and he is frequently incontinent of bowel and bladder. On 09/20/23 at 10:50 AM, upon entry to R2's room, a strong odor of urine was noted; there were two urinals hanging on the side of the trash can with urine in them. One had approximately 500 milliliters, (ml), of dark yellow urine in it and the other had approximately 200ml of dark yellow urine in it. The trash can was full of trash/food wrappers. There was a couple of pieces of trash lying on the floor in R2's room. On 09/21/23 at 1:40 PM, upon entering R2's room there was a smell of urine noted, and the urinals hanging on the waste cans in his room both had a moderate amount of urine in them. On 09/26/23 at 12:05 PM, R2 stated he would have to say they come in and empty his urinals more than once a day, but he doesn't think they come in and check and empty them every two hours. On 09/26/23 at 1:57 PM, V2, Director of Nursing, (DON), stated she would expect the urinals to be checked on every two hours. The facility's policy, Cleaning Guidelines Environmental Services, not dated, documents POLICY It is the policy of this facility that the workplace will be maintained in a clean and sanitary condition with a written schedule of cleaning and decontamination based on the area of the facility, type of surface to be cleaned, type of soil present and tasks being performed in the area. PURPOSE It is important that a clean, safe and sanitary environment is maintained for our residents.

Based on interview and record review, the Facility failed to notify the Physician/Nurse Practitioner (NP) of all pertinent information regarding a resident's change in condition for one of one resident (R324) reviewed for physician notification in the sample of 31. This resulted in R324 having a delay in treatment for a change in neurological condition. Findings include: R324's Face Sheet, undated, documents R324 had the following diagnoses: Type 2 DM (Diabetes Mellitus), CHF (Congested Heart Failure), Obesity, Major Depressive Disorder, Anxiety Disorder, HTN (Hypertension), ASHD (Atherosclerotic Heart Disease), GERD (Gastric Esophageal Reflux Disease), Neuropathies, Osteoarthritis, Asthma, Hyperlipidemia, Disease of Liver, Chronic Pain, Unspecified Kidney Failure, COVID-19. R324's Physician Order, dated [DATE], documents FULL CODE. R324's Care Plan, dated [DATE], documents Code Status: She elected for full code status. The Approach, dated [DATE], documents Family/MD to notified of any changes in her condition. R324's Care Plan, dated [DATE], documents (R324) is at risk for alteration in comfort related to impaired mobility/chronic pain R324's Care Plan documents Interventions as Assess her for c/o (complaint of) pain on scale of ,d+[DATE] and how it affects her ability to participate in ADL's (Activities of Daily Living), If she continues to verbalize pain or discomfort with current interventions, update Physician. R324's Minimum Data Set (MDS), dated [DATE], documents R324 had a BIMS (Brief Interview for Mental Status) Score of 10. A BIMS of 10 indicates R324 had a moderate cognitive impairment. R324's MDS documents R324 had clear speech, usually could make herself understood, and usually understood others. R324's Nurse's Note, dated [DATE] at 5:22 PM, documented R324 was found on the floor and sustained an abrasion to her left knee. The Nurse's Note documented R324 had gross amounts of edema and discoloration to the left knee and shin, and due to these injuries and complaints of pain, she was sent to the emergency room (ER). R324's Nurse's Note, dated [DATE] at 7:00 PM, documents R324 returned to the facility with a large hematoma/bruising to left lower extremities. R324's Nurse's Note, dated [DATE], documented R324 had bruises, black and blue in color, located to the left knee and lower leg, which was grossly edematous with numerous large red and yellow fluid filled blisters. R324's [DATE] Medication Administration Record (MAR) documents the following medications: Morphine 100 MG (milligram)/5 ML (milliliter) give 1 ML (milliliters) every two hours PRN (as needed), Hydrocodone-Acetaminophen ,d+[DATE] MG one tab Q (every) 6 hr. (hour) PRN (as needed), Naloxone (Narcan) Inject 1 MG/ML (milliliter) SC (subcutaneous)/IM (intramuscular) into thigh PRN for Opioid Overdose. May repeat two-three minutes PRN. R324's Nurse's Note, dated [DATE] at 10:15 PM, written by V23, Licensed Practical Nurse/ LPN, documents, Resident moaning. flopping arms around. Resident shook head when asked if she was in pain. PRN Morphine given. There was no documentation V23 notified V25, Physician, or V27, Nurse Practitioner, that R324 was unable to verbalize. R324's Nurse's Note, dated [DATE] at 03:00 AM, written by V23 documents, [Recorded as Late Entry on [DATE] 21:38] Resident continues to be resting. No response to verbal or tactile stimuli. Narcan administered per nursing judgment. There was no documentation in R324's medical record V23 notified V25 or V27 that R324 was not responding to verbal/tactile stimuli, and she had administered Narcan. On [DATE] at 3:25 PM, V23, LPN, stated I worked that Friday and Saturday night ([DATE]-[DATE]). I started start my shift off at 6:00 PM. During the shift change on [DATE], I was told that they got a new order for liquid Morphine for (R324), and she had already received a couple of doses. I did my assessment and (R324) was lying in bed, not really alert but moaning when she was moved, but was not talking at all. Saturday night ([DATE]) I gave her one dose of Morphine around 10:30 PM because she was moaning and groaning loudly. She seemed to be resting quietly after that. I checked on her around 3:00 AM and there wasn't much changed. She was still lying there resting, her vital signs were stable, but she wasn't responding to me at all. I gave a dose of Narcan because I wanted to give myself peace of mind that (R324) did not get too much Morphine and I wanted to set my mind at ease. She seemed like she was resting well. After I gave the dose, nothing changed. There was no response to the Narcan, so I didn't think a second or third dose was necessary. She seemed to be getting her much needed sleep. I did not feel the need to call 911 or to even call the physician. R324's Nurse's Note, dated [DATE] at 6:10 AM, written by V23 documents, [Recorded as Late Entry on [DATE] 21:43] Resident was assessed again by writer and day shift nurse (V24, LPN/Licensed Practical Nurse). Resident exhibited some mild moaning. R324's Nurse's Note, dated [DATE] at 6:20 AM, written by V24, LPN, documents, Resident resting in bed at this time, occasionally resident moans in pain. PERRLA (pupils equal round reactive light accommodation). Respirations even and unlabored. Incontinent care provided. Resident repositioned. Resident still not eating or drinking. Dressing CDI (clean dry intact) to LLE (left lower extremity) hematoma with open blisters. There was no documentation in R324's medical record V24 notified V25 or V27 that R324 was not verbalizing her needs, or not eating/drinking. On [DATE] at 2:55 PM, V32, Certified Nurse's Aide (CNA), stated, I took care of (R324) almost every day. She would complaint of pain off and on but was pretty easy to get along with. (R324) is normally alert and would talk to us and let us know her needs. I came in that morning of [DATE] at 5:00 AM. I got to her hall around 6:00 AM, and was in her room between 6:,d+[DATE]:30 AM to check for incontinence and turn and position her. (R324) was not talking or responding, was not moving, or helping at all. It seemed like her body was there, but she wasn't. She had a little moan when we moved her but that was it. V32 stated, When we went in some time after 10:00 AM to check and reposition her, she was breathing really weird. She would breathe fast, and then real slow, then would speed up again. She would not respond at all. We immediately called for the nurse (V24, LPN) who came in and assessed her. I took care of (R324) almost every time I worked, and that was not (R324) that morning. R324's Nurse's Note, dated [DATE] at 11:11 AM, written by V24 documents, Writer called to resident's room at 10:55 AM. Resident noted to be unresponsive with bilateral wheezing throughout lung fields. Writer preformed sternal rub and resident still does not rouse. Writer placed call to (V27, Family Nurse Practitioner Certified/FNPC) at 11:00 AM and updated on condition, new orders received to send resident to nearest ER (emergency room ). At 11:03 AM, call placed to 911. On [DATE] at 1:10 PM, V24 stated, When I got report from (V23, LPN) didn't really tell me about any symptoms (R324) was having, she just said she gave a dose of Narcan to (R324) for her own peace of mind that (R324) was not overdosed. After report, I went and did my own assessment on (R324), and I thought she was just the same as she was at 6:00 PM the night before when I left. (R324's) pupils were reactive, lungs were CTA (clear to auscultation), respirations were unlabored. I said good morning to her, and she opened her eyes for me. I asked her if she was hurting, and she made a groaning sound that I took as no. I was the one who called 911 after the CNAs yelled for me to check on (R324). I told 911 that the resident did have a leg injury from a fall, but I believe I also told them that she was unresponsive. R324's Nurse's Note, dated [DATE] at 1:00 PM, documents, Call placed to (Local Hospital) at this time to check on resident, Nurse stated that resident went into full cardiac arrest in the ambulance, was coded for 25 minutes in the ER, and expired at 11:58 AM. (V28) at hospital with resident. (V27, FNPC) updated at 13:24 PM. R324's Emergency Department Hospital Record, dated [DATE], documents, History is provided by the EMS. EMS said the nursing home staff gave her a dose of 'Narcan' at 3:00 AM with no response. It is uncertain what took place all the hours between 3:00 AM and the time the ambulance was called to bring her to the ED (Emergency Department). It continues The onset was unknown. The total time from the patient's arrest until ambulance arrival was unknown. On [DATE] at 10:10 AM, V2, Director of Nursing (DON) stated, It all started when (R324) fell on [DATE], and was sent to (Local ER) for evaluation and was told there was nothing fractured and that she just had a deep tissue ecchymosis. (R324) continued to complain of pain and we were having a pain control issue with her, so we decided to send her out to another hospital for evaluation. (R324) had a history of not tolerating pain medications well, causing her to have altered mental status with pain meds. What we were giving her wasn't working, so we discussed with her family, and they wanted us to do anything we can to control her pain. Early morning on [DATE] around 3:00 AM, (V23, LPN) found (R324) lethargic with no response to verbal or tactile stimuli. (V23) gave Narcan and watched her for fifteen minutes and she didn't see any changes other than (R324) bit down on an oral swab while swabbing her mouth. I know that (V23) did not call 911 or the Physician after administering Narcan, and she should have done that. (V23) was disciplined for that, and I have in serviced all nurses since then. I had a meeting with our Medical Director (V25, Physician), and we now have a Narcan order for all residents who have Narcotics ordered along with the nurse to Call 911, Call the Physician, Call the DON after administering the Narcan. On [DATE] at 12:15 PM, V26, EMTP (Emergency Medical Technician Paramedic), stated, I was the one who was on the call to the facility. I believe the call came in right around 11:00 AM. We were paged out for a female who was having Left Lower Leg pain from a fall days prior. When we arrived to the facility, we found the resident with snoring respirations, and unconscious. The nurse had told me that the resident had been receiving a lot of Morphine the day prior and had her last dose of Morphine 20 MG was given at 10:00 PM the night prior. The nurse stated that she had given one dose of Narcan at 3:00 AM. After that, I am not sure what they did for the resident until we got the call eight hours later. V26 stated, I knew the events leading up to this day for this resident. (R324) fell and was taken to the hospital, was given pain medications, and sent back to another hospital. She was returned to the facility with more pain medications. I would have assumed that after a first dose of Narcan, that the nurse would have either called 911 immediately, or at least administer another dose of Narcan as it was ordered. On [DATE] at 1:30 PM, V25, Physician, stated, I was notified of this incident regarding (R324) and I was told that the first dose of Narcan did not do anything for the resident. I would have expected the nurse to call the physician on call, and that physician would have made the decision to send the resident to the hospital or not. V25 stated, I know the nurse called my Nurse Practitioner (NP) at one point, and I believe the NP is the one who decided to send her out to the hospital. What I think should have happened is the nurse who gave the Narcan, should have called the physician and most likely the physician would have sent the resident out to the hospital at that time. I do think it was a delay, and a long-time frame from when the first dose of Narcan was given until the Nurse Practitioner was called and the resident was sent to the hospital. On [DATE] at 11:13 AM, V27, NP, stated, I document my assessments in the electronic medical record. I was aware of (R324's) fall on [DATE]. I'm usually at the facility on Mondays and Thursdays. That week, I came in on Thursday ([DATE]) and was told of (R324's) fall the day before ([DATE]). I went and assessed her and her leg and from the knee down was a deep dark purple with blisters. I have never seen anything like that before. I decided to send her to back to the ER because she was in extreme pain and her leg looked bad. I gave an order for a one-time liquid Morphine 20 MG PO order to hold her over until she gets to the ER. V27 stated she was notified on [DATE] and [DATE] that R324 continued to be in pain, and she gave orders for pain medications. V27 stated, Then on Sunday ([DATE]) (V24, LPN) called me around 11:00 AM and told me that (R324) was not doing well. I don't recall her telling me she was unresponsive, but that she just wasn't doing well. I was told about her receiving Narcan, but not sure who told me that. It may have been the next day (Monday [DATE]) when I came in. Narcan is supposed to be given for a suspected overdose. They should have given it and immediately notified the Physician. They can give up to three doses, and honestly, they should have called 911 if they had to give Narcan. I would have expected that nurse to give another dose of Narcan and/or call 911. Anytime they give Narcan, they should be sending the resident out. On [DATE] at 1:10 PM, V27, Nurse Practitioner, stated, (R324) was always alert and oriented and able to carry on a conversation with me. There are times when (R324) would chew on a washcloth or the bed linen when she was in pain, but I am not sure if it was a habit or what, because sometimes it would not correlate with her pain. I never got multiple calls about (R324) having a change in condition. The one call I remember was (R324) spitting out her medications, and that is when I transitioned to the liquid Morphine. Any time a resident has a change in condition, they should be notifying the provider on call. Yes, I would have sent (R324) out to the hospital if they would have called me with her change in mental status. I don't mess around with anyone, especially a full code, having mental status changes. I would definitely give them the order to send the resident out. I would consider if you had to use tactile stimulation to arouse someone when they normally respond to verbal, that should be considered a change in condition. It sounds like there should have been more done for (R324) that what was done. The Facility's Change in Condition Policy, dated ,d+[DATE], documents, It is the policy of (This Company) that resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely manner. Definition: Change in condition is defined as an improvement or decline in the resident's physical, mental or psychosocial status that effects less than two areas of activities of daily living. Significant change is defined as an improvement or decline in the resident's physical, mental or psychosocial status that effects two or more areas of activities of daily living. Procedure: 1. The staff person who first notices the change reports resident change in condition immediately to the licensed nurse. 2. The licensed nurse assesses the resident including vital signs and notes signs and symptoms, regarding physical and mental changes in condition. 3. The results of the assessment, including the vital signs, signs, symptoms and any physical and/or mental changes in condition are documented in the resident's medical record. 4. The resident's primary physician or designated alternate will be notified immediately of any change in resident's physical or medical condition, this includes: a. accident involving the resident. b. Deterioration in health, mental, or psychosocial status. c. Need to alter treatment (i.e., Need to discontinue an existing form of treatment due to adverse consequences or to commence new form of treatment). d. A decision to transfer or discharge from the facility. 5. The resident's designated medical contact or guardian will also be notified. The Policy documents Nursing judgement should be used given the time of day and the severity of the resident change. 6. Notification of physician and/or responsible parties shall be documented in the clinical record as well as on the 24-hour report form. Status changes, which are not significant enough to be reported, must also be documented in the medical record. 7. Significant change in condition requires a comprehensive resident reassessment (MDS) with associated documentation in the clinical record and care plan. The assessment must address all aspects of the resident's condition affected by the change. Acute conditions such as stroke or broken hip, life threatening conditions such as heart disease or cancer, or clinical complications such as advanced skin breakdown or recurrent UTI's can trigger a reassessment. 8. The Director of Nursing/Designee will assist in determining significant change in condition for purposes of reassessment when questions arise. Nursing staff who are in doubt about this, should automatically refer to the DON for assistance in a determination. 11. All changes of condition must be completely and objectively documented in the clinical chart. 12. It is the responsibility of the nursing staff to inform the resident's medical contact of any change in condition. Appropriate follow through from shift to shift is imperative for all residents with any change in condition. The nursing staff must utilize the tools provided for formal communication from shift to shift.

Based on interview and record review, the facility failed to recognize a change in neurological condition, notify the physician/nurse practitioner (NP) of all pertinent information, and provide service to address changes in condition for one of one resident (R324) reviewed for quality of care in the sample of 31. This resulted in R324 having a delay in treatment for a change in neurological condition. Findings include: R324's Face Sheet, undated, documents R324 was admitted on [DATE], and was discharged on [DATE]. The Face Sheet documented R324 had the following diagnoses: Type 2 DM (Diabetes Mellitus), CHF (Congested Heart Failure), Obesity, Major Depressive Disorder, Anxiety Disorder, HTN (Hypertension), ASHD (Atherosclerotic Heart Disease), GERD (Gastric Esophageal Reflux Disease), Neuropathies, Osteoarthritis, Asthma, Hyperlipidemia, Disease of Liver, Chronic Pain, Unspecified Kidney Failure, and COVID-19. R324's Physician Order (PO), dated [DATE], documents FULL CODE. R324's Minimum Data Set (MDS), dated [DATE], documents R324 had a BIMS (Brief Interview for Mental Status) Score of 10, indicating R324 had moderately impaired cognition. R324's MDS documents R324 had clear speech, usually could make herself understood, and usually understood others. R324's MDS documented R324 was totally dependent upon two staff members for transfers, toileting, personal hygiene, and bathing. R324's Care Plan, dated [DATE], documents, (R324) is at risk for alteration in comfort related to impaired mobility/chronic pain. R324's Care Plan Interventions document Administer pain meds per order (Hydrocodone/Oxycontin/Morphine as needed) Mx (monitor) effectiveness of pain meds. Attempt to establish causative factors of pain in attempt to minimize discomfort for her, assess her for c/o (complaint of) pain on scale of ,d+[DATE] and how it affects her ability to participate in ADL's (Activities of Daily Living), If she continues to verbalize pain or discomfort with current interventions, update Physician. It continues (R324) requires extensive-total staff assist with ADL's related to impaired mobility related to obesity/chronic pain. R324's Care Plan documents ([DATE]) Activities: (R324) is alert and oriented, attends activities of choice. Interventions: (R324's) preferred preferences per interview: Receiving a bed bath, snacks available between meals, family involved in her care discussions, choosing her own bedtime. (R324) was admitted to facility on [DATE]. (R324) is on 500-hall. (R324) eats all meals in resident's room. (R324) sister visits often. (R324) sister brings resident in groceries upon resident request. (R324) likes to listen to music, socialize with staff and residents, and watch/listen to TV. R324's Physician Order, dated [DATE], documents, Naloxone (Narcan) 1 MG/ML (milligram/milliliter), Inject 2 MG/2 ML (2 syringes) SC/IM (subcutaneous/intramuscular injection) every two-three minutes PRN (as needed) for Opioid Overdose. R324's Nurse's Note, dated [DATE] at 5:22 PM, documented R324 was found on the floor and sustained an abrasion to her left knee. The Nurse's Note documented R324 had gross amounts of edema and discoloration to the left knee and shin and due to these injuries and complaints of pain, and she was sent to the emergency room (ER). R324's Nurse's Note, dated [DATE] at 7:00 PM, documents R324 returned to the facility with a large hematoma/bruising to left lower extremities, and had negative results from all diagnostic tests performed at the ER for fractures. R324's Nurse's Note, dated [DATE], documented R324 had bruises, black and blue in color, located to the left knee and lower leg which was grossly edematous with numerous large red and yellow fluid filled blisters. R324's [DATE] Medication Administration Record (MAR) documented R324 had the following medications: Morphine 100mg/5ml give 1 ML (milliliters) every two hours PRN (as needed), Hydrocodone-Acetaminophen ,d+[DATE]mg one tab Q (every) 6 hr. (hour) PRN, Naloxone Inject 1 MG/ML (milliliter) SC (subcutaneous)/IM (intramuscular) into thigh PRN for Opioid Overdose. May repeat two-three minutes PRN. R324's Nurse's Note, dated, [DATE] at 6:10 AM, documents, Lying in bed, bed in low position, call light within reach. Moaning in pain, states that pain is severe. Left knee and lower leg bruised, black and blue in color, grossly edematous with numerous large red and yellow fluid filled blisters. States that any pressure applied to her leg hurts too much. Resident agreed to try an ice pack, ice pack from therapy applied to left lower leg at this time and tolerating well. Call placed to on call Dr regarding pain med d/t (due to) Tylenol Arthritis not helping severe pain. NP will be here this am and will see resident. R324's Nurse's Note, dated [DATE] at 10:15 PM, written by V23, Licensed Practical Nurse/LPN, documents, Resident moaning. flopping arms around. Resident shook head when asked if she was in pain. PRN Morphine given. R324's Nurse's Note, dated [DATE] at 03:00 AM, written by V23 documents, [Recorded as Late Entry on [DATE] 21:38] Resident continues to be resting. No response to verbal or tactile stimuli. Narcan administered per nursing judgment. On [DATE] at 3:25 PM, V23, LPN, stated, I worked that Friday and Saturday night ([DATE]-[DATE]). I started start my shift off at 6:00 PM. During the shift change on [DATE], I was told that they got a new order for liquid Morphine for (R324), and she had already received a couple of doses. I did my assessment and (R324) was lying in bed, not really alert but moaning when she was moved, but was not talking at all. Saturday night ([DATE]) I gave her one dose of Morphine around 10:30 PM because she was moaning and groaning loudly. She seemed to be resting quietly after that. I checked on her around 3:00 AM and there wasn't much changed. She was still lying there resting, her vital signs were stable, but she wasn't responding to me at all. I gave a dose of Narcan because I wanted to give myself peace of mind that (R324) did not get too much Morphine and I wanted to set my mind at ease. She seemed like she was resting well. After I gave the dose, nothing changed. There was no response to the Narcan, so I didn't think a second or third dose was necessary. She seemed to be getting her much needed sleep. I did not feel the need to call 911 or to even call the physician. I watched her for a good ,d+[DATE] minutes after and her BP (blood pressure) stayed the same and her breathing was same. At 6:00 AM, I gave report to (V24, LPN) and told her that (R324) had a restful night of sleep and that I gave Narcan once to make sure she did not get too much Morphine. R324's Nurse's Note, dated [DATE] at 03:15 AM, written by V23 documents, [Recorded as Late Entry on [DATE] 21:40] Resident continues to be resting. Resident did bite down on oral swab and held onto it for approximately 1 minute. VS (Vital Signs) WNL (within normal limits). R324's Nurse's Note, dated [DATE] at 6:10 AM, written by V23 documents, [Recorded as Late Entry on [DATE] 21:43] Resident was assessed again by writer and day shift nurse (V24, LPN/Licensed Practical Nurse). Resident exhibited some mild moaning. R324's Nurse's Note, dated [DATE] at 6:20 AM, written by V24, LPN, documents, Resident resting in bed at this time, occasionally resident moans in pain. PERRLA (pupils equal round reactive light accommodation). Respirations even and unlabored. Incontinent care provided. Resident repositioned. Resident still not eating or drinking. Dressing CDI (clean dry intact) to LLE (left lower extremity) hematoma with open blisters. On [DATE] at 2:55 PM, V32, Certified Nurse's Aide (CNA), stated, I took care of (R324) almost every day. She would complaint of pain off and on but was pretty easy to get along with. (R324) is normally alert and would talk to us and let us know her needs. I came in that morning of [DATE] at 5:00 AM. I got to her hall around 6:00 AM and was in her room between 6:,d+[DATE]:30 AM to check for incontinence and turn and position her. (R324) was not talking or responding, was not moving, or helping at all. It seemed like her body was there, but she wasn't. She had a little moan when we moved her but that was it. I know (V31, CNA) was there too. We probably turned and positioned her about every two hours. When we went in some time after 10:00 AM to check and reposition her, she was breathing really weird. She would breathe fast, and then real slow, then would speed up again. She would not respond at all. We immediately called for the nurse (V24, LPN) who came in and assessed her. I took care of (R324) almost every time I worked and that was not (R324) that morning. R324's Nurse's Note, dated [DATE] at 11:11 AM, written by V24 documents, Writer called to residents' room at 10:55 AM. Resident noted to be unresponsive with bilateral wheezing throughout lung fields. Writer preformed sternal rub and resident still does not rouse. Writer placed call to (V27, Family Nurse Practitioner Certified/FNPC) at 11:00 AM and updated on condition, new orders received to send resident to nearest ER (emergency room ). At 11:03 AM, call placed to 911. Call placed to (V28, R324's Sister) at 11:05 AM and updated on condition and transfer to hospital. 11:10 AM, call placed to (Local Hospital) ER and report given to nurse. On [DATE] at 1:10 PM, V24 stated, When I got report from (V23, LPN) didn't really tell me about any symptoms (R324) was having, she just said she gave a dose of Narcan to (R324) for her own peace of mind that (R324) was not overdosed. After report, I went and did my own assessment on (R324), and I thought she was just the same as she was at 6:00 PM the night before when I left. (R324's) pupils were reactive, lungs were CTA (clear to auscultation), respirations were unlabored. I said good morning to her, and she opened her eyes for me. I asked her if she was hurting, and she made a groaning sound that I took as no. I was the one who called 911 after the CNAs yelled for me to check on (R324). I told 911 that the resident did have a leg injury from a fall, but I believe I also told them that she was unresponsive. R324's Nurse's Note, dated [DATE] at 11:18 AM, documents, 11:18 AM (Local Ambulance) here to transport resident to (Local Hospital) ER. Resident moved to stretcher with transfer sheet and six staff members. All paperwork sent with EMTs (Emergency Medical Technicians). R324's Nurse's Note, dated [DATE] at 1:00 PM, documents, Call placed to (Local Hospital) at this time to check on resident, Nurse stated that resident went into full cardiac arrest in the ambulance, was coded for 25 minutes in the ER, and expired at 11:58 AM. (V28) at hospital with resident. (V27, FNPC) updated at 13:24 PM. R324's Emergency Department Hospital Record, dated [DATE], documents, History is provided by the EMS. EMS said the nursing home staff gave her a dose of Narcan at 3:00 AM with no response. It is uncertain what took place all the hours between 3:00 AM and the time the ambulance was called to bring her to the ED (Emergency Department). It continues The onset was unknown, the total time from the patient's arrest until ambulance arrival was unknown. On [DATE] at 12:15 PM, V26, Emergency Medical Technician Paramedic, EMTP, stated, I was the one who was on the call to the facility. I believe the call came in right around 11:00 AM. We were paged out for a female who was having Left Lower Leg pain from a fall days prior. When we arrived to the facility, we found the resident with snoring respirations, and unconscious. The nurse had told me that the resident had been receiving a lot of Morphine the day prior and had her last dose of Morphine 20 MG was given at 10:00 PM the night prior. The nurse stated that she had given one dose of Narcan at 3:00 AM. After that, I am not sure what they did for the resident until we got the call eight hours later. Once we got her into the ambulance, we started assisting her airway and we gave one dose of Narcan. I was working on getting an IV (intravenous catheter) in but because of her size, I ended up putting an IO (interosseous) in her and one dose of Epinephrine was given and then a second dose of Narcan. We couldn't get a BP (blood pressure) on her and had no pulse, so we started CPR (Cardiopulmonary Resuscitation) and started to transport to the hospital. I knew the events leading up to this day for this resident. (R324) fell and was taken to the hospital, was given pain medications and sent back to another hospital. She was returned to the facility with more pain medications. I would have assumed that after a first dose of Narcan, that the nurse would have either called 911 immediately, or at least administer another dose of Narcan as it was ordered. On [DATE] at 10:10 AM, V2, Director of Nursing, DON, stated, It all started when (R324) fell on [DATE] and was sent to (Local ER) for evaluation and was told there was nothing fractured and that she just had a deep tissue ecchymosis. (R324) continued to complain of pain and we were having a pain control issue with her, so we decided to send her out to another hospital for evaluation. (R324) had a history of not tolerating pain medications well, causing her to have altered mental status with pain meds. What we were giving her wasn't working, so we discussed with her family, and they wanted us to do anything we can to control her pain. Early morning on [DATE] around 3:00 AM, (V23, LPN) found (R324) lethargic with no response to verbal or tactile stimuli. (V23) gave Narcan and watched her for fifteen minutes and she didn't see any changes other than (R324) bit down on an oral swab while swabbing her mouth. I know that (V23) did not call 911 or the Physician after administering Narcan and she should have done that. (V23) was disciplined for that and I have in serviced all nurses since then. I had a meeting with our Medical Director (V25, Physician) and we now have a Narcan order for all residents who have Narcotics ordered along with the nurse to Call 911, Call the Physician, Call the DON after administering the Narcan. On [DATE] at 1:30 PM, V25, Physician, stated, I was notified of this incident regarding (R324) and I was told that the first dose of Narcan did not do anything for the resident. I would have expected the nurse to call the physician on call, and that physician would have made the decision to send the resident to the hospital or not. I know we have a Narcan Administration Policy that should tell them what to do. Another dose of Narcan could definitely have been given, it would not have hurt her at all. We give Morphine for patients with cardiac problems, such as chest pain, all the time because it could make it better. So, there is no way to know if Morphine caused a cardiac event or not. It is impossible to determine if sending her to the ER initially would have helped, that is a tough one and I wish I had an answer for you. The Morphine dose really depends on how much pain a patient is having. (R324) is getting 2 MG isn't she. Oh, she's getting 20 MG, but is it every two hours. So, she is getting 20 MG PRN and not every two hours. I know the nurse called my Nurse Practitioner (NP) at one point and I believe the NP is the one who decided to send her out to the hospital. What I think should have happened is the nurse who gave the Narcan, should have called the physician and most likely the physician would have sent the resident out to the hospital at that time. I do think it was a delay, and a long-time frame from when the first dose of Narcan was given until the Nurse Practitioner was called, and the resident was sent to the hospital. On [DATE] at 11:13 AM, V27, Nurse Practitioner (NP), stated, I document my assessments in the electronic medical record. I was aware of (R324's) fall on [DATE]. I'm usually at the facility on Mondays and Thursdays. That week, I came in on Thursday ([DATE]) and was told of (R324's) fall the day before ([DATE]). I went and assessed her and her leg and from the knee down was a deep dark purple with blisters. I have never seen anything like that before. I decided to send her to back to the ER because she was in extreme pain and her leg looked bad. I gave an order for a one-time liquid Morphine 20mg PO order to hold her over until she gets to the ER. She came back some time after I left and was contacted several times about her pain not in control. They called me on Friday ([DATE]) and said she was in extreme pain. I ordered Oxycontin 10mg. I know that the Oxycontin is basically an extended-release Morphine, and I was thinking that she needed something like that to maintain her pain control. I am not sure if there is a max dose of Morphine per 24 hours. Typically, we only use Morphine in Nursing Homes for Hospice residents, but I thought this would help her. When she came back from the ER, I don't think she came back with anything new so that is why I gave her those drugs. On Saturday ([DATE]) they called me again and I ordered the liquid Morphine at that time to be every two hours PRN. Yes, I think having all three drugs at once (Oxycontin, Hydrocodone, Morphine) would be too much, but I told them to discontinue the Oxycontin and Hydrocodone when they start the liquid Morphine. This was all a verbal order, so I assumed this was done. I felt like giving (R324) 20mg dose was sufficient because she was a very big lady. Then on Sunday ([DATE]) (V24, LPN) called me around 11:00 AM and told me that (R324) was not doing well. I don't recall her telling me she was unresponsive, but that she just wasn't doing well. I was told about her receiving Narcan but not sure who told me that. It may have been the next day (Monday [DATE]) when I came in. Narcan is supposed to be given for a suspected overdose. They should have given it and immediately notified the Physician. They can give up to three doses and honestly, they should have called 911 if they had to give Narcan. I would have expected that nurse to give another dose of Narcan and/or call 911. Anytime they give Narcan, they should be sending the resident out. I can't predict if sending (R324) out when they gave the Narcan at 3:00 AM would have changed anything, but yes, more than likely it would have. On [DATE] at 8:39 AM V14, Restorative Aide, stated she was very familiar with R324. V14 stated prior to her fall on [DATE], R324 would have her good days and bad days, physically, with bad days being when she was more sleepy and not able to participate in her own ADLs (Activities of Daily Living) as much. V14 gave the example that on bad days R324 would not help roll herself over in bed during turning and repositioning or incontinent care, but on good days R324 could roll herself onto her side and grasp the handrail to help with her ADLs. V14 stated R324 was able to feed herself after set-up by staff, and stated R324's appetite was very good, and R324 would often ask for seconds and sometimes thirds at meals. V14 stated R324 was alert and oriented and like to talk to staff about what was going on in their lives. V14 stated she did work the midnight shift for several months and did take care of R324 on that shift. V14 stated R324 would be awake a lot on midnight shift normally, and if she was asleep when they were doing rounds, R324 would wake easily and respond appropriately to staff who were performing her care. V14 stated R324 was mostly in bed, except when she got up for appointments, because it was very uncomfortable for R324 to be gotten up with the full body mechanical lift due to her size, and she preferred to stay in her bed. V14 stated if she would have gone into R324's room at night and R324 didn't speak to her, or wake up while she was providing care, she would have considered that a big change from R324's norm. On [DATE] at 8:47 AM V2 stated, Prior to her fall on [DATE], (R324) did have pain. She would put a washcloth in her mouth and moan in pain when we had to move her during care. (R324) had a history of mental status changes related to narcotic medications; her lactic acid would increase and cause the mental changes. Her doctor and nurse practitioner weighed the risks and benefits of this and decided to order narcotic medication to try to get (R324's) pain under control. She did not eat much after the fall; on [DATE], she ate ,d+[DATE]% at breakfast and lunch, and ,d+[DATE]% at dinner; on [DATE] and [DATE], the staff did not document any intake at meals for (R324). V2 stated R324 was able to communicate that she was in pain to the nurse practitioner when she saw her after her fall, and she was sent to the hospital twice due to the fall and her pain. V2 stated the staff did update the nurse practitioner on R324's increased restlessness and attempts to roll herself out of bed. V2 stated the goal was to get R324's pain under control, which they were able to do with the Morphine that was ordered. V2 stated prior to her fall on [DATE], R324 was alert and oriented time ,d+[DATE] with some occasional confusion on the time of day, but R324 was confused after the fall and V2 stated she attributed that to R324's pain medication. V2 stated she recognizes the failure by the nurse on [DATE] at 3:00 AM when she gave Narcan but did not notify the physician or call 911, and that nurse has been disciplined and educated to notify the physician and call 911 if administering Narcan. On [DATE] at 10:00 AM V9, Activity Director, stated R324 was alert times ,d+[DATE]. She stated R324 always recognized her by her voice and her southern accent because R324 could not see very well. V9 stated R324 was able to carry on a conversation about what was going on that day and let her know if she wanted a snack. V9 stated if she did not go into R324's room, R324 would send a CNA down to the activity room to get her a snack. V9 stated before R324's fall on [DATE], V9 would sometimes walk past her room and hear her moaning and sounding like she was in pain. V9 stated after R324 fell on [DATE], she was usually sleeping whenever V9 went into her room to take her snacks or to talk to her about activities that were held that day. V9 stated she would leave the snack on R324's table and instruct the CNAs to help R324 with it when she woke up. V9 stated she really didn't have any more conversations with R324 after her fall. On [DATE] at 1:10 PM, V27, Nurse Practitioner, stated, (R324) was always alert and oriented and able to carry on a conversation with me. There are times when (R324) would chew on a washcloth or the bed linen when she was in pain, but I am not sure if it was a habit or what, because sometimes it would not correlate with her pain. I never got multiple calls about (R324) having a change in condition. The one call I remember was (R324) spitting out her medications and that is when I transitioned to the liquid Morphine. Any time a resident has a change in condition, they should be notifying the provider on call. Yes, I would have sent (R324) out to the hospital if they would have called me with her change in mental status. I don't mess around with anyone, especially a full code, having mental status changes. I would definitely give them the order to send the resident out. I would consider if you had to use tactile stimulation to arouse someone when they normally respond to verbal, that should be considered a change in condition. It sounds like there should have been more done for (R324) that what was done. The Facility's Administration of Narcan, dated ,d+[DATE], documents Assess: Assess for signs of Opioid overdose (shallow breathing, decreased heart rate, pinpoint pupils, blue lips/nail beds, skin cool/clammy, confusion, or loss of consciousness. Verify Order. Activate EMS. Gather supplies, prepare syringe to withdraw dose (0.4 MG). Administer intramuscularly in thigh or upper arm (may be administered subcutaneously). Reassess: assess resident's response. May repeat dose every two-three minutes as needed. Closely monitor resident for several hours for symptom recurrence. The Facility's Change in Condition Policy, dated ,d+[DATE], documents It is the policy of (This Company) that resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely manner. Definition: Change in condition is defined as an improvement or decline in the resident's physical, mental or psychosocial status that effects less than two areas of activities of daily living. Significant change is defined as an improvement or decline in the resident's physical, mental or psychosocial status that effects two or more areas of activities of daily living. Procedure: 1. The staff person who first notices the change reports resident change in condition immediately to the licensed nurse. 2. The licensed nurse assesses the resident including vital signs and notes signs and symptoms, regarding physical and mental changes in condition. 3. The results of the assessment, including the vital signs, signs, symptoms and any physical and/or mental changes in condition are documented in the resident's medical record. 4. The resident's primary physician or designated alternate will be notified immediately of any change in resident's physical or medical condition, this includes: a. accident involving the resident. b. Deterioration in health, mental, or psychosocial status. c. Need to alter treatment (i.e., Need to discontinue an existing form of treatment due to adverse consequences or to commence new form of treatment). d. A decision to transfer or discharge from the facility. 5. The resident's designated medical contact or guardian will also be notified. In certain circumstances, the change may warrant contacting clergy or other significant persons. Nursing judgement should be used given the time of day and the severity of the resident change. 6. Notification of physician and/or responsible parties shall be documented in the clinical record as well as on the 24-hour report form. Status changes, which are not significant enough to be reported, must also be documented in the medical record. 7. Significant change in condition requires a comprehensive resident reassessment (MDS) with associated documentation in the clinical record and care plan. The assessment must address all aspects of the resident's condition affected by the change. Acute conditions such as stroke or broken hip, life threatening conditions such as heart disease or cancer, or clinical complications such as advanced skin breakdown or recurrent UTI's can trigger a reassessment. 8. The Director of Nursing/Designee will assist in determining significant change in condition for purposes of reassessment when questions arise. Nursing staff who are in doubt about this, should automatically refer to the DON for assistance in a determination. 11. All changes of condition must be completely and objectively documented in the clinical chart. 12. It is the responsibility of the nursing staff to inform the resident's medical contact of any change in condition. Appropriate follow through from shift to shift is imperative for all residents with any change in condition. The nursing staff must utilize the tools provided for formal communication from shift to shift.

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 69 residents in the facility. Findings include: On 2/6/2023 at 3:00 PM, V2, Director of Nursing (DON), stated, There was a few times in the last month that the facility has not been staffed with an RN for 8 hours in a 24-hour period. On 2/9/23 at 11:00 AM, V1, Administrator, stated, I am having difficulty getting RNs who want to work full time. I am aware that I am supposed to have an RN for 8 hours 7 days a week. The Staffing schedules were reviewed for the past month. On the dates of 1/4/2023, 1/28/23 and 1/29/2023 the facility did not have a RN for 8 consecutive hours. The Facility's Daily Staffing Information policy, dated 7/2014, documents, It is the policy of (this company) that, as required by CMS, to post daily staffing information in the facility. This must be posted in a prominent place, readily accessible to residents and visitors at the start of each shift. DON's and ADON's (any nursing management) that are not assigned to direct patient care should not be included in these numbers. The Resident Census and Conditions of Residents form, CMS 672, dated 2/5/2023 documents that the facility has 69 residents living in the facility. The CMS 672 documented that 9 residents receive Hospice care, 1 resident received dialysis, 4 residents received intravenous therapy/IV nutrition/and/or blood transfusions, 16 residents received injections, 13 residents were on antibiotics, 5 residents had pressure ulcers and 5 residents had indwelling or external catheters.

Based on observation, interview, and record review, the Facility failed to provide services to maintain resident's personal hygiene for residents who are dependent upon staff for hygiene for 4 of 4 residents (R26, R15, R35, R44) reviewed for assistance with activities of daily living in a sample size of 31. Findings include: 1. R35's Minimum Data Set (MDS), dated [DATE], documents a R35 has moderately impaired cognition. MDS documents R35 requires extensive assistance with bathing, dressing, toileting, transfers, and personal hygiene. On 2/5/23 at 9:30 AM, R35 stated the call light times are longer on the weekends; he must wait long times for showers, he hasn't had assistance with shaving, and he only gets shaved on shower days, but would like to get shaved every day. On 2/5/23 at 9:30 AM, R35 was sitting in chair with facial hair stubble. On 2/5/23 at 1:00 PM, R35 was sitting in chair with facial hair stubble. On 2/6/23 at 9:30 AM, R35 was sitting in chair with facial hair stubble. R35 states he would like to be shaved. On 2/6/23 at 1:00 PM, R35 was sitting in chair with facial hair stubble. On 2/7/23 at 9:30 AM, R35 was sitting in chair with facial hair stubble. On 2/7/23 at 2:00 PM, R35 was sitting in chair with facial stubble. V17, Licensed Practical Nurse (LPN), was present, and R35 stated to V17 that he would like to be shaved. On 2/8/23 at 10:00 AM, R35 was sitting in chair with facial hair stubble. V1, Administrator, was present, and R35 stated he can't get anyone to shave him. On 2/15/23 at 1:18 PM, V2, Director of Nursing (DON), stated, I would expect the staff to shave residents when needed and/or requested. 2. R26's MDS, dated [DATE], documents a Brief Interview of Mental Status (BIMS) of 00, which indicates R26 is severely cognitively impaired. MDS documents R26 requires extensive assistance with bathing, dressing, toileting, transfers, and personal hygiene. On 2/5/23 at 10:05 AM, R26 had food on his shirt, asleep in his chair. On 2/5/23 at 2:00 PM, R26 was in his room with food on his shirt. On 2/15/23 at 1:15 PM, V2 stated, I would expect the staff to change a resident's clothes if noticed to be soiled and provide them with clean clothes. 3. R15's MDS, dated [DATE], documents R15 requires extensive assist with bathing, dressing, toileting, transfers, and personal hygiene. On 2/5/23 at 10:17 AM, R15 was sitting up in his chair in his room with food on his shirt, and his fingernails dirty. On 2/5/23 at 11:30 AM, R15 was sitting in the dining room, still with food on his shirt, and his fingernails dirty. On 2/5/23 at 1:15 PM, R15 was up in his chair in the lounge, with food still on his shirt and his fingernails dirty. On 2/15/23 at 1:15 PM, V2 stated, I would expect the staff to change a resident's clothes if noticed to be soiled and provide them with clean clothes. I would expect staff to clean a resident's hands if appeared soiled, especially prior to dining. 4. R44's MDS, dated [DATE], documents a BIMS of 8, which indicates R44 is moderately impaired. MDS documents R44 requires extensive assist with bed mobility, bathing, dressing, toileting, transfers, and personal hygiene. On 2/5/23 at 10:05 AM, R44 was in bed facing the wall. There was bowel movement (BM) smeared on R44's pillow, and paper towels with BM laying on cushions in chair next to head of bed. R44's hands and fingernails were covered in BM. On 2/5/23 at 10:42 AM, the paper towels with BM were removed from room. There was BM on pillow, and R44's hands remain dirty with BM. On 2/5/23 at 11:30 AM, R44 was sitting up in a chair in the dining room waiting for lunch meal to be served, with his hands remained soiled with BM. The Facility's Shaving the Resident Policy, dated 7/2014, documents, The purpose of this procedure is to promote cleanliness and to provide skin care. The Facility's Dressing and Undressing the Resident Policy, dated 7/2014, documents, The purpose of this procedure is to assist the resident as necessary with dressing and undressing and promote cleanliness. The Facility's Care of Fingernails/Toenails Policy, dated 7/2014, documents, The Purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on observation, interview, and record review, the facility failed to limit the use of PRN (as needed) psychotropic medications to 14 days unless justification is provided by physician for 4 of 4 residents (R8, R46, R61 and R24) reviewed for psychotropic medication use in the sample of 31. Findings include: 1. R24's Face Sheet, undated, documents R24's diagnoses in part as major depressive disorder, single episode, and generalized anxiety disorder. On 2/8/23 at 9:00 AM, R24's Physician's Order (PO), with a start date of 9/13/2022, documents alprazolam 0.25 MG take 1 tab PO (orally) BID (twice a day) PRN **RE-EVALUATE 3/10/23**. R24's medical record contains pharmacy recommendation, dated 9/1/21, that documents end date re-eval 3/10/22, with no rationale indicated for extended use of the alprazolam. R24's Care Plan, Problem, dated 9/13/22, documents, Anti-Anxiety med use: she receives anti-anxiety med Xanax as needed, as she does become anxious, placing her at risk for significant side effects from med (medication). The Care Plan Approach, dated 9/13/22, documents Administer med per order. Labs and tests per order. Notify Md of all results, notify Md if med is ineffective. Physician to review med list with each visit. Routine pharmacist review with recommendations as needed. 32874 2. R46's Face Sheet, dated 3/8/2022, documents in part a diagnosis of anxiety disorder. On 2/7/2023 at 1:14 PM, V21, Licensed Practical Nurse (LPN), administered to R46 Alprazolam 1 milligram (mg) for anxiety. R46's PO, dated 11/8/2022, documents Alprazolam 1 MG once a day PRN. ** re-evaluate 4/19/2023. There was no documentation in R46's medical record the physician had provided justification for the extended use of this PRN medication. 3. R8's Face Sheet, dated 11/15/20216, documents in part a diagnosis of anxiety disorder, unspecified. R8's PO, dated 8/31/2022-2/25/2023, documents Ativan tablet 1 MG every 4 hours PRN. There was no documentation in R8's medical record the physician had provided justification for the extended us of this PRN medication. 4. R61's Face Sheet documents in part a diagnosis of generalized anxiety disorder. R61's PO, dated 8/28/2022, open ended, documents Hydroxyzine HCl 10 MG every 6 hours PRN. There was no documentation in R61's medical record that a physician had provided justification for the extended use of this PRN medication. On 2/7/2023 at 1:25 PM, V21 stated, All PRN scheduled medications are re-evaluated every 6 months. The facility policy Psychotropic Medication Use, dated revision 2018, documents, Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days.

Based on observation, interview, and record review, the Facility failed to ensure appropriate care and placement of indwelling urinary catheter drainage bags and tubing to prevent infection for 2 of 4 residents (R34, R52) reviewed for catheter care in the sample of 31. Findings include: 1. R34's undated Face Sheet documents the diagnoses to include, Urinary tract infection (UTI), site not specified, Neuromuscular dysfunction of bladder, and Retention of urine. R34's Care Plan documents goal for R34 will remain free from s/s (signs/symptoms) of UTI thru next review. Interventions: Position the collection bag below the bladder, ensure the bag and tubing are off the floor at all times. On 2/9/23 at 8:05 AM, R34's Minimum Data Set (MDS), dated [DATE], documents R34 requires extensive assist with bed mobility, dressing, and dependent on staff for toileting, transfers and personal hygiene. On 2/5/23 at 10:00 AM, V4, Certified Nursing Assistant (CNA), and V10, CNA, transferred R43 to bed with full body lift. V4 placed the urinary bag on R43's stomach, then V4 and V10 transferred R43 to bed. V4 raised the urinary bag above the level of R43's bladder multiple times while situating R43 in the bed and removing R43's clothing. V4 finished with R43's care, and then held urinary bag below the level of the bladder that allowed the urine that had collected in the tubing to drain into the urinary drainage bag. V4 then placed R43's urinary bag inside the dignity bag that was attached to the bed frame. On 2/5/23 at 10:20 AM, V4, CNA, stated, I know I am supposed to keep the urinary bag below the bladder, but I didn't do it. On 2/8/2023 V2, Director of Nursing (DON), stated, I expect the staff to maintain the urinary bag below the level of bladder. 2. R52's undated Face Sheet documents diagnoses to include: Benign prostatic hyperplasia with lower urinary tract symptoms, Retention of urine, Neuromuscular dysfunction of bladder, and Urinary tract infection. R52's MDS, dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 9, which indicates R52 is moderately impaired. MDS documents R52 requires extensive assist with bathing, dressing, toileting, transfers and personal hygiene. R52's Care Plan documents the following intervention: Keep tubing free from any kinks, anchor cath (catheter) securely to thigh, over the leg to drainage bag. On 2/5/23 at 9:40 AM, R52 states he has a urinary catheter and is wearing a leg bag. R52's Urinary catheter bag was hanging on bed. The catheter drainage bag was not in a dignity bag and the uncapped catheter tip was hanging at bedside. On 2/5/23 at 1:00 PM, R52's Urinary Catheter bag remained hanging on the bed without a dignity bag, and the uncapped catheter tip was hanging at bedside. On 2/6/23 at 9:30 AM, R52's Urinary Catheter bag was again hanging on the bed without a dignity bag, and the uncapped catheter tip was hanging at bedside. On 02/7/23 at 12:00 PM, R52's Urinary Catheter bag was hanging in the bathroom in a black garbage bag. On 2/8/23 at 10:00 AM, R52's urinary catheter bag was again hanging in the bathroom in a black garbage bag. The Facility's Catheter Care, Urinary policy and procedure, dated 7/2017, documents, The purpose of this procedure is to prevent catheter-associated urinary tract infections. General guidelines 1. Maintain a closed drainage system. 2. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. Infection Control: 2. b. Be sure the catheter tubing and drainage bag are kept off the floor. It also documents, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on interview, observation, and record review, the facility failed to implement Range of Motion (ROM) programs and implement interventions to prevent a further decline for residents with limited ROM in 4 of 10 residents (R4, R12, R52, and R69) reviewed for ROM in the sample of 29. Findings include: 1. R4's Face Sheet, undated, documents R4 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set (MDS), dated [DATE], documents R4 has limited ROM in one side of upper extremities. On 1/11/22 at 9:47 AM, R4 was in R4's room with limited ROM to the bilateral upper and lower extremities. On 1/12/22 at 10:35 AM, V10, Therapy Program Director, stated R4 does not have a ROM program in place. 2. R12's Face Sheet, undated, documents R12 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R12's MDS, dated [DATE], documents R12 has limited ROM in the bilateral upper and lower extremities. R12's Care Plan, dated 1/16/15, documents R12 requires Passive Range of Motion (PROM) to the bilateral upper extremities. R12's Contracture Risk assessment, dated 12/31/21, documents R12 is at moderate risk for development of contractures. R12's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's ROM program, dated 7/16/19, documents R12 has decreased ROM to the left hand and right hand, with interventions to perform PROM to both hands and shoulders; clean and dry both hands and apply splint to left hand and a washcloth to right hand. The ROM program fails to document the impaired ROM or interventions to prevent a further decline in ROM to the lower extremities. On 1/12/22 at 12:59 PM and 1/13/22 at 10:39 AM, R12 was in R12's room, and the washcloths were not in place to R12's hands. On 1/12/22 at 1:30 PM, R12's ROM was observed with V12, Certified Nurse's Assistant (CNA), and V13, CNA. R12 had limited ROM to the bilateral upper and lower extremities with the left side more impaired than the right. On 12/12/22 at 2:20 PM, V10, Therapy Program Director, stated V10 does the ROM assessments for the MDS quarterly, and agreed R12 had decreased ROM to the bilateral lower extremities. 3. R52's Face Sheet, undated, documents R52 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R52's MDS, dated [DATE], documents R52 has limited ROM in the bilateral upper and lower extremities. R52's ROM Program, dated 12/7/20, documents R52 has decreased ROM in the bilateral upper extremities with interventions to perform PROM to the bilateral upper extremities. The ROM program fails to document the impaired ROM to the lower extremities. On 1/12/22 at 2:10 PM, ROM was observed with V12, CNA, and V13, CNA. R52 was observed with decreased ROM to the bilateral upper and lower extremities. On 1/12/22 at 2:20 PM, V10, Therapy Program Director, stated V10 does the ROM assessments quarterly with the MDS, and agreed R52 has decreased ROM to the bilateral lower extremities. 4. R69's Face Sheet, undated, documents R69 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R69's MDS, dated [DATE], documents R69 has limited ROM to the bilateral upper and lower extremities. R69's Contracture Risk Assessment, dated 12/10/21, documents R69 is at moderate risk for development of contractures. On 1/11/22 at 9:44 AM, R69 was observed with limited ROM to the bilateral upper and lower extremities. On 1/12/22 at 10:35am, V10, Therapy Program Director, stated R69 does not have ROM program in place. The PROM policy, undated, documents The purpose of the PROM program is to provide residents the opportunity to achieve the highest possible degree of PROM and strength. May include but are not limited to the residents with the following conditions: Decreased PROM. The Splint/Brace policy, undated, documents The purpose of the Splint/Brace program is to provide residents the opportunity to achieve the highest possible degree of independence in use and care of his/her splint/brace. May include but are not limited to residents with the following conditions: Contractures.

Based on observation, interview, record review, the facility failed to provide safe transport by failing to secure a resident in a wheelchair (R2), causing the resident to fall out of a wheelchair when the facility van turned a corner. This failure resulted in the resident receiving a facial laceration requiring sutures and bruising to face and top of legs. Findings include: 1. R2's face sheet documents R2 had diagnosis of pneumonia, congestive heart failure, hypertension, cerebral infarction. R2's care plan, dated [DATE], documents R2 is at high risk for falls. R2's fall risk assessment documents R2 is at high risk for falls. MDS, (Minimum Data Sheet), updated [DATE], does not document BIMS score. Vehicle Safety Checklist dated [DATE], documents vehicle was in satisfactory condition and good condition. All 8 safety latches, seatbelt, and lift all worked properly. Investigation completed by facility Administrator documents on [DATE] V1 spoke with V3 regarding incident in the facility van with R2. V3 stated R2 was in her wheelchair and R2 and wheelchair were securely fastened in the van. V3 was transporting resident to local hospital for ordered tests. After V3 rounded a corner, he noticed that R2 was not sitting up in the wheelchair. V3 immediately pulled the van over to the side of the road to assess R2. V3 called facility and stated R3 was currently in the ER. On [DATE], V1 spoke to V3 on 500 hall of facility at 11:30 AM regarding coming in the next day to reenact what happened during his transportation that caused R2 to be injured and go to the hospital. V3 said V3 had things planned for his day off, and V1 told V3 this was very important that he be here. V3 stated, I'm done, with tears in his eyes, and threw the clean linen he was carrying on the floor. V3 then walked to the employee break room and clocked out and left the facility. V1, Administrator, stated, (V3, CNA, Van Driver) said he had (R2) strapped in correctly. (V3) stated he turned a corner and looked in rear view mirror and she (R2) wasn't there. (V3) took (R2) to the ER. The next day, (V1) had (V3) come in to re-enact what had happened. (V3) got tearful and threw down some towels and walked out of the facility and quit. V2, Director of Nursing, stated, I wasn't here when the incident with (R2) occurred. I was told that (V3) was transporting (R2) to the doctor's office. (V3) reported when he turned a corner, (V3) looked in the rearview mirror and he couldn't see (R2). (R2) had fallen out of the wheelchair and was laying on van floor. (V3) took (R2) to the ER. (V3) then called facility to inform them what had occurred. A few days later, (V1) asked (V3) to go to facility van and reenact what happened involving (R2). (V3) stated he quit and walked out. V4, Maintenance Supervisor, stated, (V3) said he strapped (R2) in correctly. V4 stated, There are 2 straps for the front of wheelchair and 2 straps for the back of the wheelchair. Then the actual seatbelt is used to strap across the resident. V4 stated V4 investigated the straps and seatbelt, and all worked fine. Attempted to contact V3, on several occasions. No answer and no voicemail available. R2's progress notes document: On [DATE] at 4:20 PM, call received from (V3), stating (R2) fell out of wheelchair and hit her head causing a bruise and head laceration. (V3) stated that he had (R2) in the ER at this time. On [DATE] at 7:50 PM, called local hospital for update on (R2). (R2) will be returning to facility. (R2) has 3 stitches to forehead. Received CT scan of the c spine, (Cervical Spine), bilateral legs and chest x ray were noted as all normal. On [DATE] at 10:35 PM, (R2) returned to facility via ambulance. Bruising noted to bilateral eyes. 3 cm, (centimeter), laceration to mid forehead with 3 stitches in place with mild bleeding. On [DATE] at 11:29 PM, Neuros continue due to fall. Facial bruising noted with laceration to forehead with 3 sutures. On [DATE] at 10:08 PM, (R2) admitted to hospice. On [DATE] at 8:00 PM, (R2) expired. R2's death certificate documents cause of death congestive heart failure and [CONDITION(S)]. Documents provided by facility include Van Wheelchair Seatbelt/Tie Down Training Checklist completed by V3 on [DATE]. 2. R1 has diagnosis of dementia, seizures, anxiety, GERD, (Gastroesophageal Reflux Disease) and pure [CONDITION(S)]. R1's progress notes document: On [DATE] at 11:30 AM, CNA was walking down hallway and noted (R1) laying on right side on the floor in bedroom next to the bathroom door. (R1) informed writer that he's not sure what caused him to fall but, that he was walking back to his wheelchair from the bathroom. On [DATE] at 8:17 PM, CNA was walking down hallway and noticed (R1) standing outside by his wheelchair reaching for a broom. Before CNA could get outside to help (R1), he fell sideways between the two patio chairs and landed on his buttocks. (R1) denies any pain r/t, (Related to), fall. On [DATE] at 4:10 AM, writer was in hallway passing medications and noted (R1) ambulating without cane, (R1) was unsteady, as writer went into (R1's) room to offer assistance (R1) fell to ground landing on buttocks. (R1) states he bumped his right elbow on his wheelchair as he fell , no redness or deformity noted. (R1) stated he lost his balance mam (R1) did not hit head. denies pain at this time, (R1) educated to use his cane with ambulation. Care plan, updated [DATE], documents R1 is fall risk. MDS updated, [DATE], documents BIMS score 9.0 MDS, documents R1 is independent or required set up with ADLs. R1's fall risk assessment documents R1 is at moderate fall risk. 3. R3's face sheet documents diagnosis of neck fracture, dementia, [CONDITION(S)], polyneuropathy. R3's progress notes document: On [DATE] at 6:45 PM, (R3) sitting in room in wheelchair when she attempted to stand unassisted and fell to the ground hitting her head on her dresser. Reddened area noted to back of head. No other injuries apparent. Range of motion within normal limits. (R3) denies any pain. Neuro checks initiated and WNL. (R3) assisted back to wheelchair and assisted with needs. On [DATE] at 3:20 PM, Writer heard (R3) calling out for help, upon investigation (R3) was sitting on the floor when writer reached her room. (R3) stated she was trying to get out of her recliner and fell to the floor. Resident states she hit her head on the floor. Writer assessed (R3) and no apparent injury noted. Neuro check is WNL for this R3. ROM is WNL for this resident. (R3) was wearing slipper socks at the time of fall. Writer asked resident if she had removed her alarm and she stated yes. R3's Care Plan, dated [DATE], documents R3 is a fall risk. R3's MDS documents BIMS score of 8. MDS documents R3 is extensive assist of 2. MDS documents tab alarm used. R3's fall risk assessment, dated [DATE], documents R3 is at high risk for falls. Transportation Policy documents Facility will arrange for transportation in the most cost effective and safe manner in order to assist residents and guests to physician or clinic appointments.

Based on interview and record review, the facility failed to provide adequate supervision and respond timely to call light for 1 of 1 resident (R2) reviewed for falls in the sample of 10. Findings include: R2's Facesheet documents that R2 was admitted to facility on 7/21/2015 with [DIAGNOSES REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documents that (R2) requires extensive assistance of two staff members for most activities of daily living. R2's Nurses note, dated 11/10/2020, documents, Writer called into room by CNA. CNA stated that resident fell out of bed. Writer entered room and resident was lying on her back on the floor. Resident able to move arms but when writer attempted to check lower extremity ROM (range of motion), resident screamed out in pain. Writer stayed with resident at this time. R2's Nurses note, dated 11/10/2020, documents, Dr made aware of resident fall. Order to send resident to ER (emergency room ) for evaluation. DON (Director of Nursing) made aware of fall at this time. Area Ambulance called to transport resident to ER. R2's Nurses note, dated 11/10/2020, documents, Returned to facility from ER, all x-rays negative for fractures, resident was given (pain shot, pain pill, and pain patch) to right knee in the ER before departure. Assisted to bed from stretcher per 6 people and sling, tolerated well. Call light within reach. Skin assessment with no visible sign of injury noted. POA (power of attorney) notified of return to facility. V20's employee witness statement, dated 11/10/2020, documents the last time provided care to (R2) was at 1:50 AM. V20's statement documents: Put resident on bed pan, went across hall to change another resident, when returned resident was on floor. (Resident frequently takes self off bed pan). When did incident happen documents 2:10 AM. V21's employee witness statement, dated 11/20/2020, documents the last time provided care to (R2) was at 1:50 AM. V21's statement documents: Put resident on the bed pan went across hall to check and change another resident. V21 stated, Went to check on (R2) again and she was on the floor. (Resident frequently takes self off bedpan). When did the incident happen documents 2:10 AM. R2's Care Plan, dated 12/9/2020, documents: Resident is at risk for falls r/t impaired mobility (obesity) uses contributing meds ([MEDICATION NAME]). Interventions: air mattress (per her request) removed from bed and regular foam mattress provided (fell out of bed 11/10/2020) Resident requires staff assist with adls (activities of daily living) r/t (related to) impaired mobility r/t obesity/chronic pain. Interventions: Encourage her to perform all adls to max potential. Assisting her as needed for task completion and her safety. On 1/19/2021 at 12:00 PM, R2 stated, One night the aides put me on the bed pan and the girl told me that she would be right back. R2 stated, I waited, waited and waited, tried to take myself off bed pan. R2 stated, I then started to roll and the air in the mattress went behind me, so I screamed and hollered and no staff came. R2 stated, I tried to grab my trapeze, but I was on the floor at that time. R2 stated, I really didn't get hurt. On 1/20/2021 at 2:16 PM, V19, Licensed Practical Nurse (LPN), stated, The aides placed (R2) on a bed pan, then left room to change another resident. V19 stated, I think I was up front putting medications away when the aides came and got me stating that they had placed (R2) on bed pan and when they returned to her room (R2) was on the floor. V19 stated, (R2) would normally call out when she was done. On 1/20/2021 at 2:20 PM, V20, Certified Nurses Assistant (CNA), stated her and V21, CNA, were doing their bed checks and (R2) requested a bed pan. V20 stated after placing (R2) on the bed pan, they continued down the hallway doing their bed checks. V20 stated when they reached the end of the hallway, they returned to (R2) and she stated she needed more time. V20 stated she and V21 then entered another resident's room that takes a while and when finished returned to (R2)'s room to find her on the floor still on the bed pan and all the linens off the bed. V20 stated (R2)'s call light was on. V20 stated the foam bed that (R2) has now is better than the air bed that she was on when she rolled out of bed. V20 stated, When we would roll (R2) on the air bed, all the air would go to one side and there would be no air underneath (R2). On 1/21/2021 at 10:40 AM, V21, CNA, stated, Myself and (V20) were doing bed checks and (R2) requested a bed pan, so we placed (R2) onto the bed pan and left to continue down the hallway doing bed checks. V21 stated, We checked back on (R2) and she stated she needed more time, so we went into another residents room and closed the door to assist another resident. V21 stated, After we finished, we returned to (R2)'s room and found her on the floor. V21 stated that (R2)'s call light was on. V21 stated, We had the door closed so we didn't hear (R2) yelling. On 1/20/2021 at 12:15 PM, V11, LPN. stated, I would expect aides to check on a resident who is on the bed pan about every 2-3 minutes, because the bed pan can become uncomfortable. On 1/20/2021 at 12:30 PM, V13, LPN, stated, It depends on the resident, but I would expect staff to check on a resident in about 5 minutes or so. The Facility's Bedpan/Urinal, Offering/Removing policy and procedure, dated July 2019, documents, General Guidelines: Do not allow the resident to sit on bedpan for extended periods. (Note: This is not only uncomfortable to the resident, it also causes skin breakdown.)

Based on interview, observation and record review, the facility failed to assess and identify the root cause of falls and develop/implement an effective falls prevention plan for 1 of 3 residents (R2) reviewed for falls in a sample of 7. This failure resulted in R2 having multiple falls with the last occurring on 3/10/19 where she sustained a fractured nasal bone and laceration requiring 10 sutures. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] identified R2 as having severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 6 requiring minimal assist of one staff for transfers, walk in room and corridor with assist and walker. On 3/20/19 at 10am, R2 was sitting in the hallway and had extensive bruising of yellow to various shades of red to purple across her entire face extending down into her neckline. R2 had a large laceration with sutures mid to left forehead. R2 had a pressure pad alarm under her. A Fall Risk assessment dated [DATE] identifies R2 to be high risk. The Fall Log provided by V2 Director of Nursing (DON) on 3/20/19 identifies R2 to have had unwitnessed falls on 11/5/18 and 11/9/18. From 1/1/19 through 3/10/19, R2 was documented as falling on 1/12/13, 1/13/19, 1/26/19, 1/28/19, 2/21/19, 2/25/19 and 03/10/19. Of these falls, three (2/25/19, 2/21/19, and 1/13/19) were documented as having the alarm sounding with staff being unable to reach her before she fell to the floor. Progress notes entered on 3/10/19 at 12:40am document R3's alarm was sounding and when staff responded, she was found on the floor by the bathroom door with a large amount of blood on her face with a 2cm x 21cm laceration to her forehead. The note documents 911, was called and R2 was sent to the emergency room for evaluation. Progress notes dated 3/10/19 at 6:45am document R2 returned to the facility with a fractured nasal bone and 10 sutures to her forehead. A timeline provided by V2 on 3/21/19 at 10:30am documents interventions added as a result of falls are as follows: 1/12/19 - encourage resident to call for assistance with Activities of daily living, 1/13/19 - pressure pad alarm, 1/26/19 - staff to remind resident to ensure back of legs are touching recliner when sitting in recliner, 1/28/19 - encourage resident to attend activities, 2/21/19 - encourage resident to use walker at all times, 2/25/19 - continue to remind resident to call for assistance with transfers and on 3/10/19 - 2 hour toileting. Most of these interventions added based on the residents ability to remember to do things and are questionably effective given R2's severe cognitive impairment. On 3/21/19, a comprehensive fall assessment was requested with none provided. On 3/21/19 at 10:30am, V20 Care Plan Coordinator (CPC)/Licensed Practical Nurse (LPN) described R2 as impulsive getting up numerous times a day unassisted thinking she can walk when she can't as her gait is very unsteady. V20 stated R2 has experienced an overall decline in activities of daily living since late last fall. V20 stated care plan interventions were added to the fall's prevention plan to remind her to call for staff, etc., but agreed are probably not effective given her cognitive status. V20 stated they have considered room changes for others to increase visibility but didn't say they had for R2 and acknowledged that her room is over 1/2 way down the hall from the nurse's station. On 3/21/19 at 1pm, V4 LPN stated R2 is very impulsive and quick adding that she can get across a hallway before staff can get to her. V4 stated R2's gait is very unsteady. V4 stated R2 doesn't realize she can't walk but reminding her to call for assistance just doesn't work because she doesn't remember. V4 stated R2's alarm may go off 3-4 times a shift at least. V4 stated R2 can be aggressive at times with staff and doesn't always respond to redirection to sit down. On 3/21/19 at 1:36pm, V7 Social Service Designee (SSD) stated R2 is very impulsive and gets up repeatedly without staff. V7 stated it would not work to remind R2 to call for help due to her cognitive impairment. V7 stated they have moved R2 up the hall a little as she used to be in the last room at the far end. On 3/21/19 at 2:15pm, V17 Certified Nurse Aide (CNA) stated R2 has no safety awareness and will at times, remove her alarm and take it with her when she gets up. V17 stated she's very confused and will only at times, follow redirection. V17 stated sometimes she just wants to walk. V17 stated if you hear her alarm you better go running because she is quick. V17 stated she is also very motherly and likes to check things out if she hears other residents having a problem which will cause her also to get up. On 3/21/19 at 3pm, V22 Physical Therapist Aide (PTA) stated R2 has been on therapy since 1/23/19 due to a decline in mobility and increased weakness. V22 stated R6 can make her needs known like needing to use the toilet etc., but is very difficult to redirect. V22 stated R2 wouldn't necessary use a call light or ask for assistance but would just get up and go stating she agreed that the facility should identify the issue of her getting up and moving quickly as a problem with interventions being specific to that. Physical Therapy notes for service from 1/23/19 to 3/23/19 documents justification for skilled services remaining impairments: balance deficits, strength impairments and vestibular system deficits. R2's care plan dated 1/18/19 identifies R2's problems as at risk for falls or trauma, as res has alteration in mobility, hx (history) of falls with a goal to not experience injury r/t (related to) falls thru next review but fails to identify R2's primary cause of falling is her impulsiveness in getting up unassisted thinking she can walk and her lack of safety awareness. Interventions reflect the ones given on the time line in part but none address the need for staff to immediately respond to R2's alarm, R2's impulsiveness, frequency at getting up unassisted and her need for increased monitoring which is the root cause of most of her falls. The facility's policy/procedure entitled Falls Management dated (MONTH) (YEAR) documents it is the policy to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions.