Every finding on record at Monument Healthcare Murray Creek

Based on interview, observation, and record review, it was determined that the facility failed to ensure that a resident's environment remained free of accident hazards for one of one resident reviewed for accidents (Resident #11). Specifically, the facility failed to ensure a mechanical lift sling was in safe, functional condition, resulting in a strap breakage during a transfer. This failure caused Resident #11 to fall, resulting in a 1cm scalp laceration and severe pain (9/10).The facility's noncompliance was determined to be Past Noncompliance. The facility developed and implemented a corrective action plan on August 26, 2025, which included staff retraining on mechanical lift competencies, disposal and replacement of all slings, and verification of interventions prior to the start of the survey on March 30, 2026. Review of Resident #11's medical records revealed that Resident 11 had a diagnosis of Parkinson's Disease. Review of a facility Incident Report dated August 5, 2025 revealed that while two Certified Nursing Assistants (CNAs) were transferring Resident #11 from the bed to a chair using a mechanical (Hoyer) lift, a sling strap broke. This equipment failure caused Resident #11 to fall to the floor.Review of Nursing Notes and Interdisciplinary Team (IDT) Fall Review notes dated August 5, 2025 documented that Resident #11 sustained an abrasion to the back of the head, a 1cm laceration to the scalp, and reported pain in the shoulders and neck following the fall. The resident was subsequently transferred to the hospital for evaluation.Review of Nurse Practitioner (NP) notes dated August 6, 2025 confirmed the 1cm scalp laceration was bleeding and documented that Resident #11 rated his back pain as a 9 out of 10 on a numeric pain scale.During an interview on March 31, 2026, CNA #1 stated that upon arriving to assist CNA #2 with the transfer on August 5, 2025, Resident #11 was already positioned in the sling. CNA #1 reported that as the resident was being lifted, the strap snapped, causing the resident to fall and strike his head.Review of the manufacturer's instructions for the mechanical lift and slings explicitly required staff to inspect slings and lifting straps for signs of wear, fraying, or weakness prior to every use. Although maintenance records showed a general audit was conducted on July 15, 2025, there was no evidence that the specific sling used for Resident #11 had been inspected for integrity prior to the transfer on August 5, 2025.During an interview on March 31, 2026, Administrator #2 acknowledged the equipment failure and stated that the breakage resulted in the resident's fall and subsequent injury.The facility's failure to identify a worn or defective sling strap resulted in Actual Harm for Resident #11. The facility provided evidence of the following corrective actions implemented prior to the survey:On August 5, 2025, the facility removed the defective sling from service.By August 26, 2025, the facility disposed of all existing slings and replaced them with new equipment.Between August 5, 2025 and August 26, 2025, the facility completed mechanical lift and sling competency training for CNA #1 and all other nursing staff, focusing on the requirement to inspect straps for wear before every lift.The facility updated its maintenance protocols to include specific documentation of sling integrity.The survey team verified the replacement of equipment and reviewed training logs, confirming that the corrective actions were implemented and effective by August 26, 2025.

Based on interview and record review, the facility failed to ensure that each resident was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with professional standards of practice. Specifically, for 1 of 12 residents reviewed for medication administration, one nurse failed to follow professional standards for medication identification, resulting in the administration of two medications (Lorazepam and Carvedilol) to the wrong resident (Resident #1).The facility's noncompliance was determined to be Past Noncompliance. The facility developed and implemented a corrective action plan on August 13, 2025, which included staff education on the five rights of medication administration, skills competency check-offs, and internal monitoring to ensure no further errors occurred. The survey team verified these interventions were completed prior to the survey start date of March 30, 2026. A review of facility incident reports on March 30, 2026 revealed an entry dated July 21, 2025 involving Resident #1. The report documented that a nurse inadvertently administered 0.25 mL of Lorazepam (an anti-anxiety medication) and 25 mg of Carvedilol (a beta-blocker used for blood pressure) to Resident #1. These medications were intended for a different resident.Professional standards of medication administration (the Five Rights) require that the right medication is given to the right resident, in the right dose, via the right route, at the right time.A review of a facility Progress Note dated July 22, 2025 at 7:07 AM documented that Resident #1's vital signs were monitored throughout the night following the medication error. The note indicated that the hospice nurse, nurse practitioner, and family were notified of the error. The note stated, The resident remained stable, alert, and without any signs of distress throughout the shift.During an interview on March 31, 2026, Administrator 1, Administrator 2, and the Director of Nursing (DON) acknowledged the medication error. The DON confirmed that the nurse failed to properly identify the resident prior to administering the medications.The facility provided evidence of the following corrective actions implemented prior to the start of the survey:By August 13, 2025, the facility implemented mandatory education for all licensed staff who administer medications. This training included a review of the facility's medication administration policy and the five rights of medication administration.The facility completed clinical skills check-offs (competency evaluations) for medication administration for all nursing staff to ensure adherence to safety protocols.The facility conducted a retrospective review of medication error logs and current administration cycles, which revealed no additional concerns regarding residents receiving incorrect medications.The survey team verified the completion of the education logs and competency check-offs. Through interviews and a review of quality assurance documentation, it was determined that the facility's corrective actions were implemented and effective as of August 13, 2025, prior to the current survey.

Based on interview, record review, document review, and facility policy review, the facility failed to protect the residents' rights to be free from verbal and sexual abuse by a resident. Residents #33, #71, and #351 all reported they felt threatened and/or uncomfortable around Resident #346, a resident who was know to display sexually inappropriate behaviors. The facility further failed to protect the residents' rights to be free from physical abuse by staff. On 02/14/2025, Registered Nurse (RN) #9 willfully and intentionally yanked a walker from Resident #402, which caused the resident to fall to the floor. Resident #402 sustained a 2-inch goose egg to the forehead and bruised knees. The facility substantiated that abuse occurred and terminated the employment of RN #9. These deficient practices affected 4 (Residents #33, #71, #351, and #402) of 20 sampled residents.The undated facility policy titled, Abuse Prevention Program, indicated It is the policy of this community to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy specified, a. Abuse is defined as the willful infliction of injury; unreasonable confinement; intimidation; punishment with resulting physical harm, pain or mental anguish; or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 1. An admission Record revealed the facility admitted Resident #346 on 06/20/2023. According to the admission Record, the resident had a medical history that included diagnoses of paraplegia, anxiety disorder, major depressive disorder, muscle weakness, difficulty in walking, and need for assistance with personal care. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2024, revealed Resident #346 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #346's Care Plan Report included a focus area initiated 06/21/2023, that indicated the resident was challenging and argumentative with staff, made sexually inappropriate comments and gestures to staff during care, and made inappropriate comments during group activities that were disruptive to other residents. Interventions specified the Administrator and Social Worker met with the resident to discuss their inappropriate sexual comments and the resident stated they would do their best to be respectful (initiated 06/16/2024), staff would provide 1:1 activities in the resident's room (initiated 02/03/2025), staff was instructed to perform care in pairs (initiated 12/16/2024), and staff would strive to interact pleasantly and patiently with the resident and report issues to management for assistance to manage a situation (initiated 10/16/2024). 1a. An admission Record revealed the facility admitted Resident #351 on 02/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of generalized anxiety disorder, depression, and muscle weakness. Per the admission Record, Resident #351 discharged home on [DATE]. A MDS, with an ARD of 05/20/2024, revealed Resident #351 had a BIMS score of 15, which indicated the resident had intact cognition. A Grievance/Concern Report written by Resident #351 and dated 06/21/2024, indicated Resident #351 reported that Resident #346 insulted them in front of five witnesses. The Grievance/Concern Report revealed Resident #351 reported that Resident #346 said we had a deal and you would sit on my lap during bingo or [poker]. I did not appreciate it at all. I feel threatened. A Grievance/Concern Report written by Resident #351 and dated 06/24/2024, indicated Resident #351 reported that Resident #346 was stalking them and requested the resident give them an apology. During a telephone interview on 06/27/2025 at 8:52 AM, Resident #351 stated they filed the grievance to report Resident #346 because they were emotionally stressed. Resident #351 stated Resident #346 would look at them in a way that made them feel uncomfortable. According to Resident #351, they reported their concerns to the former Administrator, who did not talk with Resident #346 right away, but later told them the facility was handling the concern. Resident #351 stated they did not know what happened afterwards because they were discharged from the facility. During an interview on 06/27/2025 at 9:13 AM, the Dietary Manager (DM) stated she was assigned to do the investigation after Resident #351 filed a grievance on 06/21/2024. The DM stated she did not remember what was said or done about the grievance filed on 06/21/2024. 1b. An admission Record revealed the facility admitted Resident #33 on 06/19/2023. According to the admission Record, the resident had a medical history that included diagnoses of need for assistance with personal care and muscle weakness. An an annual MDS, with an ARD of 04/30/2025, revealed Resident #33 had a BIMS score of 15, which indicated the resident had intact cognition. A typed and handwritten note addressed to Resident #33 indicated this note was left in Resident #33's room by Resident #346, who stated I have a note of affection and left it on [Resident #33's] floor and left. The typed portion of the note had multiple explicative words. During an interview on 06/25/2025 at 9:52 AM, Resident #33 stated that Resident #346 was one of the worst individuals they had ever met. Resident #33 stated that Resident #346 would say a lot of inappropriate comments, thinking it was funny, and it was not. Resident #33 stated the comments made by Resident #346 were sexual in nature. According to Resident #33, it took a long time to get rid of Resident #346. Resident #33 stated that it was so bad that Resident #346 would be in the room and they would leave as they did not want to be around Resident #346, and they lost out on activities because of Resident #346. Per Resident #33, they reported to the activity staff that they would not be participating in activities because of Resident #346. Resident #33 stated Resident #346 gave them a note, and they gave it to the Administrator. Resident #33 stated they did not know what happened to the note once they gave it to the Administrator. Resident #33 stated, they felt threatened by Resident #346, and this was why they did not want to be around Resident #346. 1c. An admission Record revealed the facility admitted Resident #71 on 11/18/2023. According to the admission Record, the resident had a medical history that included diagnoses of cerebral palsy and muscle weakness. A quarterly MDS, with an ARD of 05/21/2025, revealed Resident #71 had a BIMS score of 15, which indicated the resident had intact cognition. During an interview on 06/26/2025 at 1:37 PM, Resident #71 stated that Resident #346 was nice, but would not take no for an answer. Resident #71 stated Resident #346 made them uncomfortable, would say they loved them and wanted their email address. Resident #71 described Resident #346's behaviors as abusive. According to Resident #71, Resident #346 would send them letters to which they did not read. According to Resident #71, the facility staff kept the letters that Resident #346 gave them. During an interview on 06/27/2025 at 9:13 AM, the DM stated she remembered that in recreation Resident #71 had to be separated from Resident #346. The DM stated that Resident #346 was attracted to Resident #71. The DM stated she never witnessed Resident #346 being inappropriate, but she would sit in her office, which was close to the recreation area, and she heard Resident #346 speak inappropriate things towards Resident #71; however, she did not remember exactly what was said. The DM stated that Resident #71 would feel uncomfortable in recreation. The DM stated that she did not know exactly who told her, but it was a known fact to take Resident #346 away from Resident #71. During a telephone interview on 06/26/2025 at 9:50 AM, the former Resident Advocate (RA) stated Resident #346 made sexual comments to Resident #71 that made the resident uncomfortable. The former RA stated she reported the incident to the former Administrator. During a telephone interview on 06/27/2025 at 8:07 AM, the former Administrator stated there were so many instances that letters and notes were given to him, and those letters and notes were written by Resident #346. 2. An admission Record revealed the facility admitted Resident #402 on 06/06/2024. According to the admission Record, the resident had medical history that included diagnoses of heart failure, hypertension, and chronic respiratory failure. A quarterly MDS, with an ARD of 11/26/2024, revealed Resident #402 had a BIMS score of 1, which indicated the resident had severe cognitive impairment. impaired cognition. The MDS revealed the resident used a walker and required supervision or touching assistance with ambulation. Resident #402's Care Plan Report revealed a focus area initiated 06/18/2024, that indicated the resident was at risk for falls related to confusion, gait/balance problems, poor communication/comprehension, and unawareness of safety needs. Resident #402's incident report prepared by Registered Nurse (RN) #9 and dated 02/14/2025 indicated the resident had a witnessed fall in the hall at approximately 5:30 AM on 02/14/2025. The incident report indicated Resident #402 was agitated, held their walker and repeatedly pushed and pulled on their walker in the back and forth motion. Per the incident report, the resident fell to the ground, landed on their hands and knees, and bumped their forehead on the floor. According to the incident report, the resident did not experience a loss of consciousness, was assisted by to their feet by RN #9, and administered as needed morphine for their reported pain. The incident report indicated the Director of Nursing (DON) received a call from RN #9, who reported that Resident #402 had a fall. According to the incident report, once the DON arrived in the facility to check on the resident, Resident #402 reported to the DON that RN #9 made them fall. The facility Follow-Up Investigation Report dated 02/21/2025 revealed staff originally stated the incident occurred from a fall sustained by Resident #402; however, the facility was in possession of material which showed the employee (RN #9) acted in a manner that looked to be result of an independent decision made by RN #9 that was not permitted by a medical professional. Per the Follow-Up Investigation Report, it was verified by material on hand at the facility that RN #9 acted outside of approved medical practice from the facility that was a direct line to resident abuse. The Follow-Up Investigation Report indicated Resident #402 sustained bruises along with mental abuse from the incident. According to the Follow-Up Investigation Report, RN #9 was immediately placed on suspension pending investigation and their employment was terminated effective 02/20/2025 upon completion of the investigation. RN #9's undated typed statement indicated I changed [Resident #402's] oxygen last night. [He/She] became agitated this morning because [he/she] needed an oxygen tank switched. Was trying to switch [his/her] oxygen tank but [he/she] kept slapping in my arms. [He/She] was pulling [his/her] walker back and forth when I was trying to change the tank. I tried to pull the walker closer to me so I can [could] switch the oxygen tank. I pulled the walker aggressively and [he/she] fell on the floor. [He/She] thinks I said [explicative] word directly to [him/her] but I wasn't saying to [him/her]. I was frustrated and said [explicative] word but it wasn't directed to [him/her]. [He/She] said I caused [his/her] fall. Witness - no one was around when it happened. Later CAN's [CNAs, certified nursing assistants] came around when [he/she] started screaming. The Central Supply/Scheduler's typed statement dated 02/14/2025 indicated he went to get copies from the printer around 5:40 AM/5:45 AM on 02/14/2025 when he found Resident #402 in the hallway yelling hello. Per the statement, he asked the resident what was wrong and Resident #402 stated an old man pushed [him/her] down. The statement indicated the resident stated that the man pulled their cart (walker) away from them and they fell and hit their head. Per the statement, there was a bit of pink discoloration above the resident's left eye, but no other signs of trauma were noticeable at the time. The statement indicated the Central Supply/Scheduler reported to the oncoming shift what the resident stated and an investigation was started into the matter. On 06/25/2025 at 3:02 PM and 3:17 PM and 06/26/2025 at 8:54 AM, an attempt was made to interview RN #9. There was no answer, a voicemail message was left and no return call was received. During an interview on 06/25/2025 at 3:32 PM, the Central Supply/Scheduler stated when he arrived to work on 02/14/2025 between 5:00 AM and 6:00 AM, he noticed Resident #402 was in the hallway yelling that an old man had pushed them down. The Central Supply/Scheduler stated he did not ask the resident who the old man was, but he thought RN #9 was at the nurse's station. The Central Supply/Scheduler stated he took the resident back to their room and Resident #402 reported that an old man pulled their cart (walker) away from them and they fell and hit their head. The Central Supply/Scheduler stated he noticed a little bit of pink discoloration on the left side of the resident's head. The Central Supply/Scheduler stated he passed this information onto an oncoming shift certified nursing assistant (CNA) and a nurse around 5:45 AM, but he did not remember the names of the CNA or nurse. The Central Supply/Scheduler stated he also reported the incident to the Maintenance Manager (MM). During a follow-up interview on 06/27/2025 at 3:16 PM, the Central Supply/Scheduler stated he forgot to inform the surveyor that he also reported the incident to the DON. The Central Supply/Scheduler stated he called the DON after he and the MM watched the video surveillance footage of the incident. The Central Supply/Scheduler stated he saw on the video surveillance footage that RN #9 and Resident #402 stood in the hall and RN #9 pulled the resident's walker away and Resident #402 fell to the ground. During an interview on 06/26/2025 at 10:52 AM, the MM stated he came to work on 02/14/2025 around 5:30 AM and during a conversation he had with the Central Supply/Scheduler around 5:30 AM/5:45 AM, the Central Supply/Scheduler stated a resident had a fall in the hallway. The MM stated he and the Central Supply/Scheduler watched the video surveillance footage around5:50 AM and then the Central Supply/Scheduler called the DON at 6:05 AM, while he called the former Administrator at 6:05 AM. During a follow-up interview on 06/27/2025 at 3:10 PM, the MM stated when he watched the video surveillance footage, he saw RN #9 interacting with Resident #402, then the resident moved their walker away from RN #9. The MM stated he saw there was a conversation between RN #9 and Resident #402, then RN #9 yanked the walker from the resident and Resident #402 fell to the floor. The MM stated RN #9 then helped the resident back up to their feet and picked up the resident's walker. According to the MM, the timestamp on the video surveillance footage was 5:00 AM. During an interview on 06/26/2025 at 11:19 AM, the DON stated she received a telephone call from RN #9 on 02/14/2025 at 5:40 AM and RN #9 asked if he was going to lose his job. The DON stated RN #9 reported that he helped Resident #402 with their oxygen and in the process the resident pushed him with their walker and fell to the ground on their knees. The DON stated she asked RN #9 if the resident was okay and RN #9 reported that the resident was good and sitting in the lobby. The DON stated then around 7:00 AM she received a call from the Central Supply/Scheduler who stated come in now that he was sitting in the lobby with Resident #402. The DON stated she arrived in the facility around 7:15 AM she found the Central Supply/Scheduler sitting with Resident #402. According to the DON, the Central Supply/Scheduler whispered to her that RN #9 did something to Resident #402. The DON stated when she asked the resident what happened, Resident #402 reported that RN #9 made them fall. The DON stated she assessed the resident at 7:15 AM and found the resident had a 2-inch sized goose egg on their forehead and bruised knees. The DON stated she then notified the former Administrator of the incident around 7:50 AM/8:00 AM and the investigation was initiated. During a follow-up interview on 06/27/2025 at 3:41 PM, the DON stated RN #9 did acknowledge that he used a curse word during the incident with Resident #402, but the curse word was not directed towards the resident. The DON stated she watched the video surveillance footage and saw RN #9 and Resident #402 standing in the hall, then it looked like they were having a conversation and then RN #9 very strongly pulled the walker away from the resident which caused the resident to fall. The DON stated she saw Resident #402 on the floor and then she walked away from watching the video because she was so upset about what she saw. During an interview on 06/27/2025 at 2:23 PM, the former Administrator stated he received a call on 02/14/2025 around 7:30 AM/8:00 AM from the DON that Resident #402 alleged abuse and reported they were pushed or some act made them fall to the ground and the incident needed to be looked into. The former Administrator stated when he arrived in the facility around 8:30 AM on 02/14/2025, he interviewed Resident #402 and reviewed the video surveillance footage. The former Administrator stated after he watched the video surveillance footage, RN #9 was placed on suspension, the resident was moved to a different room, staff were in-serviced on abuse, and reports were made to the state survey agency. The former Administrator stated after the investigation was completed RN #9's employment was terminated. During an interview on 06/28/2025 at 2:04 PM, the Administrator stated he was out of the country on vacation during the time of the incident and returned to the facility on [DATE]. The Administrator stated when he returned on 02/17/2025, the investigation had been completed and the outcome indicated there was substantiated abuse by a staff (RN #9) to a resident (Resident #402).

Based on interview, record review, and document review, the facility failed to ensure residents and/or their representatives were afforded 30 days to revoke their signed binding arbitration agreement for 3 (Residents #62, #78, and #82) of 3 sampled residents reviewed for arbitration.The facility Binding Arbitration Agreement with a copyright date of 2024, indicated 9. Revocation: This Agreement may be revoked by the Resident by written notice mailed to the Administrator of the Facility, using certified mail with return receipt requested, within ten (10) days after the date hereof, and if not revoked shall govern all aspects of the relationship between Facility and Resident upon and after the date of the Agreement.1. An admission Record indicated the facility admitted Resident #62 on 05/19/2023.Resident #62's undated Binding Arbitration Agreement signed by the resident and the printed name of the Dietary Manager indicated, 9. Revocation: This Agreement may be revoked by the Resident by written notice mailed to the Administrator of the Facility, using certified mail with return receipt requested, within ten (10) days after the date hereof, and if not revoked shall govern all aspects of the relationship between Facility and Resident upon and after the date of the Agreement.2. An admission Record indicated the facility admitted Resident #78 on 06/22/2025.Resident #78's undated Binding Arbitration Agreement signed by the resident and the Medical Records Manager indicated, 9. Revocation: This Agreement may be revoked by the Resident by written notice mailed to the Administrator of the Facility, using certified mail with return receipt requested, within ten (10) days after the date hereof, and if not revoked shall govern all aspects of the relationship between Facility and Resident upon and after the date of the Agreement.3. An admission Record indicated the facility admitted Resident #82 on 05/14/2025.Resident #82's Binding Arbitration Agreement dated 05/16/2025 and signed by the resident and a facility representative indicated, 9. Revocation: This Agreement may be revoked by the Resident by written notice mailed to the Administrator of the Facility, using certified mail with return receipt requested, within ten (10) days after the date hereof, and if not revoked shall govern all aspects of the relationship between Facility and Resident upon and after the date of the Agreement.During an interview on 06/25/2025 at 9:54 AM, the Marketing Admissions Director stated she was responsible for getting residents and/or their representatives to sign the binding arbitration agreements. The Marketing Admissions Director stated the binding arbitration agreement only allowed for 10 days to revoke the agreement.During an interview on 06/25/2025 at 10:15 AM, the Administrator stated that according to the state regulations, 10 days was a sufficient period to rescind the binding arbitration agreement. The surveyor provided the Administrator with the federal regulation related to the revocation of a binding arbitration agreement and the Administrator stated he would look into it.During a follow-up interview on 06/25/2025 at 11:00 AM, the Administrator stated he would obtain a corrected binding arbitration agreement.During an interview on 06/26/2025 at 3:33 PM, the Director of Nursing stated she did not know anything about the binding arbitration agreement.During an interview on 06/27/2025 at 8:52 AM, the Administrator stated his expectation was to follow both the state and federal regulations related to the binding arbitration agreement.

Based on interview, record review, and document review, the facility failed to ensure residents and/or their representatives were afforded an arbitration venue convenient to both parties for 3 (Residents #62, #78, and #82) of 3 sampled residents reviewed for arbitration.The facility Binding Arbitration Agreement with a copyright date of 2024, revealed no evidence to indicate for the selection of an arbitration venue that was convenience to both parties.1. An admission Record indicated the facility admitted Resident #62 on 05/19/2023.Resident #62's undated Binding Arbitration Agreement signed by the resident and the printed name of the Dietary Manager revealed no evidence to indicate for the selection of an arbitration venue that was convenience to both parties.2. An admission Record indicated the facility admitted Resident #78 on 06/22/2025.Resident #78's undated Binding Arbitration Agreement signed by the resident and the Medical Records Manager revealed no evidence to indicate for the selection of an arbitration venue that was convenience to both parties.3. An admission Record indicated the facility admitted Resident #82 on 05/14/2025.Resident #82's Binding Arbitration Agreement dated 05/16/2025 and signed by the resident and a facility representative revealed no evidence to indicate for the selection of an arbitration venue that was convenience to both parties.During an interview on 06/25/2025 at 9:54 AM, the Marketing Admissions Director stated she was responsible for getting residents and/or their representatives to sign the binding arbitration agreements. The Marketing Admissions Director stated it was discussed with residents about how the arbitration might be held at a neutral location, but she was unsure if it was specifically provided for in the binding arbitration agreement.During an interview on 06/25/2025 at 10:15 AM, the Administrator stated the state regulations did not require the facility specify a neutral location. The surveyor provided the Administrator with the federal regulation related to an arbitration venue that was convenience to both parties.the revocation of a binding arbitration agreement and the Administrator stated he would look into it.During a follow-up interview on 06/25/2025 at 11:00 AM, the Administrator stated he would obtain a corrected binding arbitration agreement.During an interview on 06/26/2025 at 3:33 PM, the Director of Nursing stated she did not know anything about the binding arbitration agreement.During an interview on 06/27/2025 at 8:52 AM, the Administrator stated his expectation was to follow both the state and federal regulations related to the binding arbitration agreement.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff were fit tested annually. This deficient practice had the potential to affect all residents who resided in the facility. The facility failed to ensure staff performed proper hand hygiene during the provision of dialysis for 1 (Resident #82) of 1 sampled resident reviewed for dialysis. The facility further failed to ensure staff cleaned and stored respiratory equipment for 1 (Resident #40) of 2 sampled residents reviewed for respiratory care.1. During an interview on 06/26/2025 at 3:20 PM, the Director of Nursing (DON) stated the facility followed the Centers for Disease Control and Prevention (CDC) guidelines for fit tests.An undated document published by the Centers for Disease Control and Prevention and the National Institute for Occupational Safety and Health, indicated How Often Must Fit Testing Be Conducted? In addition to fit testing upon initially selecting a model of respirator, OSHA [Occupational Safety and Health Administration] requires that fit testing be conducted annually, and repeated whenever an employee reports, or the employer or the physician or other licensed health care professional makes visual observations of changes in the employee's physical condition that could affect respirator fit.During an interview on 06/26/2025 at 1:22 PM, the DON, who also served as the Infection Preventionist, stated the facility did not fit test the staff in 2024.During a follow-up interview on 06/26/2025 at 1:53 PM, the DON stated the facility last fit tested staff in 2022. Per the DON, a lot of staff had been hired since 2022 and the facility just passed out a respirator mask to everyone.During an interview on 06/27/2025 at 8:52 AM, the Administrator stated the facility followed the CDC guidelines related to fit tests and staff should be fit tested annually.During an interview on 06/28/2025 at 4:14 PM, the Central Supply/Scheduler stated he had no idea when he was last fit tested.During an interview on 06/28/2025 at 4:15 PM, the Maintenance Manager stated he was last fit tested in 2022.During an interview on 06/28/2025 at 4:15 PM, the DON stated she was last fit tested in 2022.During an interview on 06/28/2025 at 4:20 PM, Licensed Practical Nurse #6 stated she did not remember when she was last fit tested.During an interview on 06/28/2025 at 4:22 PM, Registered Nurse Unit Manager #5 stated she was last fit tested in 2022.2. The Central Venous Catheter Care & Dressing Change, policy and procedure dated 04/2024, revealed 1. All Central Venous Catheter dressings will be changed using aseptic technique to prevent infection.An admission Record indicated the facility admitted Resident #82 on 05/14/2025. According to the admission Record, the resident had a medical history to include diagnoses of end stage renal disease and dependence of renal dialysis.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2025, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident received dialysis.Resident #82's Care Plan Report included a focus area initiated 05/17/2025, that indicated the resident needed hemodialysis related to end stage renal disease. Interventions indicated the resident received in-house dialysis from an outside dialysis provider.During an observation on 06/25/2025 at 11:28 AM, Patient Care Technician (PCT) #8 touched a marker, Resident #82's medical record, medical tape, the dialyzer machine and her mask. PCT #8 was noted to not change her gloves or wash her hands before she applied a catheter needle to the resident's access site.During an interview on 06/25/2025 at 11:38 AM, PCT #8 confirmed she did not sanitize her hands when she changed her gloves after she touched objects and before she performed care on the resident. PCT #8 stated she was expected to do so.During an interview on 06/25/2025 at 11:42 AM, Registered Nurse (RN) #25 stated she was the head nurse at the dialysis center. RN #25 confirmed staff were to sanitize their hands when they changed their gloves during sterile procedures. According to RN #25, PCT #8 should have sanitized her hands after she touched nonsterile objects and before she inserted the catheter.During an interview on 06/26/2025 at 1:22 PM, the Director of Nursing (DON) stated staff were expected staff to sanitize their hands when they changed their gloves. Per the DON, staff were expected to sanitize their hands after they touched nonsterile objects and before they inserted a catheter into a resident's access site.During an interview on 06/27/2025 at 8:52 AM, the Administrator stated he expected staff to follow proper infection control procedures during the provision of care.3. A facility policy titled, Respiratory/Pulmonary Conditions: CPAP/BiPAP [continuous positive airway pressure/bilevel positive airway pressure] Support, dated 01/01/2024, indicated, 6. Mask, nasal pillows, and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses.An admission Record indicated the facility admitted Resident #40 on 07/27/2018. According to the admission Record, the resident had a medical history that included diagnoses of systemic lupus erythematosus, insomnia, and sleep apnea.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2025, revealed Resident 40 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment.Resident #40's Care Plan Report included a focus area initiated 06/06/2022 and revised 07/18/2023, that indicated the resident had altered respiratory status and difficulty breathing related to sleep apnea. Interventions revealed the resident had a CPAP and the CPAP should be administered as ordered by the physician (initiated 06/06/2024 and revised 06/27/2024).Resident #40's Order Summary Report for active orders as of 06/24/2025, revealed and order dated 06/17/2024, for CPAP to be worn when sleeping every night shift and an order dated 06/27/2024, for CPAP/BiPAP daily mask cleaning and storage.During an observation on 06/23/2025 at 10:16 AM, 06/24/2025 at 8:20 AM, and 06/25/2025 at 8:18 AM, Resident #40 was noted in bed and the resident's CPAP mask was lying on top of the machine with dried debris inside the mask. The mask was not stored in a bag, and there was no bag visible in the resident's room.During an observation on 06/25/2025 at 2:53 PM and 06/26/2025 at 1:33 PM, Resident #40 was not present in their room, but there CPAP mask was on top of the machine on the nightstand. The CPAP was not stored in a bag, there was no bag visible in the room, and there was dried debris on the mask.During an interview on 06/26/2025 at 3:40 PM, Registered Nurse (RN) #2 stated CPAP masks should be cleaned after use with a wipe and stored in a bag. RN #2 stated she did not do anything with Resident #40's CPAP since they wore it at night. RN #2 stated she had never cleaned Resident #40's mask, but knew it was supposed to be done daily. RN #2 confirmed the mask was lying on top of the machine, the mask had not been cleaned, and there was not a bag to store the mask in.During an interview on 06/28/2025 at 8:56 AM, the Director of Nursing stated CPAP tubing and masks should be cleaned with soap and water and then stored in a bag.During an interview on 06/28/2025 at 9:25 AM, RN Unit Manager #5 stated CPAP masks should be cleaned with water and soap and placed in a bag when not in use.During an interview on 06/28/2025 at 10:23 AM, the Administrator stated he would expect staff to follow their policy for the cleaning and storage of CPAP equipment.

Based on interview, document review, and facility policy review, the facility failed to ensure quarterly quality assurance performance improvement (QAPI) meetings were conducted and the facility maintained a list of staff who were present/participated in the quarterly QAPI meetings. These deficient practices had the potential to affect all residents who resided in the facility.A facility policy titled, QAPI Program, with a copyright date of 2024, indicated, [Facility name] QAPI team shall meet at least quarterly to review all Quality Assurance Performance Improvement items.During an interview on 06/28/2025 at 11:50 AM, the Administrator the facility was recently purchased from another company, so the current administrative team had only had one QAPI meeting, which was in 03/2025. The Administrator reported he was not able to find documentation of the 03/2025 QAPI meeting, to include the list of attendees. According to the Administrator, the only evidence he had of QAPI meetings was the documentation listed in the QAPI binder.The facility binder titled QAPI-2024 revealed documentation to indicate a QAPI meeting was held on 03/19/2024 and 04/24/2024. There was no evidence to indicate who attended/participated in the QAPI meeting held on 03/19/2024 or 04/24/2024.During a follow-up interview on 06/28/2025 at 1:43 PM, the Administrator reported he would expect the facility to have quarterly QAPI meetings and for there to be a sign-in sheet to show who attended the meetings.

Based on interview, record review, document review, and facility policy review, the facility failed to thorough investigate allegations of abuse that involved 4 (Residents #33, #71, #351, and #402) of 20 sampled residents.Findings included: The undated facility policy titled, Abuse Prevention Program, indicated 4 Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether anyone has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of property by the accused individual. An admission Record revealed the facility admitted Resident #402 on 06/06/2024. According to the admission Record, the resident had medical history that included diagnoses of heart failure, hypertension, and chronic respiratory failure. A quarterly Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 11/26/2024, revealed Resident #402 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. impaired cognition. The MDS revealed the resident used a walker and required supervision or touching assistance with ambulation. Resident #402's incident report prepared by Registered Nurse (RN) #9 and dated 02/14/2025 indicated the resident had a witnessed fall in the hall at approximately 5:30 AM on 02/14/2025. The incident report indicated Resident #402 was agitated, held their walker and repeatedly pushed and pulled on their walker in the back and forth motion. Per the incident report, the resident fell to the ground, landed on their hands and knees, and bumped their forehead on the floor. According to the incident report, the resident did not experience a loss of consciousness, was assisted by to their feet by RN #9, and administered as needed morphine for their reported pain. The incident report indicated the Director of Nursing (DON) received a call from RN #9, who reported that Resident #402 had a fall. According to the incident report, once the DON arrived in the facility to check on the resident, Resident #402 reported to the DON that RN #9 made them fall. The facility Follow-Up Investigation Report dated 02/21/2025 revealed staff originally stated the incident occurred from a fall sustained by Resident #402; however, the facility was in possession of material which showed the employee (RN #9) acted in a manner that looked to be result of an independent decision made by RN #9 that was not permitted by a medical professional. Per the Follow-Up Investigation Report, it was verified by material on hand at the facility that RN #9 acted outside of approved medical practice from the facility that was a direct line to resident abuse. The Follow-Up Investigation Report indicated Resident #402 sustained bruises along with mental abuse from the incident. According to the Follow-Up Investigation Report, RN #9 was immediately placed on suspension pending investigation and their employment was terminated effective 02/20/2025 upon completion of the investigation. During an interview on 06/26/2025 at 11:19 AM, the DON stated when she asked the resident what happened, Resident #402 reported that RN #9 made them fall. The DON stated she assessed the resident at 7:15 AM and found the resident had a 2-inch sized goose egg on their forehead and bruised knees. The DON stated she then notified the former Administrator of the incident around 7:50 AM/8:00 AM and the investigation was initiated. The DON stated she and Administrator in Training (AIT) #11 were responsible for the investigation of the allegation. The DON stated she was responsible for conducting body audits while social services interviewed residents who resided on the same hall as Resident #402. The DON stated she was not aware body audits were not conducted on all the residents or that the facility failed to interview all residents. The DON acknowledged the investigation only centered around residents on the hall that Resident #402 resided on. The DON stated she did not think about the other residents since RN #9 had access to all residents of the facility. During an interview on 06/26/2025 at 9:41 AM, AIT #11 stated the DON notified him of the incident on 02/14/2025 between 8:00 AM and 8:30 AM. AIT #11 stated it was first reported Resident #402 tried to push away from RN #9 and fell. AIT #11 stated he reviewed the video surveillance footage, placed RN #9 on suspension pending the investigation, interviewed Resident #402 and then had the resident moved to a different room. AIT #11 stated the resident was assessed and found to have minimal injuries, to include a bump on their forehead. AIT #11 stated he was directed by the Chief Nursing Officer (CNO) to interview all residents that resided on the same unit as Resident #402. AIT #11 stated statements were obtained from Resident #402, RN #9, the Central Supply/Scheduler, the DON, and Certified Nursing Assistant #12. According to AIT #11, other notifications included the local police, the physician, the resident's family, the Ombudsman, and Adult Protective Services. AIT #11 stated the facility did not interview other residents that resided throughout the facility or conducted body audits of residents who were not interviewable as the result of the incident. During an interview on 06/27/2025 at 1:41 PM, the CNO stated when she arrived in the facility the investigation was already underway and she provided support to the staff. The CNO stated she could not speak to why only other residents were not interviewed or why body audits were not conducted on residents who were not interviewable. 2. An admission Record revealed the facility admitted Resident #346 on 06/20/2023. According to the admission Record, the resident had a medical history that included diagnoses of paraplegia, anxiety disorder, major depressive disorder, muscle weakness, difficulty in walking, and need for assistance with personal care. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2024, revealed Resident #346 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. 2a. An admission Record revealed the facility admitted Resident #351 on 02/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of generalized anxiety disorder, depression, and muscle weakness. Per the admission Record, Resident #351 discharged home on [DATE]. A Minimum Data Set (MDS), with an Assessment Reference Data (ARD) of 05/20/2024, revealed Resident #351 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A Grievance/Concern Report written by Resident #351 and dated 06/21/2024, indicated Resident #351 reported that Resident #346 insulted them in front of five witnesses. The Grievance/Concern Report revealed Resident #351 reported that Resident #346 said we had a deal and you would sit on my lap during bingo or [poker]. I did not appreciate it at all. I feel threatened. A Grievance/Concern Report written by Resident #351 and dated 06/24/2024, indicated Resident #351 reported that Resident #346 was stalking them and requested the resident give them an apology. During a telephone interview on 06/27/2025 at 8:52 AM, Resident #351 stated they filed the grievance to report Resident #346 because they was emotionally stressed. Resident #351 stated Resident #346 would look at them in a way that made them feel uncomfortable. According to Resident #351, they reported their concerns to the former Administrator, who did not talk with Resident #346 right away, but later told them the facility was handling the concern. Resident #351 stated they did not know what happened afterwards because they discharged from the facility. During an interview on 06/27/2025 at 9:13 AM, the Dietary Manager (DM) stated she was assigned to do the investigation after Resident #351 filed a grievance on 06/21/2024. The DM stated she did not remember what was said or done about the grievance filed on 06/21/2024. Review of facility documents revealed no evidence to indicate an investigation had been conducted related to the concerns expressed by Resident #351. 2b. An admission Record revealed the facility admitted Resident #33 on 06/19/2023. According to the admission Record, the resident had a medical history that included diagnoses of need for assistance with personal care and muscle weakness. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2025, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A typed and handwritten note addressed to Resident #33 indicated this note was left in Resident #33's room by Resident #346, who stated I have a note of affection and left it on [Resident #33's] floor and left. The typed portion of the note had multiple explicative words. During an interview on 06/25/2025 at 9:52 AM, Resident #33 stated that Resident #346 was one of the worst individuals they had ever met. Resident #33 stated that Resident #346 would say a lot of inappropriate comments, thinking it was funny, and it was not. Resident #33 stated the comments made by Resident #346 were sexual in nature. According to Resident #33, it took a long time to get rid of Resident #346. Resident #33 stated that it was so bad that Resident #346 would be in the room and they would leave as they did not want to be around Resident #346, and they lost out on activities because of Resident #346. Per Resident #33, they reported to the activity staff that they would not be participating in activities because of Resident #346. Resident #33 stated Resident #346 gave them a note, and they gave it to the Administrator. Resident #33 stated they did not know why happened to note once they gave it to the Administrator. Resident #33 stated, they felt threatened by Resident #346, and this was why they did not want to be around Resident #346. Review of facility documents revealed no evidence to indicate an investigation had been conducted related to the concerns expressed by Resident #33. 2c. An admission Record revealed the facility admitted Resident #71 on 11/18/2023. According to the admission Record, the resident had a medical history that included diagnoses of cerebral palsy and muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During an interview on 06/26/2025 at 1:37 PM, Resident #71 stated that Resident #346 was nice, but would not take no for an answer. Resident #71 stated Resident #346 made them uncomfortable, would say they loved them and wanted their email address. Resident #71 described Resident #346's behaviors as abusive. According to Resident #71, Resident #346 would send them letters to which they did not read. According to Resident #71, the facility staff kept the letters that Resident #346 gave them. Review of facility documents revealed no evidence to indicate an investigation had been conducted related to the concerns expressed by Resident #71. During an interview on 06/27/2025 at 9:13 AM, the Dietary Manager (DM) stated she remembered that in recreation Resident #71 had to be separated from Resident #346. The DM stated that Resident #346 was attracted to Resident #71. The DM stated she never witnessed Resident #346 being inappropriate, but she would sit in her office, which was close to the recreation area, and she heard Resident #346 speak inappropriate things towards Resident #71; however, she did not remember exactly what was said. The DM stated that Resident #71 would feel uncomfortable in recreation. The DM stated that she did not know exactly who told her, but it was a known fact to take Resident #346 away from Resident #71. During a telephone interview on 06/26/2025 at 9:50 AM, the former Resident Advocate (RA) stated Resident #346 made sexual comments to Resident #71 that made the resident uncomfortable. The former RA stated she reported the incident to the former Administrator. During a telephone interview on 06/27/2025 at 8:07 AM, the former Administrator stated there were so many instances that letters and notes were given to him, and those letters and notes were written by Resident #346. The former Administrator acknowledged the incidents perpetrated by Resident #346 that involved Residents #33, #71, and #351 were not investigated because the residents never reported they were abused.

Based on interview, record review, document review, and facility policy review, the facility failed to timely report to the state survey agency an allegation of abuse and further failed to submit their completed investigation to the state survey agency within five working days for 1 (Resident #402) of 2 sampled residents reviewed for abuse. The facility further failed to report allegations of abuse to the state survey agency that involved 3 (Residents #33, #71, and #351) of 20 sampled residents.Findings included: The undated facility policy titled, Abuse Prevention Program, indicated VII. External Reporting of Potential Abuse 1. Initial Reporting of Allegations Any allegations of abuse will be reported to the Administrator immediately and to the State Department of Health and the resident's representative immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. The policy specified, 2. Five-day Final Abuse Investigation Report - Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the community has taken in response to the allegation, will be send the Department of Health. 1. An admission Record revealed the facility admitted Resident #402 on 06/06/2024. According to the admission Record, the resident had medical history that included diagnoses of heart failure, hypertension, and chronic respiratory failure. A quarterly Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 11/26/2024, revealed Resident #402 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. impaired cognition. The MDS revealed the resident used a walker and required supervision or touching assistance with ambulation. Resident #402's incident report prepared by Registered Nurse (RN) #9 and dated 02/14/2025 indicated the resident had a witnessed fall in the hall at approximately 5:30 AM on 02/14/2025. The incident report indicated Resident #402 was agitated, held their walker and repeatedly pushed and pulled on their walker in the back and forth motion. Per the incident report, the resident fell to the ground, landed on their hands and knees, and bumped their forehead on the floor. According to the incident report, the resident did not experience a loss of consciousness, was assisted by to their feet by RN #9, and administered as needed morphine for their reported pain. The incident report indicated the Director of Nursing (DON) received a call from RN #9, who reported that Resident #402 had a fall. According to the incident report, once the DON arrived in the facility to check on the resident, Resident #402 reported to the DON that RN #9 made them fall. The facility reported incident report indicated the facility notified the state survey agency of an allegation of physical, mental/verbal abuse on 02/14/2025 at 10:00 AM. Per the report and based on information received from Resident #402 and RN #9, physical and verbal abuse may have occurred. The facility Follow-Up Investigation Report dated 02/21/2025 revealed staff originally stated the incident occurred from a fall sustained by Resident #402; however, the facility was in possession of material which showed the employee (RN #9) acted in a manner that looked to be result of an independent decision made by RN #9 that was not permitted by a medical professional. Per the Follow-Up Investigation Report, it was verified by material on hand at the facility that RN #9 acted outside of approved medical practice from the facility that was a direct line to resident abuse. The Follow-Up Investigation Report indicated Resident #402 sustained bruises along with mental abuse from the incident. According to the Follow-Up Investigation Report, RN #9 was immediately placed on suspension pending investigation and their employment was terminated effective 02/20/2025 upon completion of the investigation. There was no evidence to indicate the facility reported submitted their Follow-Up Investigation Report to the state survey agency. During an interview on 06/25/2025 at 3:32 PM, the Central Supply/Scheduler stated when he arrived to work on 02/14/2025 between 5:00 AM and 6:00 AM, he noticed Resident #402 was in the hallway yelling that an old man had pushed them down. The Central Supply/Scheduler stated he took the resident back to their room and Resident #402 reported that an old man pulled their cart (walker) away from them and they fell and hit their head. The Central Supply/Scheduler stated he noticed a little bit of pink discoloration on the left side of the resident's head. During a follow-up interview on 06/27/2025 at 3:16 PM, the Central Supply/Scheduler stated he forgot to inform the surveyor that he also reported the incident to the DON. The Central Supply/Scheduler stated he called the DON after he and the Maintenance Manager watched the video surveillance footage of the incident. The Central Supply/Scheduler stated he saw on the video surveillance footage that RN #9 and Resident #402 stood in the hall and RN #9 pulled the resident's walker away and Resident #402 fell to the ground. During an interview on 06/26/2025 at 11:19 AM, the DON stated she received a telephone call from RN #9 on 02/14/2025 at 5:40 AM and RN #9 asked if he was going to lose his job. The DON stated RN #9 reported that he helped Resident #402 with their oxygen and in the process the resident pushed him with their walker and fell to the ground on their knees. The DON stated then around 7:00 AM she received a call from the Central Supply/Scheduler who stated come in now that he was sitting in the lobby with Resident #402. The DON stated she arrived in the facility around 7:15 AM she found the Central Supply/Scheduler sitting with Resident #402. According to the DON, the Central Supply/Scheduler whispered to her that RN #9 did something to Resident #402. The DON stated when she asked the resident what happened, Resident #402 reported that RN #9 made them fall. The DON stated she assessed the resident at 7:15 AM and found the resident had a 2-inch sized goose egg on their forehead and bruised knees. The DON stated she then notified the former Administrator of the incident around 7:50 AM/8:00 AM. The DON acknowledged the allegation of abuse that involved Resident #402 and RN #9 was not reported to the state survey agency within two hours as it was reported at 10:00 AM. During an interview on 06/27/2025 at 2:23 PM, the former Administrator stated he received a call on 02/14/2025 around 7:30 AM/8:00 AM from the DON that Resident #402 alleged abuse and reported they were pushed or some act made them fall to the ground and the incident needed to be looked into. The former Administrator stated when he arrived in the facility around 8:30 AM on 02/14/2025, he interviewed Resident #402 and reviewed the video surveillance footage. The former Administrator stated after he watched the video surveillance footage, RN #9 was placed on suspension, the resident was moved to a different room, staff were in-serviced on abuse, and reports were made to the state survey agency. The former Administrator stated the incident was reported to the state survey agency on 02/14/2025 at 10:00 AM. According to the former Administrator, the allegation of abuse was late being reported to the state survey agency. Email correspondence from the state survey agency dated 06/27/2025 at 4:24 PM indicated the facility did not send a five-day report for the staff-to-resident abuse that occurred on 02/14/2025. 2. An admission Record revealed the facility admitted Resident #346 on 06/20/2023. According to the admission Record, the resident had a medical history that included diagnoses of paraplegia, anxiety disorder, major depressive disorder, muscle weakness, difficulty in walking, and need for assistance with personal care. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/26/2024, revealed Resident #346 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. 2a. An admission Record revealed the facility admitted Resident #351 on 02/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of generalized anxiety disorder, depression, and muscle weakness. Per the admission Record, Resident #351 discharged home on [DATE]. A Minimum Data Set (MDS), with an Assessment Reference Data (ARD) of 05/20/2024, revealed Resident #351 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A Grievance/Concern Report written by Resident #351 and dated 06/21/2024, indicated Resident #351 reported that Resident #346 insulted them in front of five witnesses. The Grievance/Concern Report revealed Resident #351 reported that Resident #346 said we had a deal and you would sit on my lap during bingo or [poker]. I did not appreciate it at all. I feel threatened. A Grievance/Concern Report written by Resident #351 and dated 06/24/2024, indicated Resident #351 reported that Resident #346 was stalking them and requested the resident give them an apology. During a telephone interview on 06/27/2025 at 8:52 AM, Resident #351 stated they filed the grievance to report Resident #346 because they was emotionally stressed. Resident #351 stated Resident #346 would look at them in a way that made them feel uncomfortable. According to Resident #351, they reported their concerns to the former Administrator, who did not talk with Resident #346 right away, but later told them the facility was handling the concern. Resident #351 stated they did not know what happened afterwards because they discharged from the facility. During an interview on 06/27/2025 at 9:13 AM, the Dietary Manager (DM) stated she was assigned to do the investigation after Resident #351 filed a grievance on 06/21/2024. The DM stated she did not remember what was said or done about the grievance filed on 06/21/2024. 2b. An admission Record revealed the facility admitted Resident #33 on 06/19/2023. According to the admission Record, the resident had a medical history that included diagnoses of need for assistance with personal care and muscle weakness. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2025, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A typed and handwritten note addressed to Resident #33 indicated this note was left in Resident #33's room by Resident #346, who stated I have a note of affection and left it on [Resident #33's] floor and left. The typed portion of the note had multiple explicative words. During an interview on 06/25/2025 at 9:52 AM, Resident #33 stated that Resident #346 was one of the worst individuals they had ever met. Resident #33 stated that Resident #346 would say a lot of inappropriate comments, thinking it was funny, and it was not. Resident #33 stated the comments made by Resident #346 were sexual in nature. According to Resident #33, it took a long time to get rid of Resident #346. Resident #33 stated that it was so bad that Resident #346 would be in the room and they would leave as they did not want to be around Resident #346, and they lost out on activities because of Resident #346. Per Resident #33, they reported to the activity staff that they would not be participating in activities because of Resident #346. Resident #33 stated Resident #346 gave them a note, and they gave it to the Administrator. Resident #33 stated they did not know why happened to note once they gave it to the Administrator. Resident #33 stated, they felt threatened by Resident #346, and this was why they did not want to be around Resident #346. 2c. An admission Record revealed the facility admitted Resident #71 on 11/18/2023. According to the admission Record, the resident had a medical history that included diagnoses of cerebral palsy and muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During an interview on 06/26/2025 at 1:37 PM, Resident #71 stated that Resident #346 was nice, but would not take no for an answer. Resident #71 stated Resident #346 made them uncomfortable, would say they loved them and wanted their email address. Resident #71 described Resident #346's behaviors as abusive. According to Resident #71, Resident #346 would send them letters to which they did not read. According to Resident #71, the facility staff kept the letters that Resident #346 gave them. During an interview on 06/27/2025 at 9:13 AM, the Dietary Manager (DM) stated she remembered that in recreation Resident #71 had to be separated from Resident #346. The DM stated that Resident #346 was attracted to Resident #71. The DM stated she never witnessed Resident #346 being inappropriate, but she would sit in her office, which was close to the recreation area, and she heard Resident #346 speak inappropriate things towards Resident #71; however, she did not remember exactly what was said. The DM stated that Resident #71 would feel uncomfortable in recreation. The DM stated that she did not know exactly who told her, but it was a known fact to take Resident #346 away from Resident #71. During a telephone interview on 06/26/2025 at 9:50 AM, the former Resident Advocate (RA) stated Resident #346 made sexual comments to Resident #71 that made the resident uncomfortable. The former RA stated she reported the incident to the former Administrator. During a telephone interview on 06/27/2025 at 8:07 AM, the former Administrator stated there were so many instances that letters and notes were given to him, and those letters and notes were written by Resident #346. The former Administrator acknowledged the incidents perpetrated by Resident #346 that involved Residents #33, #71, and #351 were not reported to the state survey agency because the residents never reported they were abused.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's room provided enough space so that they could access their bathroom in a motorized wheelchair for 1 (Resident #15) of 5 sampled residents reviewed for the environment.Findings included: A facility policy titled, Resident Rights/Dignity: Homelike Environment, dated 02/01/2024, revealed Our facility's environment and staff behaviors are directed toward assisting the resident maintaining and/or achieving safe independent functioning dignity and well-being. The policy specified, 3. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. An admission Record revealed the facility admitted Resident #14 on 11/22/2023. According to the admission Record, the resident had a medical history that included diagnoses of complete traumatic amputation at level between right hip and knee, difficulty in walking, muscle weakness, and complete traumatic amputation at level between knee and ankle, left lower leg. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/26/2025, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident used a wheelchair as a mobility device, had impairments on the both sides in their lower extremities, required partial/moderate assistance with toileting hygiene and toilet transfer, and was occasionally incontinent of bladder and frequently incontinent of bowel. Resident #14's Care Plan Report included a focus area initiated 07/09/2024, that indicated the resident had limited physical mobility. Interventions revealed the resident used a motorized wheelchair (initiated 07/09/2024.) During a concurrent interview and observation on 06/23/2025 at 9:24 AM, Resident #14 stated they wore an incontinence brief because their bed did not allow enough room for them to enter their bathroom with their motorized wheelchair. The surveyor observed Resident #14 attempt to enter the bathroom in their motorized wheelchair. The resident's motorized wheelchair bumped the foot of their bed and did not allow enough space to reach the door, open the door, or enter the bathroom. During a follow-up interview on 06/27/2025 at 3:17 PM, Resident #14 stated they told Registered Nurse (RN) Unit Manager #5 that their bed blocked access to the bathroom and RN Unit Manager #5 stated that their bed could be placed against the other wall in their room. During an observation on 06/27/2025 at 3:17 PM, Resident #14's headboard was not against the wall, this created a gap of several inches and impeded access to the bathroom door. During an interview on 06/27/2025 at 3:36 PM, RN Unit Manager #5 stated Resident #14 had been in their new room for about three weeks. RN Unit Manager #5 stated she did not think Resident #14 had any issues going into their bathroom. Per RN Unit Manager #5, when the resident was in their old room, they went to the bathroom, but she needed to find out why the resident no longer went into the bathroom. RN Unit Manager #5 denied the resident told her that their bed blocked access to the bathroom. During an interview on 06/28/2025 at 12:55 PM, the Director of Nursing stated Resident #14 should be able to access their bathroom in their motorized wheelchair. During an interview on 06/28/2025 at 1:09 PM, the Administrator stated he expected a resident to be able to access a bathroom commode with a power wheelchair, if appropriate.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the licensed nursing staff documented the refusal of medication for 1 (Resident #97) of 5 residents observed for medication administration. The facility further failed to ensure the licensed nursing staff documented why medication was not administered to 1 (Resident #82) of 1 sampled resident reviewed for insulin.1. A facility policy titled, Medication: Documentation of Medication Administration, dated 02/01/2024, indicated, A medication administration record [MAR] is used to document all medications administered. The policy specified, 2. Administration of medication is documented immediately after it is given. 3. Documentation of medication administration includes, as a minimum: a. the resident's name; b. name and strength of the drug; c. dosage; d. route of administration; e. date and time of administration; f. reason(s) why a medication was withheld, not administered, or refused (as applicable); g. initials, signature and title of the person administering the medication; h. resident response to the medication, if applicable; and i. the condition of the venipuncture or vascular access device site before and after medication administration (if administered intravenously).An admission Record indicated the facility admitted Resident #97 on 06/23/2025. According to the admission Record, the resident had a medical history that included a diagnosis of a fracture of the right lower leg.Resident #97's Order Summary Report for active orders as of 06/26/2025 revealed an order dated 06/25/2025, for MiraLAX oral powder 17 grams per scoop, give 17 grams by mouth two times a day for constipation and hold for loose stool. There was also an order dated 06/23/2205, for senna s oral tablet 8.6-50 milligram, give one tablet by mouth two time a day for constipation and hold for loose stool.During medication administration observation on 06/25/2025 at 9:54 AM, Licensed Practical Nurse (LPN) #4 prepared medications to administer to Resident #97. The resident refused the MiraLAX and senna s and it was noted that LPN #4 did not document on the resident's MAR that the resident refused the medications.During an interview on 06/25/2025 at 1:54 PM, LPN #4 stated he forgot to document that Resident #97 refused the laxatives (MiraLAX and senna s) but should have. LPN #4 stated it would be important to document so that others were aware that the laxatives were not received.During an interview on 06/25/2025 at 2:03 PM, Registered Nurse Unit Manager #1 stated if a resident refused medication during the medication administration pass, the nurse should document that it was refused.During an interview on 06/28/2025 at 8:56 AM, the Director of Nursing stated if a medication was refused during the medication administration, the nurse should document that it was refused, and it should be documented right away; otherwise, the nurse might forget.During an interview on 06/28/2025 at 10:23 AM, the Administrator stated he deferred all medication administration questions to nursing.2. A facility policy titled, Medications: Administering Medications, dated 02/01/2024, indicated Medications are administered in a safe and timely manner, and as prescribed. The policy specified, 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR [medication administration record] space provided for that drug and dose or document in electronic health record.An admission Record indicated the facility admitted Resident #82 on 05/14/2025. According to the admission Record, the resident had a medical history to include a diagnosis of type 2 diabetes mellitus.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/2025, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition.Resident #82's Care Plan Report included a focus area initiated 05/17/2025, that indicated the resident had diabetes mellitus. Interventions directed staff to administer diabetes medication as ordered by the doctor.Resident #82's Order Recap Report for the timeframe 06/01/2025 - 06/30/2025, revealed an order dated 06/01/2025, for NovoLog injection solution 100 units per milliliter (mL), inject 3 units subcutaneously before meals and at bedtime and hold for a blood sugar 180 milligrams per deciliter (mg/dL) or less. There was also an order dated 06/03/2025, for NovoLog injection solution 100 unit/mL, inject 6 units subcutaneously before meals and hold for a blood sugar 180 mg/dL or less.Resident #82's Medication Administration Record for the timeframe 06/01/2025 - 06/30/2025, revealed no evidence to indicate what the resident's blood sugar level was or that the resident received 3 units of NovoLog on 06/02/2025 at 5:00 PM or 06/03/2025 at 5:00 PM. There was also no evidence to indicate what the resident's blood sugar was or that the resident received 6 units of NovoLog on 06/08/2025 at 5:00 PM.Resident #82's progress notes for the timeframe 05/24/2025 - 06/24/2025 revealed no evidence to indicate what the resident's blood sugar level was or that the resident received 3 units of NovoLog on 06/02/2025 at 5:00 PM or 06/03/2025 at 5:00 PM. There was also no evidence to indicate what the resident's blood sugar was or that the resident received 6 units of NovoLog on 06/08/2025 at 5:00 PM.During an interview on 06/26/2025 at 10:46 AM, Resident #82 stated they did not remember if they received their insulin (NovoLog) during the evening shift.During an interview on 06/25/2025 at 8:21 AM, Licensed Practical Nurse (LPN) #6 stated she did not know if she forgot the check Resident #82's blood sugar or if she just forgot to document the resident's blood sugar reading.During an interview on 06/25/2025 at 9:45 AM, Registered Nurse (RN) Unit Manager #5 stated the nursing staff should not leave blank spaces on a resident's MAR. RN Unit Manager #5 stated sometimes Resident #82 went out of the facility and if the resident was not in the facility during the scheduled medication administration time, that should be documented.During a follow-up interview on 06/25/2025 at 4:06 PM, LPN #6 stated Resident was away from the facility from 2:00 PM - 9:00 PM on 06/03/2025, and that was why there was no indication the resident received NovoLog. LPN #6 stated it was a nursing expectation to document on the MAR and not leave blank spaces.During an interview on 06/26/2025 at 3:33 PM, the Director of Nursing (DON) stated she expected a resident's blood sugar to be checked and insulin to be administered as ordered and for staff to document as required.During an interview on 06/27/2025 at 8:52 AM, the Administrator stated he referred all questions related to insulin administration to the DON.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident received treatment and services to increase a range of motion (ROM) in their left hand contracture for 1 (Resident #47) of 3 sampled residents reviewed for position, mobility.Findings included: A facility policy titled, Rehabilitative/Restorative Care: Resident Mobility and Range of Motion, dated 02/01/2024, revealed 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. An admission Record indicated the facility admitted Resident #47 on 12/16/2024. According to the admission Record, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following cerebral infarction left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) on 05/26/2025, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had functional limitations in ROM in their upper and lower extremity on one side. Resident #47's occupational therapy daily notes dated 04/29/2025, revealed the resident was educated for setting up a brace and the use of a carrot orthotic. The daily note indicated the resident reported they did not want to use it during the day due to weird feeling. Per the daily note, the therapist educated the resident to wear the carrot at night to build tolerance and increase stretch and opening for the third digit, and the resident reported understanding. During a concurrent observation and interview on 06/23/2025 at 12:23 PM, the surveyor noted Resident #47's left hand was contracted, with the middle finger bent down against the palm and pointed outward, with the ring finger lying on top of the middle finger. Resident #47 stated they was told the facility had a splint that they ordered for them, but they did not have it yet. During an interview on 06/25/2025 at 1:45 PM, Occupational Therapist (OT) #18 stated occupational therapy should have passed on the monitoring of the use of the carrot at night to nursing. OT #18 stated she could not find documentation that the resident was monitored for the use of the carrot during the night and did not know how it was determined that the resident wore the carrot at night. During a follow-up interview on 06/26/2025 at 10:29 AM, OT #18 stated Resident #47 was evaluated occupational therapy on 06/17/2025 and it was indicated a palm guard was needed forthe resident. OT #18 stated the palm guard had arrived, but it had not given it to the resident as she wanted to redo the resident's plan of care to indicate the use of a carrot. During an interview on 06/25/2025 at 3:00 PM, the Director of Rehabilitation stated the facility remained responsible for maintaining the resident's current ROM and they did not want it to get worse. During an interview on 06/25/2025 at 2:13 PM, Certified Nursing Assistant (CNA) #21 stated she usually was assigned to care for Resident #47 during the 2:00 PM to 10:00 PM shift on Sundays through Thursdays. CNA #21 stated she was responsible for placing the resident in the bed at night. According to CNA #21, she was not aware of anything to do for the resident's left-hand contracture and did not need to do anything for the resident's contracture prior to placement of the resident in the bed. During an interview on 06/27/2025 at 8:28 AM, CNA #22 stated he cared for Resident #47 during the 6:00 AM to 2:00 PM shift three times per week. CNA #22 stated he did not have anything he needed to do for the resident's left hand, and there were no devices the resident utilized for their left hand. CNA #22 described the resident's left hand as contracted but relaxed. During a concurrent observation and interview on 06/25/2025 at 2:39 PM, Licensed Practical Nurse (LPN) #23 entered Resident # 47's room and stated the resident's left hand was contracted. LPN #23 described the resident's fingers on their left hand as contracted inward toward the palm, and one finger stuck out. LPN #23 stated he cared for Resident #47 for about six months and was not aware if the resident had a device for their contracture as he had not seen the resident wear one. LPN #23 reviewed the resident's medical record and stated there was no order for a device for the resident's contracture. Per LPN #23, he expected there to be an order if the resident had a device and he would not apply one without an order because he would need directions on how to apply it, such as the length of time and what directions the resident's fingers needed to go. LPN #23 stated there was no monitoring by nursing of the resident's hand contracture. According to LPN #23, a contracture could become worse, cause more discomfort or more pain, if the resident had a device for a contracture and it was not being used. During an interview on 06/27/2025 at 8:49 AM, LPN #24 stated Resident #47 did not have an orthotic device for their contracture and she was not required to monitor the resident's contracture. During an interview on 06/25/2025 at 3:11 PM, the Director of Nursing (DON) stated the facility was responsible for identifying residents with contractures and referring the resident to occupational therapy, and if the resident needed a splint or a brace, then they would get those for the resident. The DON stated there would need to be an order for a brace, splint, or carrot because it was considered a treatment, and all treatments needed orders. The DON stated Resident #47 had a contracture of their left hand. According to the DON, she expected the resident's contracture to be monitored, but the resident's medical record did not reveal the contracture had been monitored. During an interview on 06/25/2025 at 3:52 PM, the Administrator stated his expectation for a resident with a contracture was to maintain daily functional ability and ROM development. Per the Administrator, a contracture could impede a resident's quality of life.

Based on observation, interview, and record review, the facility failed to provide 1 (Resident #399) of 1 sampled resident reviewed for activities with an activity calendar and further failed to ensure staff provided the resident with activities of their choice.Findings included: An admission Record indicated the facility admitted Resident #399 on 06/04/2025. According to the admission Record, the resident had a medical history that included a diagnosis of need or assistance with personal care. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2025, revealed Resident #399 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated it was very important for the resident to be around animals such as pets. Resident #399's Care Plan Report included a focus area initiated 06/04/2025, that indicated the resident was a new admission adjusting to the facility. Interventions directed the staff to post an activity calendar in the resident's room, invite the resident to leisure diversionary programs and observe for recreation and leisure patterns, and provide leisure materials and support independent leisure choices. During an interview on 06/23/2025 at 10:56 AM, Resident #399 stated they had no activity calendar and the staff did not invite them to activities. During a concurrent observation and interview on 06/27/2025 at 8:22 AM, the surveyor noted there was no activity calendar in Resident #399's room and the resident confirmed there was no activity calendar in their room. During an interview on 06/27/2025 at 8:29 AM, Registered Nurse #19 stated there should be an activity calendar in each resident room. During an interview on 06/27/2025 at 8:39 AM, the Activity Manager (AM) stated each month the activity department distributed the activity calendar to the residents. Per the AM, Resident #399 admitted to the facility after the activity calendars were passed out. The AM stated Resident #399 expressed an interest in animal therapy, which was offered twice a week. The AM stated that because of Resident #399's cognition level, if the resident stated they had not been visited by animal therapy, then she was sure animal therapy had not visited the resident. During an interview on 06/27/2025 at 8:46 AM, Resident #399 stated they had not been provided with animal therapy. According to Resident #399, someone from the activity department asked them their interests during admission, but they had not seen that person since admission. Resident #399 stated it would be nice if animal (pet) therapy visited them. During a follow-up interview on 06/27/2025 at 9:10 AM, the AM stated she was almost certain Resident #399 answered yes to their like of animals. The AM stated she knew Resident #399 was on the list to see animal therapy, but did not know why animal therapy had not visited the resident. During an interview on 06/27/2025 at 9:17 AM, the Director of Nursing stated she deferred all questions related to activities to the AM. During an interview on 06/27/2025 at 10:29 AM, the Administrator stated every resident should have access to an activity calendar and he expected residents to be provided with individualized activities of their choice.

Based on observation, interview, record review, and facility policy review, the facility failed to provide personal hygiene care to 1 (Resident #399) of 3 sampled residents reviewed for activities of daily living (ADLs).Findings included: A facility policy titled, Personal Care: Activities of Daily Living (ADL), Supporting, dated 02/01/2024, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. An admission Record indicated the facility admitted Resident #399 on 06/04/2025. According to the admission Record, the resident had a medical history that included a diagnosis of need or assistance with personal care. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2025, revealed Resident #399 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required substantial/maximal assistance with personal hygiene. Resident #399's Care Plan Report included a focus area initiated 06/05/2025, that indicated the resident was at risk for functional self-care deficits. During a concurrent observation and interview on 06/23/2025 at 10:46 AM, the surveyor noted facial hair on Resident #399. Resident #399 stated they asked Certified Nursing Assistant (CNA) #26 to shave their facial hair, which CNA #26 failed to do. Resident #399 stated the facial hair bothered them. During an observation on 06/25/2025 at 2:29 PM, brown facial hair was noted on Resident #399's upper lip. During an interview on 06/27/2025 at 12:52 PM, Resident #399 stated they wanted to be shaved and had asked staff to shave them, but nothing happened. During an observation on 06/27/2025 at 12:53 PM, Resident #399 was noted to have hair that was approximately half an inch in length on their chin and nose. During an interview on 06/27/2025 at 12:58 PM, CNA #26 stated she was expected to shave residents when they needed it or if the resident asked for it. CNA #26 stated she did not usually provide care for Resident #399. During an interview on 06/27/2025 at 1:04 PM, CNA #13 stated residents were shaved with they received a shower or when the resident requested. Per CNA #13, she was surprised that Resident #399 was observed to have facial hair as he had not noticed facial hair on the resident. During an interview on 06/27/2025 at 1:10 PM, Registered Nurse (RN) #19 stated it had not occurred to her that Resident #399 might need to be shaved. RN #19 stated she had not noticed the resident's facial hair but would be more mindful when she saw the resident next. RN #19 stated that if a resident asked staff for assistance with ADL care, the staff should assist them. During an interview on 06/28/2025 at 9:17 AM, the Director of Nursing (DON) stated she expected personal hygiene and grooming to be performed every shift. The DON stated residents usually were shaved when they received their shower and should be offered to both male. According to the DON, if a resident asked for staff assistance with ADL care, staff were expected to assist the resident with ADL care. During an interview on 06/28/2025 at 10:29 AM, the Administrator stated CNAs should provide grooming and personal hygiene care daily and if a resident asked staff for care to be provided, care should be provided.

Based on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan for the care and treatment of a resident with a left hand contracture for 1 (Resident #47) of 3 sampled residents reviewed for position, mobility.Findings included: A facility policy titled, Rehabilitative/Restorative Care: Resident Mobility and Range of Motion, dated 02/01/2024, revealed 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline, and/or improve mobility and range of motion. An admission Record indicated the facility admitted Resident #47 on 12/16/2024. According to the admission Record, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following cerebral infarction left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) on 05/26/2025, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had functional limitations in ROM in their upper and lower extremity on one side. Resident #47's Care Plan Report with an admission date of 12/16/2024 revealed no evidence to indicate a care plan had been developed and implemented to address the resident's left hand contracture. During an observation on 06/23/2025 at 12:23 PM, the surveyor noted Resident #47's left hand was contracted, with the middle finger bent down against the palm and pointed outward, with the ring finger lying on top of the middle finger. During an interview on 06/25/2025 at 2:39 PM, Licensed Practical Nurse (LPN) #23 entered Resident # 47's room and stated the resident's left hand was contracted. LPN #23 described the resident's fingers on their left hand as contracted inward toward the palm, and one finger stuck out. During an interview on 06/27/2025 at 9:49 AM, the Registered Nurse (RN) Care Coordinator stated she would need to be told to initiate a care plan for a resident with a hand contracture because it was not part of MDS assessment. The RN Care Coordinator stated a resident'scontracture would be a required to be care planned; however, Resident #47 did not have a care plan that addressed their hand contracture. During an interview on 06/25/2025 at 3:11 PM, the Director of Nursing (DON) stated a resident with a contracture would require a care plan to establish a baseline and continuation of care. The DON reviewed Resident #47's medical record and stated there was no care plan that addressed the resident's contracture. During a follow-up interview on 06/25/2025 at 3:40 PM, the DON stated her expectation was that the facility should have care planned the contracture for Resident #47 and added interventions and monitoring. During an interview on 06/25/2025 at 3:52 PM, the Administrator stated his expectation for a resident with a contracture was to have a care plan that addressed the resident's contracture that included individualized goals and interventions to meet the needs of the resident.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #58) of 5 residents observed for medication administration were assessed to be able to safely self-administer their medication before a nurse left medication at the resident's bedside.A facility policy titled, Medications: Administering Medications, dated 02/01/2024, indicated, 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.An admission Record indicated the facility admitted Resident #58 on 05/21/2025. According to the admission Record, the resident had a medical history that included diagnoses of spinal stenosis of the lumbar region, low back pain, and age-related osteoporosis.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2025, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.Resident #58's Order Summary Report for active orders as of 06/26/2025 revealed an order dated 06/06/2025, for vitamin D3 oral tablet, give 2,000 international units by mouth one time a day. There was no evidence the resident could self-administer this medication.During medication administration observation on 06/25/2025 at 8:02 AM, Registered Nurse (RN) #2 prepared medications, to include vitamin D3 to administer to Resident #58. Resident #58 took the medications but held onto the vitamin D3 tablet, stated they would take the medication at 3:00 AM, and asked RN #2 to leave the medication at their bedside. According to Resident #58, they liked to take the vitamin D3 with food, they did not like to eat in the morning and would take the medication when they ate a snack at 3:00 AM. RN #2 offered to bring the medication back to the resident, but the resident asked for the medication to be left at their bedside. RN #2 left the vitamin D3 at the bedside of the resident then returned to the medication cart and confirmed the resident did not have an order to leave medications at their bedside. RN #2 stated she thought the resident had been assessed to self-administer the medication but she was not sure.Resident #58's medical record revealed no evidence to indicate the resident had been assessed to safely administer their medication.During an interview on 06/28/2025 at 8:56 AM, the Director of Nursing (DON) stated medications were not to be left at a resident's bedside. The DON stated if a resident were able, the facility would do a self-administration evaluation to determine if the resident was able to safely administer their medications.

Based on interview and record review, it was determined that the facility did not ensure that 1 out of 9 sampled residents received adequate supervision and assistance devices to prevent accidents. Specifically, a resident who was assessed as being a high risk for falls did not have interventions in place to prevent falls. The resident had a fall and sustained a maxillary fracture. Resident identifier: 3. Findings include: 1. Resident 3 was initially admitted to the facility on [DATE] and again on 9/13/23 with diagnoses which included cerebral infarction, dysphagia, ataxia, nontraumatic intracerebral hemorrhage, type 2 diabetes mellitus, difficulty in walking, muscle weakness, need for assistance with personal care, atrial fibrillation, cognitive communication deficit, insomnia, nausea, heartburn, abnormalities of gait and mobility, and depression. Resident 3's medical record was reviewed. Resident 3 had a fall risk evaluation form completed on 9/1/23 that documented that resident 3 was assessed at being at risk for falls. Resident 3's care plan was reviewed. The care plan was initiated on 9/14/23 and stated, [resident 3] is at risk for falls . The goal stated, [resident 3] will have no untreated injuries RT [related to] falls, through next review date. The intervention stated, Educated resident to use assistance when ambulating and using the restroom. A Nursing Note from 9/11/23 at 6:01 AM documented, Pt [patient] found on floor with blood near face. when asked what happened pt states he fell but does not remember how he fell . pt denies hitting his head on fall but has swelling to the left cheek and dry blood from nose. pt assisted x2 to the wheelchair. pt face cleaned and assessment of face. pt's vital signs taken BP [blood pressure]: 174/101 P [pulse]: 98 O2 [oxygen]: 94% on room air. pt denies feeling light headed or dizziness. bleeding from nose has stopped. pt given ice for swelling of face. MD [Medical Director] notified of fall states he will assess patientin [sic] morning and no further orders given. Nurse manager notified of incident and states will assess situation during morning. Pt fall protocol started per facility. pt at nurses station in wheelchair resting c [sic] eyes open. resp [respirations] even and unlabored. no bleeding noted. A Physician Note from 9/11/23 at 8:22 AM documented, discussed using call light to prevent falls. Will order XR [x-ray] of the facial bones. Apply ice to the left orbit . A Nursing Note from 9/11/23 at 2:14 PM documented, New order per NP [Nurse Practitioner - Name redacted]. 3 view x-ray of facial bones r/t [related to] pain and swelling following GLF [ground level fall]. Resident continued on neuro checks throughout this shift. Vital signs stable; swelling to left side of face increased significantly and caused left eye to swell shut - unable to open and examine. Resident wanted to be sent to [hospital name redacted] for further evaluation . NP and UM [unit manager] notified . Ambulance services transported. Report called into ER [emergency room ]. A Nursing Note from 9/11/23 at 8:00 PM documented, [Hospital name redacted] called for update regarding pt's condition. Per ED nurse pt was to be admitted to the hospital for acute kidney injury and maxillary fracture to the left side of face. ED nurse denies pt is experiencing intracranial bleeding. No further information given . Resident 3's progress notes from the emergency department documentation from 9/11/23 was reviewed. The document stated, Patient is lying comfortably in the hospital bed. Patient is confused why he is in the hospital but knows he hurt his face. Patient relates he had a stroke a few weeks ago. He lives in an assisted living facility and fell . He reports his back is hurting his morning as well as his left knee. Patient denies, nausea, vomiting, fever, chills, shortness of breath and chest pain. Resident 3's hospital History and Physical document from 9/11/23 was reviewed. The document revealed that resident 3 obtained a maxillary fracture from a ground level fall, stating, CT found acute fracture of the anterior wall of the left maxillary sinus as above. No other acute osseous injury of the face . A Nursing Note from 9/13/23 at 4:22 PM documented, Resident readmitted at approx [approximately] 1615 [4:15 PM] via private transport, in a wheelchair. Resident was reoriented to his room and unit. Resident was educated on importance of asking for assistance with call light for transfers. Resident verbalized understanding. Call light was given to resident . On 1/31/24 at 1:10 PM an interview with the MDS Coordinator (MDSC) was conducted. The MDSC stated that she helped with completing the care plans. The MDCS stated that when a resident arrived at the facility, a baseline care plan was created and it addressed things like the residents' diagnoses, medications, skin impairments, and risk for falls. The MDCS stated that the care plans were used by all of the departments, and that care plans helped to take care of that specific resident. The MDSC stated that resident 3's care plan for falls was created on 9/14/23. The MDSC stated that resident 3 did not have a baseline care plan that addressed falls prior to his fall on 9/11/23. On 1/31/24 at 1:33 PM an interview with CNA 1 was conducted. CNA 1 stated that staff used the care plans to learn what interventions were in place for the specific cares a resident required. CNA 1 stated that they looked in the care plans to find what interventions were in place for residents who were at risk for falls. CNA 1 stated that for most residents who were a high fall risk, CNA 1 stated that all residents were supposed to have two hours checks. On 1/31/24 at 1:25 PM an interview with Registered Nurse (RN) 1 was conducted. RN 1 stated that when a resident was admitted to the facility, the resident had a care profile that contained information about the residents needs. RN 1 stated that the residents had a care plan when they were admitted to the facility. RN 1 stated that the staff used the care plan to find out if a resident is at risk for falls and the interventions to prevent falls would be located in the care plan. On 1/31/24 at 1:05 PM an interview with the Director of Nursing (DON) was conducted. The DON stated that interventions for fall prevention could be found in a resident's care plan. The DON stated that when a resident who was at risk for falls was admitted to the facility, the residents baseline care plan would include the fall care plan. The DON stated that when a resident had a fall at the facility, the care plan would have been updated to include new interventions. The DON stated that resident 3 was admitted to the facility on [DATE], and his care plan was initiated on 9/14/23. On 1/31/24 an interview with resident 3 was conducted. Resident 3 stated that he felt safe in the building. Resident 3 stated that he did not recall having a fall at the facility.

Based on observation, interviews, facility document review, and review of the United States Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure dietary staff routinely monitored food temperatures on the meal service line. Specifically, the facility failed to take the temperatures of all food and drink items that required temperature control for safety to limit microorganism growth and failed to have temperature logs available on several days. This had the potential to affect 98 of 98 residents who received meals from the dietary department. Findings included: A review of the FDA's 2022 Food Code, Chapter 3 Food, revealed, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C [Celsius] (135 F [Fahrenheit]) or above or (2) At 5 C (41 F) or less. A review of a facility document titled, Resource: Food Temperature Log, revealed the Cold Holding Reference for milk was listed as less than 45 degrees F. A review of the Food Temperature Logs for the timeframe from 08/14/2023 to 08/28/2023 revealed the following concerns: - On 08/14/2023, no temperature was recorded for the milk for the breakfast meal. - On 08/15/2023, no temperature was recorded for the milk for the lunch or dinner meal. - On 08/16/2023, no temperature logs were provided for the breakfast or lunch meals. For the dinner meal, no temperature was recorded for the milk. - On 08/17/2023, no temperature logs were provided for the breakfast or lunch meals. For the dinner meal, no temperature was recorded for the milk. - On 08/18/2023, no temperature logs were provided for the breakfast or lunch meals. For the dinner meal, no temperature was recorded for the milk. - On 08/19/2023, no temperature logs were provided for the breakfast or lunch meals. For the dinner meal, no temperature was recorded for the milk. - No temperature logs were provided for the breakfast, lunch, or dinner meals for the timeframe from 08/20/2023 to 08/27/2023. During an observation of meal service on 08/29/2023 at 11:40 AM, the Cook was observed checking temperatures of food items on the meal service line; however, the Cook did not check the temperature of the milk. During an interview on 08/29/2023 at 11:44 AM, the Dietary Manager (DM) stated he would remind the staff to take the temperatures of all the food and drink items. He stated he expected the staff to check the temperatures every meal. During an interview on 08/31/2023 at 2:41 PM, the Director of Nursing (DON) stated he expected the kitchen staff to make sure foods were at the right temperatures.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure comprehensive care plans were developed for 8 (Residents #33, #39, #45, #88, #93, #96, #97, and #262) of 27 sampled residents whose care plans were reviewed. Findings included: Review of a facility policy titled, Comprehensive Care Plans, revised 05/04/2023, revealed the purpose of the policy was, To provide each resident with a person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychosocial needs. The policy also indicated, 1. The care plan will be comprehensive and person-centered. It will drive the type of care and services that a resident receives and will describe the resident's medical, nursing, physical, mental and psychosocial needs and preferences; as well as how the facility will assist in meeting these needs and preferences. The policy revealed, 3. The comprehensive care plan will be reviewed and revised by the IDT [Interdisciplinary Team] following both comprehensive and quarterly review assessments. 1. A review of an Admission Record indicated the facility admitted Resident #45 on 06/19/2023 with diagnoses that included encounter for orthopedic aftercare following surgical amputation and type 2 diabetes mellitus. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/23/2023, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident required extensive staff assistance with bed mobility, transfers, dressing, and toilet use. The resident had received insulin, anticoagulant, antibiotic, and opioid medications during all seven days of the seven-day lookback period. A review of Resident #45's Order Summary Report for 08/31/2023 revealed an order, dated 06/20/2023, for cephalexin (an antibiotic), 500 milligrams (mg) every six hours for chronic suppression. A review of a physician order for Resident #45, dated 06/22/2203, revealed an order for Humulin 70/30 insulin, inject 85 units in the morning with breakfast and inject 52 units in the afternoon with dinner for diabetes mellitus. Review of Resident #45's comprehensive care plan revealed the care plan did not address the insulin nor the antibiotic use. During an interview on 08/30/2023 at 2:17 PM, Registered Nurse (RN) #7 indicated Resident #45 was on antibiotic prophylactically for an amputation and was on insulin for type 2 diabetes mellitus. RN #7 indicated she was not sure who was supposed to make sure medications were on the care plans. During an interview on 08/31/2023 at 1:55 PM, the Director of Nursing (DON) indicated the MDS Coordinator was responsible for part of the care plan and the nursing department was also responsible. The DON indicated if a resident was on an antibiotic or insulin at admission, then it should be addressed on the baseline care plan, and the nursing department would do that. The DON indicated the antibiotic and insulin should have been addressed on the comprehensive care plan. The DON indicated his expectation was that on admission those medications would be addressed on the baseline care plan, then when the MDS was completed, if it had not been addressed then the MDS Coordinator would make sure it was on the comprehensive care plan. During an interview on 08/31/2023 at 4:39 PM, the Administrator indicated antibiotics and insulin needed to be addressed on the care plan. The Administrator indicated he expected the insulin and antibiotics to be care planned to ensure they were monitored. 2. A review of an Admission Record indicated the facility admitted Resident #93 on 11/19/2022 with diagnoses that included displaced trimalleolar fracture (a three-part fracture) of the left lower leg. A diagnosis of unspecified atrial fibrillation was added on 01/26/2023. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2023, revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident required extensive staff assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. The resident had received antidepressant, anticoagulant, and antibiotic medications during all seven days of the seven-day lookback period. A review of Resident #93's Order Summary Report, dated 08/30/2023, revealed an order, with a start date of 06/12/2023, for apixaban (an anticoagulant), 5 milligrams (mg), two times daily. Review of Resident #93's comprehensive care plan revealed the care plan did not address the anticoagulant use. During an interview on 08/30/2023 at 2:17 PM, Registered Nurse (RN) #7 reviewed Resident #93's care plan and stated the anticoagulant monitoring was not addressed on the care plan but it should have been. RN #7 indicated she was not sure who was supposed to make sure medications were on the care plans. During an interview on 08/31/2023 at 1:55 PM, the Director of Nursing (DON) indicated the MDS Coordinator was responsible for part of the care plan and the nursing department was also responsible. The DON indicated if a resident was on an anticoagulant at admission, then it should be addressed on the baseline care plan, and the nursing department would do that. The DON indicated the anticoagulant should have been addressed on the comprehensive care plan and there was no reason the anticoagulant should not be on the comprehensive care plan. The DON indicated his expectation was that on admission, medications would be addressed on the baseline care plan, then when the MDS was completed, if it had not been addressed then the MDS Coordinator would make sure it was on the comprehensive care plan. During an interview on 08/31/2023 at 4:39 PM, the Administrator indicated anticoagulants needed to be addressed on the care plan. The Administrator indicated he expected the anticoagulants to be care planned to ensure they were monitored. 45714 3. A review of an Admission Record revealed the facility admitted Resident #33 on 08/08/2022 with diagnoses that included major depressive disorder, type II diabetes, obstructive sleep apnea, and acute respiratory failure. A review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/2023, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident required extensive staff assistance with bed mobility, transfer, toilet use, and personal hygiene and limited staff assistance for bathing. The resident received oxygen therapy and used a non-invasive mechanical ventilator (a continuous positive airway pressure [CPAP] device or a bilevel positive airway pressure [BiPAP] device). A review of Resident #33's Order Summary Report, dated 08/30/2023, revealed an order, dated 11/14/2022, for CPAP/Expiratory Positive Airway Pressure (EPAP) with humidification and oxygen inline to keep oxygen saturation greater than 90 percent (%), under the nose mask. An order, dated 08/14/2023, indicated Resident #33 was to receive oxygen via nasal canula (NC) to CPAP to keep oxygen saturation above 90% at night and as needed every shift. An order, dated 08/14/2023, indicated Resident #33 wore a CPAP device at night for sleep and naps one time a day. A review of Resident #33's comprehensive care plan revealed the care plan did not address the use of a non-invasive mechanical ventilator. During an interview on 08/30/2023 at 4:14 PM, the Director of Nursing (DON) stated Resident #33 should have a care plan in place for the use of a non-invasive mechanical ventilator. He stated the MDS Coordinator was responsible for developing and revising care plans, but the facility had not had an MDS Coordinator until recently. He expected care plans to be comprehensive. During an interview on 08/31/2023 at 9:14 AM, the Medical Director (MD) stated Resident #33 should have a care plan for the use of the CPAP. During an interview on 08/31/2023 at 4:27 PM, the Administrator stated Resident #33 should have a care plan with interventions related to the use of a CPAP. He stated the nurse management team was responsible for care plans and he expected the care plan to be comprehensive and accurate. 46659 4. Review of a facility policy titled, Quality of Care: Accident Hazards/Supervision/Devices, revised on 05/04/2023, revealed, The resident's care plan will reflect the extent of supervision, if any, is needed during smoking. A review of an Admission Record indicated the facility admitted Resident #96 on 06/01/2023 with a diagnosis that included hypertension. The Admission Record included a diagnosis of acute respiratory failure with hypoxia with an onset date of 08/25/2023. Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/06/2023 revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. The resident required staff supervision for all activities of daily living. Review of Resident #96's Progress Notes revealed a note, dated 06/01/2023 at 6:17 PM, that indicated Resident #96 was admitted to the facility and was a current some day smoker. The note indicated Resident #96 reported smoking sometimes with friends. On 08/28/2023 at 9:02 AM, 08/29/2023 at 9:55 AM, and 08/31/2023 at 3:08 PM, Resident #96 was observed smoking in the facility's smoking area. During an interview on 08/28/2023 at 11:09 AM with Resident #96, the resident stated that they had returned from smoking, and that the resident could go outside to smoke whenever they wanted to go. Review of Resident #96's comprehensive care plan revealed the care plan did not address smoking, including the extent of supervision, if any, needed during smoking. During an interview on 08/29/2023 at 10:31 AM, Registered Nurse (RN) #8 stated Resident #96 was an unsupervised smoker. During an interview on 08/30/2023 at 1:16 PM with Certified Nursing Assistant (CNA) #12, she stated Resident #96 was an independent smoker. During an interview on 08/31/2023 at 4:14 PM with the Administrator, he stated the nurses were responsible for updating care plans. He expected care plans to be timely and accurate. He stated if a resident was a smoker or wanted to become a smoker, he expected it to be on the care plan and the care plan should be updated with any changes. During an interview on 08/31/2023 at 2:41 PM with the Director of Nursing (DON), he stated the baseline care plan should be done within the first 48 hours of admission and the comprehensive care plan needed to be done within two weeks, and if there were any changes the nurses were responsible for updating the care plan. 45555 5. A review of a facility policy titled, Resident Rights: Right to Self-Administer Medication, revised 05/04/2023, revealed, The resident has the right to self-administer medications, if the interdisciplinary team has determined that this practice is clinically appropriate. The policy also indicated, Appropriate documentation of the determinations will be documented in the resident's medical record and care plan. A review of an Admission Record indicated the facility admitted Resident #262 on 07/17/2023 with diagnoses that included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and end stage renal disease (ESRD). The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/22/2023, revealed Resident #262 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS indicated the resident required limited assistance of one person for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene, and required supervision with eating. The MDS indicated the resident received oxygen therapy and dialysis while a resident. Observations on 08/29/2023 at 12:24 PM revealed Resident #262 was lying in bed watching television. The resident had a central line for dialysis to the right upper chest and the resident stated the dialysis center handled all the care to the access site. The resident had a continuous positive airway pressure (CPAP) device on the nightstand with the mask and tubing lying on top of it. There were also two fluticasone (a steroid) and salmeterol (a bronchodilator) inhalers on the nightstand next to the CPAP device. The resident stated they used the inhalers themself. A review of Resident #262's comprehensive care plan revealed the care plan did not address Resident #262's respiratory or dialysis needs. The care plan also did not address Resident #262 administering their own medications or keeping their medications at the bedside. A review of Resident #262's physician orders revealed an order, dated 07/19/2023, for dialysis every Monday, Wednesday, and Friday. The resident did not have orders for the use of the CPAP device, to self-administer medications, or to have medications left at the bedside. During an interview on 08/31/2023 at 9:14 AM, the MDS Coordinator stated if a resident received dialysis, that should be addressed in the care plan. During an interview on 08/31/2023 at 10:20 AM, Registered Nurse (RN) #1 stated the use of a CPAP device, self-administration of medications, leaving medications at the bedside, and dialysis should be included on a resident's care plan. During an interview on 08/31/2023 at 11:35 AM, RN #2 stated he would know if a resident was able to self-administer their medications if it was indicated on their care plan. He stated the nurse managers and MDS Coordinator usually created the care plan, but the nurse could update them if needed. He stated a resident receiving dialysis should have a care plan for it. During an interview on 08/31/2023 at 2:57 PM, the Director of Nursing (DON) stated the use of a CPAP machine, self-administering medications, and leaving medications at the bedside should be addressed on the care plan. The DON stated a resident receiving dialysis should have a care plan and it should include monitoring, location, and times. During an interview on 08/31/2023 at 7:33 PM, the Administrator stated a resident receiving dialysis should have a care plan for it. 6. A review of a facility policy titled, Resident Rights: Right to Self-Administer Medication, revised 05/04/2023, revealed, The resident has the right to self-administer medications, if the interdisciplinary team has determined that this practice is clinically appropriate. The policy also indicated, Appropriate documentation of the determinations will be documented in the resident's medical record and care plan. A review of an Admission Record indicated the facility admitted Resident #39 on 10/01/2022 with diagnoses that included asthma, cough, shortness of breath (SOB), wheezing, and dependence on supplemental oxygen. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2023, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. The MDS indicated the resident required supervision of one person for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, dressing, eating, and toilet use, and required limited assistance from staff with personal hygiene. Observations on 08/29/2023 at 12:17 PM revealed two vials of ipratropium-albuterol solution (used to treat symptoms caused by ongoing lung disease) on the nightstand in Resident #39's room. There was an albuterol inhaler and a budesonide-formoterol inhaler (used to treat symptoms of asthma or ongoing lung disease) on the window ledge and an albuterol inhaler on the sink counter. A review of Resident #39's comprehensive care plan indicated the care plan did not address the self-administration of medications or approval to leave medications at the resident's bedside. A review of Resident #39's physician orders revealed orders that included: - Ipratropium-albuterol solution inhaled orally, two times a day for SOB/wheezing, with a start date of 05/31/2023. - Ipratropium-albuterol solution inhaled orally, every four hours as needed for SOB or wheezing via nebulizer, rinse after administration, with a start date of 10/03/2022. - Albuterol sulfate aerosol solution, two puffs inhaled orally every six hours as needed, for moderate to severe reactions, ordered 10/02/2022. - Resident is incapable of administering own medications, with a revision date of 10/02/2022. Further review of physician's orders revealed Resident #39 did not have orders for the budesonide-formoterol inhaler that was observed in their room. The resident did not have an order to self-administer medications or to leave medications at the bedside. During an interview on 08/31/2023 at 10:20 AM, Registered Nurse (RN) #1 stated self-administering medications and leaving medications at the bedside should be included on a resident's care plan. During an interview on 08/31/2023 at 11:35 AM, RN #2 stated he would know if a resident was able to self-administer their medications if it was indicated on their care plan. He stated the nurse managers and MDS Coordinator usually created the care plan, but the nurse could update them if needed. During an interview on 08/31/2023 at 2:57 PM, the Director of Nursing (DON) stated self-administering medications and leaving the medications at the bedside should be included on the care plan. 7. A review of a facility policy titled, Resident Rights: Right to Self-Administer Medication, revised 05/04/2023, revealed, The resident has the right to self-administer medications, if the interdisciplinary team has determined that this practice is clinically appropriate. The policy also indicated, Appropriate documentation of the determinations will be documented in the resident's medical record and care plan. A review of Resident #88's medical record revealed the facility admitted the resident on 06/24/2022 with diagnoses that included pulmonary fibrosis, shortness of breath (SOB), and dyspnea (difficulty breathing). The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2023, revealed Resident #88 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required supervision for transfers, locomotion on and off the unit, eating, and toilet use. Resident #88 required limited assistance from staff to walk in their room, dressing, and personal hygiene, required extensive assistance from staff for bed mobility, and required physical help with bathing. Observations on 08/28/2023 at 10:33 AM revealed Resident #88 was lying on the bed and there was a box with a bottle of fluticasone propionate (Flonase, an inhaled corticosteroid) on the over-the-bed table. A review of Resident #88's comprehensive care plan, initiated on 06/25/2022, revealed the care plan did not address self-administration of medications or allowing the resident to keep medications in their room. A review of Resident #88's physician orders revealed orders included Flonase allergy relief nasal suspension, dated 08/03/2023, two sprays in both nostrils for nasal congestion every morning as needed. The order indicated Resident #88 could keep the Flonase at the bedside and self-administer. An order, dated 06/24/2022, indicated the resident was capable of administering their own medications. During an interview on 08/31/2023 at 10:20 AM, Registered Nurse (RN) #1 stated self-administering medications and leaving medications at the bedside should be included on a resident's care plan. During an interview on 08/31/2023 at 11:35 AM, RN #2 stated he would know if a resident was able to self-administer their medications if it was indicated on their care plan. He stated the nurse managers and MDS Coordinator usually created the care plan, but the nurse could update them if needed. During an interview on 08/31/2023 at 2:57 PM, the Director of Nursing (DON) stated self-administering medications and leaving the medications at the bedside should be included on the care plan. 8. A review of an Admission Record indicated the facility admitted Resident #97 on 07/19/2023 with a diagnosis that included obstructive sleep apnea (OSA). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/22/2023, revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS indicated the resident required supervision for all activities of daily living (ADLs) including bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident had shortness of breath or trouble breathing when lying flat. The MDS indicated Resident #97 used a non-invasive mechanical ventilator. Observations on 08/28/2023 at 9:51 AM revealed Resident #97 was lying in bed with a CPAP device lying on the bed behind them against the wall, and the mask was lying on the bed. The resident stated they preferred the machine to be on the bed, and the staff did not do anything with it. The resident stated they did not clean the mask or tubing and was supposed to put distilled water in it, but the resident usually just got the water from the sink. Observation on 08/29/2023 at 8:46 AM revealed Resident #97 was lying in bed with the CPAP device behind them and the mask lying on the mattress. Review of Resident #97's comprehensive care plan revealed the care plan did not address the resident's respiratory issues, the diagnosis of OSA, or the use of a continuous positive airway pressure (CPAP) device. A review of Resident #97's physician orders revealed Resident #97 did not have an order for the use of a CPAP device. A review of a Nursing Note, dated 07/19/2023, indicated Resident #97 wore a CPAP at night with humidification and would bring the CPAP device from home. A review of a Clinical Admission note, dated 07/21/2023, indicated Resident #97 received oxygen via CPAP device at night only. During an interview on 08/31/2023 at 10:20 AM, Registered Nurse (RN) #1 stated the use of a CPAP device should be included on a resident's care plan. During an interview on 08/31/2023 at 11:35 AM, RN #2 stated the nurse managers and MDS Coordinator usually created the care plan, but the nurse could update them if needed. During an interview on 08/31/2023 at 2:57 PM, the Director of Nursing (DON) stated the use of a CPAP device should be included on the care plan.

Based on observations, record review, interviews, and review of the facility policy, it was determined that the facility failed to ensure 3 (Residents #33, #39, and #262) of 4 residents who were self-administering medications, were assessed to determine whether it was safe to self-administer the medications and to keep the medications at the bedside. Findings included: A review of the facility's policy titled, Right to Self-Administer Medication, last revised 05/04/2023, indicated, The resident has the right to self-administer medications, if the interdisciplinary team has determined that this practice is clinically appropriate. 1. If a resident has requested to self-administer medications, it is the responsibility of the interdisciplinary team to determine it is safe before the resident exercises the right. A resident may self-administer medications after the interdisciplinary team has determined which medications may be self-administered. 2. Considerations in determining if the resident is clinically appropriate to self-administer include: a. Which medications are appropriate and safe for self-administration. b. The resident physical capacity to swallow without difficulty and to open medication packaging. c. The resident's cognitive status, including ability to correctly identify medications and know for which conditions s/he is taking the medication. 3. Appropriate documentation of the determinations will be documented in the resident's medical record and care plan. 1. A review of an Admission Record indicated the facility admitted Resident #39 on 10/01/2022 with diagnoses that included asthma, cough, shortness of breath (SOB), wheezing, and dependence on supplemental oxygen. A review of Resident #39's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required supervision of one person for activities of daily living including eating. A review of Resident #39's care plan, last revised 07/18/2023, indicated the resident had altered respiratory status/difficulty breathing related to asthma, SOB, wheezing, and cough. Interventions instructed staff to elevate the head of the bed, maintain a clear airway by encouraging the resident to clear their own secretions with effective coughing and if secretions could not be cleaned, suction as ordered/required to clear secretions, and to monitor for signs and symptoms of acute respiratory insufficiency and respiratory distress and report to the physician. The resident did not have a care plan to self-administer medications or leave medications at the bedside. Observations on 08/28/2023 at 10:08 AM revealed two inhalers were on the over-the-bed table and one inhaler was on the nightstand in Resident #39's room. Observations on 08/29/2023 at 12:17 PM revealed two vials of DuoNeb solution (medication for a nebulizer [breathing treatment] machine to treat and prevent symptoms of lung disease) were on the nightstand in Resident #39's room. There was an albuterol inhaler (helps open the tubes to the lungs to increase air flow) and a Symbicort inhaler (contains medications that reduce inflammation and relaxes the muscles in the airway to improve breathing) on the window ledge and an albuterol inhaler sitting on the sink counter. Observations on 08/30/2023 at 9:10 AM revealed two vials of DuoNeb solution were on the nightstand in Resident #39's room. Observations on 08/31/2023 at 8:11 AM revealed an Albuterol inhaler on the mattress at the head of the Resident #39's bed. There was an albuterol inhaler and Symbicort inhaler on the window ledge in the room. A review of Resident #39's physician orders revealed medication orders included: - Ipratropium-albuterol (DuoNeb) solution 0.5-2.5 (3) milligrams (mg)/3 milliliters (ml), inhale 3 ml two times a day for SOB/wheezing, ordered 05/31/2023. - Ipratropium-albuterol (DuoNeb) solution 0.5-2.5 (3) mg/3ml, inhale 3 ml orally every four hours as needed for SOB or wheezing via nebulizer, rinse after administration, ordered 10/03/2022. - albuterol sulfate aerosol solution 108 micrograms (mcg) per actuation, inhale two puffs orally every six hours as needed for moderate to severe reactions, ordered 10/02/2022. A review of a Self-Administration of Medication assessment, dated 10/03/2022, indicated Resident #39 wanted to self-administer medications, had no visual impairment, was alert and oriented to person, place, and time, was physically able to self-administer medications, and there was no reason the resident should not be able to self-administer medications. The assessment indicated the determination was that the resident was capable of self-administering medications. The assessment did not address keeping medications at Resident #39's bedside. However, a review of Resident #39's physician orders revealed an order, dated 10/01/2022, that indicated the resident was incapable of administering own medications. There was no documented evidence Resident #39 had physician orders to self-administer medications or to leave medications at the bedside. During an interview on 08/31/2023 at 8:35 AM, the Administrator stated the facility did not have a physician's order to leave medications at the bedside for Resident #39. During an interview on 08/31/2023 at 10:20 AM, Registered Nurse (RN) #1 stated a resident may self-administer medications if they were alert and oriented, an assessment determined the resident was proficient, and they had a physician's order to self-administer medication. RN #1 stated Resident #39 was very obsessive with their inhalers. She stated the hospice nurse allowed the resident to have the inhalers and the resident used them; however, the RN was unsure if the resident had an order to self-administer them. During an interview on 08/31/2023 at 11:35 AM, RN #2 stated if a resident was able to self-administer medications, it would be on the resident's care plan and there would be a physician order. He stated Resident #39 was able to use the inhalers themself, but he assisted the resident with the nebulizer treatments. RN #2 did not know whether Resident #39 had been assessed for self-administration of medication. During an interview on 08/31/2023 at 2:57 PM, the Director of Nursing (DON) stated a resident was able to self-administer medications with proper documentation, which included a physician order, an evaluation, and proper storage of the medication in the room. 2. A review of an Admission Record indicated the facility admitted Resident #262 on 07/17/2023 with diagnoses that included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and morbid obesity. A review of a 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/22/2023, revealed Resident #262 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required supervision with eating. A review of Resident #262's care plan, initiated 07/22/2023, revealed the resident did not have a care plan to address their respiratory status, self-administration of medication, or leaving medications at the bedside. Observations on 08/28/2023 at 10:03 AM revealed an Advair (contains fluticasone, a medication that reduces inflammation, and salmeterol, a medication that relaxes the muscles in the airway to improve breathing) inhaler on the nightstand of Resident #262's room. Observations on 08/29/2023 at 12:24 PM revealed a Wixela (a generic Advair inhaler that contains fluticasone and salmeterol, the same medications as Advair) and an Advair inhaler on the nightstand of the resident's room. An interview with the resident at this time revealed they used the inhalers themself. Observations on 08/30/2023 at 12:49 PM revealed an Advair and Wixela inhaler were on the nightstand. A review of Resident #262's physician orders, revealed an order, ordered 07/18/2023, for salmeterol xinafoate inhalation (Serevent Diskus) aerosol powder, one puff inhale orally two times a day for congestion, cough, and SOB. The order did not include the medication fluticasone, which was found in the inhalers that were observed in the resident's room. Further review revealed Resident #262 did not have a physician's order to self-administer medications or to leave medications at the bedside. A review of Resident #262's electronic health record (EHR) revealed no documented evidence that the facility conducted an assessment for self-administering medications. During an interview on 08/31/2023 at 10:20 AM, Registered Nurse (RN) #1 stated medications should not be left at the bedside. She stated leaving inhalers at the bedside would require an assessment and they needed to have a physician's order to leave medications at the bedside. During an interview on 08/31/2023 at 11:35 AM, RN #2 stated he was unsure whether Resident #262 had an assessment to self-administer medications. He stated he was not aware Resident #262 had inhalers in their room but thought the resident would be able to use the inhalers. RN #2 did not remove the inhalers from the room. During an interview on 08/31/2023 at 2:57 PM, the Director of Nursing (DON) stated a resident was able to self-administer medications with proper documentation, which included a physician order, an evaluation, and proper storage of the medication in the room. During an interview on 08/31/2023 at 8:35 AM, the Administrator stated the facility did not have an assessment to self-administer medications or an order to leave medications at the bedside for Resident #262. 45714 3. A review of an Admission Record revealed the facility admitted Resident #33 on 08/08/2022 with diagnoses that included major depressive disorder, type II diabetes, obstructive sleep apnea, and acute respiratory failure with hypoxia. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2023, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, the resident had behaviors not directed towards others that occurred one to three days a week. The MDS identified that the resident required extensive assistance with bed mobility, toilet use, and personal hygiene, and was totally dependent on staff for transfers and bathing. The MDS noted the resident was on antidepressants, anticoagulants, and opioids. A review of Resident #33's Care Plan, initiated on 11/18/2022, revealed the resident used antidepressant medications to help manage neuropathy. Approaches initiated on 11/18/2022 directed staff to administer antidepressant medication as ordered by the physician. Per the Care Plan, Resident #33 also had pain related to renal failure and gout. Approaches initiated on 08/09/2022 directed staff to evaluate the effectiveness of pain interventions and review for compliance, the alleviating of symptoms, dosing schedules, and resident satisfaction with results. The care plan did not indicate the resident was deemed safe to self-administer medications. On 08/28/2023 at 11:35 AM, Resident #33 was observed in bed with a 6-ounce bottle of ZzzQuil (an antihistamine used as a sleeping aide) on the bedside with approximately 25% remaining in the bottle. Resident #33 stated they self-administered the ZzzQuil from time to time. On 08/29/2023 at 12:51 PM, Resident #33 was not in their room. Two 5% lidocaine patches (local anesthetic agent) were observed on the resident's dresser. A review of Resident #33's Order Summary Report for 08/2023 revealed an order, dated 02/16/2023, that directed staff to apply an external 5% Lidoderm (lidocaine patch 5%) patch to an affected area topically one time a day for pain. The order did not indicate the resident could keep the medication at the bedside. There was no physician's order for ZzzQuil. Review of Resident #33's electronic health record (EHR) on 08/30/2023 at 10:59 AM revealed no assessment to self-administer medications. During an interview on 08/30/2023 at 11:01 AM, Registered Nurse (RN) #6 stated she did not know lidocaine patches or a bottle of ZzzQuil were in Resident #33's room. She stated residents should not have medications in their room unless there was a physician order to keep the medications at the bedside. She stated Resident #33 lacked an assessment to self-administer any medications. She stated she expected the facility to adhere to safe medication practices and for medications to be stored appropriately and not at the bedside. During an interview on 08/30/2023 at 12:02 PM, the Director of Nursing (DON) indicated Resident #33 did not have an assessment to self-administer medications. During an interview on 08/30/2023 at 4:09 PM, the DON stated residents should be evaluated to self-administer medication prior to doing so, and noted medications should be stored in a locked box. He stated he expected adherence to safe medication practices. During an interview on 08/31/2023 at 9:11 AM, the Medical Director (MD) stated residents should have a medication self-administration assessment and physician order prior to self-administering medications. During an interview 08/31/2023 at 4:24 PM, the Administrator stated he did not know if Resident #33 had a medication self-administration assessment. He stated residents should have an order and be assessed as competent prior to the self-administration of medications. He stated he expected the facility to adhere to safe medication administration practices.

Based on observation, interview, and record review, it was determined for 1 of 43 sampled residents, that the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, a resident had a stroke and was not sent out to the hospital for 20 hours, which made him ineligible for many potential treatments. Additionally, the facility failed to identify and treat high blood glucose trends, and physician's orders [REDACTED]. The findings for this resident were found to have occurred at a harm level. Resident identifier: 96. Findings include: 1. Resident 96 was originally admitted to the facility on [DATE], and was readmitted status [REDACTED]. [NAME] On 8/13/19 at 9:52 AM, an interview was conducted with resident 96. Resident 96 stated that he had three [MEDICAL CONDITION] prior to being admitted to the facility, stated that he had had one stroke since being at the facility. On 8/14/19 resident 96 medical records were reviewed. A nurses' note dated 1/18/19 at 8:28 PM documented Resident complained that he was concerned he was having a TIA ([MEDICAL CONDITION]). RN (Registered Nurse) assessed his symmetry of facial expressions, grips, alertness and responsiveness. He has equal strength grips. He has clear speech and is alert and oriented. Noted his right side of his face does not respond as readily as the left side when he smiles. For the moment, will continue to monitor. (Note: no documentation of MD notification.) Another nurses' noted dated 1/19/19 at 1:45 PM documented Resident is alert and oriented x 4, noc (night) nurse reported that resident felt like having a TI[NAME] Resident was assessed by this nurse this morning an (sic) noticed resident a little bit tired but eat breakfast with difficulties swallowing. Although he was up for lunch and Bingo activities. Resident came to the nurse station with RNA (rehab nurse assistant) therapist prior going to the gym and reported having more difficulties swallowing. Performed assessment to resident finding right facial drip; increase of numbness on same side of face;No respiratory distress or chest pain; memory intact, limited random of motion on right hand and no drip from fluids while performing test. Hands grip unequal. Unit Manager Obtained orders from (MD 2) to send resident to Saint Marks Hospital after waiting for oncall system to provide me with a medical provider. Called paramedics which arrived in less than five minutes. Also, called ER (emergency room ) Department and provided report to charge nurse (name redacted). Resident left in good standing via Stretcher. BP (blood pressure) was 172/77, P (pulse) 122; R (respirations) 18 ; T (temperature) 98.2, O2 (oxygen) 94 on RA (room air). (Note: no MD documentation of stroke symptoms until after lunch.) A physician's note from the admitting hospital dated 1/21/19 at 5:32 AM, documented This is a [AGE] year-old who presents with a 20-hour history of slurring of his speech and difficulty swallowing, he reports having 3 previous [MEDICAL CONDITION]. He apparently had some slurring of speech yesterday, which was new symptom. Around dinner time, he told a caregiver, but nothing was done. He had some difficulty swallowing. The symptoms continued and therefore he presented to the ER for further evaluation. he is not a candidate for IV (intravenous) tPA (tissue plasminogen activator) because the time of onset. Resident 96 admitted back to the facility on [DATE]. A speech therapy evaluation on 2/1/19 documented the level of functional changes caused by resident 96's stroke on 1/18/19. Reason For Referral: Pt (patient) reports of difficulty swallowing and his speech is laborious. Functional Deficits a. Language, Expressive i. Prior Level: minimal (mostly normal, self-monitor/corrects) ii. Current Level: moderate (expresses needs 75-90% of time) b. Cognition i. Prior Level: minimal (81-90% ability; minimal problems, distractible) ii. Current Level: mild (71-80 % ability; occasional direction needed, difficulty with memory) c. Safty-Judgement i. Prior Level: minimal (81-90% ability; minimal problems, distractible) ii. Current Level: mild (71-80 % ability; occasional direction needed, difficulty with memory) d. Swallowing, Swallow Status i. Prior Level: minimal impairment (10-25% impairment; risk of trace aspiration, diet may need modified due to medical/dental status) ii. Current Level: moderate impairment (50-75% impairment; combination of oral and nonoral nutrition; requires thickened liquids; difficulty masticating foods) A physical therapy evaluation on 1/25/19 documented the level of functional changes caused by resident 96's stroke on 1/18/19. Functional Deficits a. Everyday Activities, Indoor mobility (ambulation) i. Prior Level: Needs Some Help - Resident needs partial assistance from another person to complete activities. ii. Current Level: Dependent - A helper completes the activities for the resident. b. Mobility, Sit to laying i. Prior Level: Setup or clean-up assistance - Helper sets up cleans up; resident completes activity. Helper assists only prior to or following the activity. ii. Current Level: Supervision or touching assistance - Helper provides verbal cues and /or touching/steady and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. c. Mobility, Lying to sitting on bed side i. Prior Level: Setup or clean-up assistance - Helper sets up cleans up; resident completes activity. Helper assists only prior to or following the activity. ii. Current Level: Supervision or touching assistance - Helper provides verbal cues and /or touching/steady and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. d. Mobility, Sit to stand i. Prior Level: Supervision or touching assistance - Helper provides verbal cues and /or touching/steady and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. ii. Current Level: Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. e. Mobility, Chair/bed-to-chair transfer i. Prior Level: Supervision or touching assistance - Helper provides verbal cues and /or touching/steady and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. ii. Current Level: Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. On 1/3/19 a facility Medicare Quarterly Assessment was completed, which documented that resident 96 was a 1 person extensive assist with bed mobility, transfers, ambulation, dressing, toilet use, bathing, and personal hygiene. On 1/31/19, following his stroke, a facility Medicare Significant Change Assessment was completed. The assessment documented that resident 96 was now a 2 person extensive assist with bed mobility, transfers, dressing, toilet use, bathing, and person hygiene. On 8/13/19 at 3:17 PM, an interview was conducted with the Physical Therapist (PT). The PT stated that resident 96 had functional decline post stroke, the most notable being speech and swallowing, stated the resident also had increased [MEDICAL CONDITION] in his right arm as well as increased weakness. The PT stated that resident 96 did not recover his lost functionality. On 8/15/19 at 3:15 PM, an interview was conducted with the DON. The DON verified there was no documentation of MD notification of resident 96's stroke symptoms until after lunch on 1/19/19. The DON stated that the MD should have been notified on 1/18/19 when the symptoms appeared. On 8/19/19 at approximately 9:00 AM, a follow up interview was conducted with the DON. The DON stated that resident 96 had right sided weakness prior to his stroke on 1/18/19. The DON verified that there was no previous documentation of a facial droop prior to that stroke. B. On 8/13/19 at 9:52 AM, an interview was conducted with resident 96. Resident 96 stated that his blood sugars were not well controlled by the facility, stated that the doctor at the hospital was concerned with how the facility was managing his blood sugars. Resident 96's medical record was reviewed on 8/14/19. On admission resident 96 had an order for [REDACTED]. Give OJ (orange juice). ; 61 - 120 = 0; 121 - 150 = 2; 151 - 200 = 4; 201 - 250 = 6; 251 - 300 = 8; 301- 350 = 10; 351 - 400 = 12; 401 - 500 = 15 Notify MD., subcutaneously before meals and at bedtime. On 7/5/18 the facility Physician ordered an A1C (estimated average glucose) to be drawn, which demonstrated resident 96's average blood glucose levels for the previous 2-3 months. Resident 96's A1C was measured at 8.0%; according to the laboratory results, normal range was 4.0-6.0%. On 7/7/18 a physician's orders [REDACTED]. with meals. On 9/1/18 this order was changed to [MEDICATION NAME] Solution (Insulin [MEDICATION NAME]) Inject 4 unit subcutaneously before meals. On 9/1/18 another physician's orders [REDACTED]. On 10/4/18 [MEDICATION NAME] was increased to 30 units subcutaneously at bedtime, related to continued high blood sugars. On 10/11/18 [MEDICATION NAME] was increased to 40 units at bedtime. On 10/14/18 [MEDICATION NAME] was again increased to 50 units at bedtime. Finally, on 10/16/18 [MEDICATION NAME] was increased to 60 units at bedtime. It should be noted that no further changes were made to resident 96's diabetic medication management from 10/16/18 to 1/19/19 when resident 96 was discharged , despite resident 96's continued high blood sugars. Resident 96's blood sugars were monitored four times a day; these values were reviewed for (MONTH) (YEAR): a. Blood sugars were >121 mg (milligrams)/dl (deciliter) 120 times. b. Blood sugars were >300 mg/dl 42 times. (Note: resident 96's blood sugars were never documented as being <121 mg/dl for the entire month of November, which required resident 96 to receive doses of his sliding scale insulin four times a day.) Resident 96's blood sugars were monitored four times a day, the three meal time blood sugars were reviewed for (MONTH) (YEAR): a. Blood sugars were >121 mg/dl 93 times. b. Blood sugars were >300 mg/dl 25 times. (Note: resident 96's blood sugars were never documented as being <121 mg/dl for the entire month of December.) Resident 96's blood sugars were monitored four times a day; these values were reviewed for (MONTH) 2019, until his discharge to the hospital on [DATE]: a. Blood sugars were >121 mg/dl 72 times. b. Blood sugars were >300 mg/dl 28 times. (Note: resident 96's blood sugars were documented as being <121 mg/dl only one time for the reviewed dates in January.) On 1/19/19 resident 96 was discharged to the hospital related to an ischemic stroke. On 1/20/19 the hospital ordered an A1C level for resident 96. The result was 10.2%, according to the laboratory normal range was 4.0-5.6%. On 1/20/19 at 1:03 PM, while at the hospital resident 96 had a diabetic education consult in relation to his high A1C. The consultation notes were as follows: Reason for Visit: consulted for DM edu (education) due to having high A1C. Pt states he has had diabetes over [AGE] years and was in good control a year ago when living in Japan. Assessment of Self Care: pt states the facility in which he lives tests his BG for him regularly but results are always in 200-300's. Medication Compliance: pt states SNF (skilled nursing facility) where he lives doses and gives him insulin. Never declines or refuses insulin at SNF. Diet: states he is given meal trays at SNF and has no control over what he is served but has a good appetite. Resident 96 returned to the facility on [DATE] with the following insulin orders: a. [MEDICATION NAME] Solution 100 UNIT/ML 16 units subcutaneously in the morning AND 65 units subcutaneously at bedtime, these orders were discontinued on 2/8/19. A new order was started on 2/9/19 for [MEDICATION NAME] Solution 100 UNIT/ML 25 units subcutaneously in the morning. On 2/16/19 [MEDICATION NAME] was increased to 35 units subcutaneously in the morning. On 2/21/19 [MEDICATION NAME] was increased to 50 units in the morning. On 2/27/19 [MEDICATION NAME] was again increased to 60 units in the morning. On 3/28/19 [MEDICATION NAME] Solution 100 UNIT/ML was changed to 50 units subcutaneously two times a day. Finally, on 4/10/19 [MEDICATION NAME] was increased to 55 units two times a day, this order was still current as of 8/14/19. b. HumaLOG 100 UNIT/ML Inject 10 units subcutaneously before meals, this order was discontinued on 3/11/19. c. On 2/15/19 an order was entered for HumaLOG Inject 20 units subcutaneously three times a day before meals if blood sugar was >300. On 3/26/19 HumaLOG was increased to 25 units before meals if blood sugar >300, as of 8/14/19 this order was still current. d. HumaLOG 100 UNIT/ML, inject per sliding scale: if 0 - 60 = 0 notify MD (Medical Director), Give orange Juice. ; 61 - 150 = 0; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401+ = 12 Give 12 and notify MD, subcutaneously before meals. On 8/7/19 this order was changed to before meals and at bedtime. A review of resident 96's Physician's Progress Notes were conducted on 8/14/19 and revealed the following notes: a. Physician/Practitioner Note 1/25/19 . [MEDICATION NAME] was held at the hospital likely due to the contrast studies-resume 1000 mg. (Note: [MEDICATION NAME] order was not resumed.) c. Physician/Practitioner Note 2/8/19 . [MEDICATION NAME] 10 units before meals if >150, 5 units if <150. [MEDICATION NAME] 16 units daily-and 65 units at bedtime-increase day [MEDICATION NAME] to 25 units. (Note: [MEDICATION NAME] order was not clarified or implemented. Additionally, the day [MEDICATION NAME] was increased to 25 units, while the bedtime [MEDICATION NAME] was discontinued contrary to the physician's orders [REDACTED].> d. Physician/Practitioner Note 2/16/19 . increase [MEDICATION NAME] 15 units before meals if >150, 5 units if <150. [MEDICATION NAME] 16 units daily-and 65 units at bedtime-increase day [MEDICATION NAME] to 25 units, increase again 35. (Note: [MEDICATION NAME] order was not clarified or implemented; [MEDICATION NAME] order was increased to 35 units in the morning, but the bedtime dose was not reactivated.) e. Physician/Practitioner Note 2/23/19 . [MEDICATION NAME] 16 units daily-and 65 units at bedtime-increase day [MEDICATION NAME] to 25 units. increase to 50 units in am. (Note: [MEDICATION NAME] order was increased to 50 units in the morning but the bedtime dose was not reactivated.) f. Physician/Practitioner Note 2/27/19 .Diabetes type 2-high, remained elevated. increase [MEDICATION NAME] 20 units before meals if >150, 5 units if <150. [MEDICATION NAME] 16 units daily-and 65 units at bedtime-increase day [MEDICATION NAME] to . 60 units. (Note: [MEDICATION NAME] order was not implemented or clarified. Additionally, [MEDICATION NAME] order was increased to 60 units in the morning but the bedtime dose was not reactivated.) On 8/14/19 at 12:02 PM, an interview was conducted with the DON. The DON stated that the Nurse Practitioner or MD would give verbal orders for the nurses to enter, or they would write it in the physician progress notes [REDACTED]. The DON verified that the Unit Managers should have caught and entered those diabetic MEDICATION ORDERS FOR [REDACTED] It should be noted that no further changes were made to resident 96's diabetic medication management from 4/10/19 to 8/7/19, despite resident 96's continued high blood sugars. Resident 96's blood sugars were monitored four times a day; these values were reviewed for (MONTH) 2019: a. Blood sugars were >150 mg/dl 101 times. b. Blood sugars were >300 mg/dl 36 times. Resident 96's blood sugars were monitored four times a day; these values were reviewed for (MONTH) 2019: a. Blood sugars were >150 mg/dl 118 times. b. Blood sugars were >300 mg/dl 54 times. Resident 96's blood sugars were monitored four times a day; these values were reviewed for (MONTH) 2019: a. Blood sugars were >150 mg/dl 105 times. b. Blood sugars were >300 mg/dl 41 times. Resident 96's blood sugars were monitored four times a day; these values were reviewed for (MONTH) 2019: a. Blood sugars were >150 mg/dl 121 times. b. Blood sugars were >300 mg/dl 47 times. On 7/5/19 the facility Physician ordered an A1C to be drawn. Resident 96's A1C was measured at 11.8%, according to the laboratory results normal range was <5.7%. On 8/14/19 at 4:21 PM, a phone interview was conducted with MD 1's office in response to a message left with MD 1's medical assistant. MD 1 was the physician responsible for care of resident 96 while he was admitted to the hospital post stroke in January. MD 1's medical assistant stated that resident 96's uncontrolled diabetes would have greatly increased his risk for stroke. On 8/13/19 at 3:56 PM, an interview was conducted with the Nurse Practitioner (NP). The NP stated that an A1C of 11% would be very concerning and should be treated aggressively. The NP stated that diabetics should strive to be under 7%, stated that resident 96 should have been monitored closer since he had consistent blood sugars in the 200-300 mg/dl range. The NP stated that diabetes, and especially uncontrolled diabetes, greatly increased the risk for stroke, stated that high blood sugars caused a lot of vascular damage. The NP stated that he had only recently become aware of resident 96's uncontrolled blood sugars. The NP stated that had he been aware of resident 96's high blood glucoses, he would have ordered a consultation for endocrinology. On 8/14/19 at 12:02 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she would expect the nurses to notify the MD for a resident that had consistently high blood sugars.

Based on interview and record review it was determined that the facility failed to protect 4 of 51 sample residents from undue adverse medication consequences with a lack of monitoring and a lack of timely and appropriate monitoring for drug titration. (Residents 139, 148, 217, and 251). The deficient practice identified for resident 217 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for resident 251 was found to have occurred at a harm level and will not be included in the Immediate Jeopardy. The deficient practice identified for residents 139 and 148 was found to have occurred at a potential for harm and also will not be included in the Immediate Jeopardy. A. On 9/3/13 resident 217's closed medical record was reviewed. Resident 217 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. (Eskalith CR is a controlled release formulation of [MEDICATION NAME].) Resident 217's admission orders [REDACTED]. On 7/30/13, a facility nurse documented resident 217's gait was slightly side to side. This documentation of the resident's gait represented a change, based on previous nursing note entries. On 8/1/13, a facility nurse documented resident 217's family had reported the resident was extremely shaky while out on a leave of absence on 7/30/13 and that the resident appeared to have some impaired memory. The nurse also documented the resident expressed not feeling well and that he wanted to speak with his physician. The nurse documented the resident had an unsteady gait. This documentation of the resident's complaint of not feeling well, family reports of shakiness and memory problems represented a change, based on previous documentation. On 8/1/13, the facility nurse practitioner documented that nursing staff reported that resident 217 had an increase in confusion, wandering behaviors, and did not make sense when speaking. The nurse practioner documented the resident was appropriate during his interview with the resident and that the resident was alert and oriented times three, but that the resident did require constant cueing during the conversation. On 8/2/13 at 12:58 AM, a facility nurse documented that the resident required limited assistance with activities of daily living. This documentation represented a change in comparison to previous documentation. On 8/2/13, a late entry note for 8/1/13 was documented and included orders for a Complete Blood Count (CBC), a Complete Metabolic Panel (CMP), a [MEDICAL CONDITION] Stimulating Hormone (TSH) level, and a urinalysis. With the exception of the urinalysis, these laboratory tests were not drawn until 8/2/13. The urinalysis was not obtained. On 8/2/13, the facility nurse practitioner ordered a [MEDICATION NAME] level to be drawn for resident 217. Resident 217's serum [MEDICATION NAME] level was 2.5 milliequivalents (mEq) per liter (L). The laboratory used by the facility listed the reference range for [MEDICATION NAME] as 0.6 to 1.2 mEq/L. The laboratory characterized resident 217's level of 2.5 mEq/L as "critical". Per documentation on the laboratory results for resident 217's [MEDICATION NAME] level on 8/2/13, a panic result was called in to a facility registered nurse. On 8/2/13, the facility nurse practitioner ordered that resident 217's [MEDICATION NAME] be held until 8/5/13, at which time another [MEDICATION NAME] level was to be drawn. Additionally, the nurse practitioner ordered for facility staff to monitor resident 217 for signs and symptoms of increased toxicity and a change in level of consciousness. The nurse practitioner documented that facility staff were to encourage fluids and that resident 217 had a history of [REDACTED]. Per documentation, between 8/2/13 and 8/4/13, resident 217's condition continued to worsen. On 8/4/13, facility staff obtained a physician's orders [REDACTED]. Review of the documentation revealed that facility staff administered two doses of both medications in an approximate 13 hour time frame. On 8/5/13 at 8:00 AM, resident 217 was transferred to an acute care hospital after being found by facility staff at 6:00 AM to be unresponsive and shaking uncontrollably. Per acute care hospital documentation, resident 217's [MEDICATION NAME] level upon admission to the Emergency Department was 2.06 mEq/L. According to the hospital admission "History and Physical" resident 217 presented to the hospital "agitated and unresponsive, disoriented and tremor right sided posturing alternating with rapid thrashing motions in all extremities." The hospital "Assessment/Plan" listed resident 217's "Active Hospital Problem" as "[MEDICATION NAME] toxicity." Resident 217 passed away on 8/9/13. Per interview with a Medical Examiner with the State of Utah's Office of Medical Examiner, resident 217's primary cause of death was [MEDICATION NAME] toxicity. On 9/3/13, the facility Administrator, Assistant Director of Nursing, and Corporate Nurse Consultant were interviewed. They stated that the facility did not have a policy in regards to drawing laboratory values for medications that required therapeutic dosing monitoring. They further stated that the laboratory values were drawn at the discretion of the facility's physician or nurse practitioner. On 9/12/13, the facility nurse practitioner was interviewed. The nurse practitioner stated that the facility does not draw routine surveillance laboratory values for residents. The nurse practitioner further stated that laboratory values for mediations would only be drawn when it was indicated. The nurse practitioner stated that those indications would be if the resident experienced a change in condition or showed signs of toxicity to the medications. B. Resident 251 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 9/11/13 resident 251's medical record was reviewed. Review of the medical record revealed the following: "Instructions for LTAC (Long-Term Acute Care Hospital), Acute Rehab, Acute Hospital or SNF (Skilled Nursing Facility): ...1. [MEDICATION NAME] trough level to be checked am on 8/12/13 with results to SNF physician, 2. Redose [MEDICATION NAME] at 1.5 grams IV (Intravenous) once [MEDICATION NAME] trough is < (less than) 20 (goal trough level : 15 -20). expected dosing is 1.5 gm IV Q (every) 48 hours . Received dose am 8/11/13, 3. [MEDICATION NAME] to be completed on 9/12/13, 4. Hold [MEDICATION NAME] 8/11/13, 5. repeat INR (International Ratio) in am on 8/12/13. 6. restart [MEDICATION NAME] once INR < 2.8, 7. further [MEDICATION NAME] dose adjustments per SNF physician (expected dose is approx 3 mg (milligrams) qhs (every night)), 8. CBC with diff (differential), Chem (Chemistry) 7, ESR (Erythrocyte Sedimentation Rate), CRP (C-Reactive Protein) every Monday while on antibiotics. 9. Right upper extremity PICC (Peripherally Inserted Central Catheter) per routine care, 10. Remove PICC upon completion of antibiotics." Review of the physician's orders [REDACTED]. No documentation could be found to show that resident 251 received the [MEDICATION NAME] or the [MEDICATION NAME]. On 8/23/13 resident 251 went to a follow up appointment at a local hospital clinic. The following was documented in the "Doctor Observation/New Orders" portion of the form: "See our original D/C (Discharge) orders, ... needed to be getting [MEDICATION NAME] all this time. Resume [MEDICATION NAME] 2 mg po QHS check PT/INR (Pro-Time/International Ratio) daily. ID (Incision and Drainage) - needed to be having IV antibiotics all this time. ..." On 8/23/13, after resident 251 attended her follow-up appointment, the following physician's orders [REDACTED]. PT/INR daily." No results could be found to show what resident 251's INR was at the time the [MEDICATION NAME] was re-instated. On 8/24/13 the following physician's orders [REDACTED]. (check) PT/INR 8/28/13 Dx (diagnosis): knee repair." No documentation could be found to show facility staff checked resident 251's PT/INR before increasing the [MEDICATION NAME] dose to 3 mg. On 8/26/13 the following physician's orders [REDACTED]. PT/INR = 2.1/32.0, 2. continue [MEDICATION NAME] 3mg po qday, 3. Re-check PT/INR on 9/2/13." No documentation could be found to show the PT/INR was done on 8/23/13, 8/24/13, or 8/25/13. On 9/2/13 the following physician's orders [REDACTED]. Review of the Laboratory values revealed that on 9/2/13 resident 251's PT/INR was PT - > (greater than) 170.0 (reference range 11-14) and INR > 13.0 (reference range of 2.0-3.5). On 9/2/13 facility staff received the following order: "D/C (discontinue) [MEDICATION NAME]. Vitamin K IM (Intramuscularly) 10mg now x (times) 1 today (now) 9/2/13 3. PT/INR on 9/3/13." On 9/3/13 the following physician's orders [REDACTED]. Re-check PT/INR on 9/413.", in addition to the following order: "9/3/13 TO: Vit K 10mg/ml injection 1x dose." Resident 251 received two doses of Vitamin K, one dose on 9/2/13 and one dose on 9/3/13 for the elevated PT/INR. On 9/18/13, Licensed Practical Nurse (LPN) 3 was interviewed. LPN 3 stated that he obtained the routine PT/INR's for residents every Monday. LPN 3 stated that if a resident was receiving antibiotics or being re-started on [MEDICATION NAME], the resident's PT/INR should be checked daily. C. Residents 139 and 148 had pharmacy recommendations that were not implemented by facility staff for approximately two to three weeks after the orders were signed by the physician. Additionally, resident 148 was receiving an anti-psychotic medication with no indication for its use. NOTICE: Notice of Immediate Jeopardy was given verbally to the Administrator on 9/12/13 at 3:00 PM. The Administrator was asked to develop an immediate plan to ensure residents' safety related to inadequate monitoring and administration of medications. PLAN: "September 16, 2013 Mr. (Name of Long Term Care Manager), Manager Long Term Care Manager Utah Department of Health 288 North 1460 West Salt Lake City, UT Dear Mr. (Name of Long Term Care Manager): In response to the Immediate Jeopardy cited at Woodland Park on 9/12/13 in the area of F329 Unnecessary Meds under adequate monitoring, the team at Wood Land Park has done the following items to abate the immediate jeopardy: 1. Woodland Park has changed back to a previous laboratory services provider effective 9/12/13. 2. The team has audited the medial records of residents to assure that all medications requiring therapeutic levels or additional blood tests have been ordered and those results have been call to the physician. 3. The clinical team has performed a triple check audit of all physician order [REDACTED]. 4. A process of (sic) for chart audits of admissions at 24 hours, 48 hours, 7 days, and 14 days has been instituted and DON, ADONs, and Medical Records has been educated on same. 5. A process has been put into place to audit telephone orders to assure appropriate monitoring is in place on new orders. 6. Licensed nurses have been re-educated regarding medications that require therapeutic monitoring of blood levels and additional blood tests such as a comprehensive metabolic panel, as well as the effects of renal or hepatic insufficiency on blood levels of medications by a licensed pharmacist. They have also been re-educated regarding notification of abnormal lab values to physicians. These in-services will continue through Tuesday but at this point greater than 60% of licensed nurses have received that education. It is our belief that after review of the 122 records and re-education of the staff, the facility has done what is required to abate the immediate jeopardy situation as of 9/16/13. We look forward to your review of the facility in regards to abatement of the immediate jeopardy deficiency. " Prior to leaving the facility on 9/16/13, the surveyors confirmed the components outlined above in the written plan of action had been implemented. During the survey on 9/16/13 the surveyors confirmed removal of the Immediate Jeopardy situation as of 9/16/13. Deficient practice with actual harm and the potential for more than minimal harm remained for inadequate monitoring of medications. Findings include: A. Immediate Jeopardy: Resident 217 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/3/13 resident 217's closed medical record was reviewed. Review of the physician admission orders [REDACTED]. (Note: Eskalith CR is a controlled release formulation of [MEDICATION NAME]. According to Discharge instructions from the hospital, Eskalith was a different type of [MEDICATION NAME] formulation for resident 217. Resident 217 had been taking [MEDICATION NAME], a short-acting formulation of [MEDICATION NAME]). No documentation could be found on the admission orders [REDACTED]. Review of the medical record revealed the following nurse's notes entries: "7/1/13 6:26 PM: ... Pt (patient) is a new admit today he came with walking (sic) with son and daughter... Pt is alert and oriented and he is able to comunicated (sic) his needs... Pt is continent of B/B (bowel and bladder)..." "7/8/13 6:01 PM: Pt remains alert and oriented X (times) 3. ...Communicates needs without difficulty. ... Cont (Continent) of B/B. ..." "7/9/13 1:07 PM: ... Speech is clear and concise. Communicates needs without difficulty. Cont of B/B. ..." "7/28/13 1:44 PM: ... Pt A/O (alert and oriented) X 3. ... Independent with bed mobility and transfers. ... Went out with family for church. ..." "7/29/13 6:12 PM: ... Stand by assist required with bed mobility, transfers and toilting (sic). Extensive assist required with showers. ... Out for LOA (leave of absence) with family members this evening. ... Cont of B/B with assist." "7/30/13 5:48 PM: ... Stand by assist with bed mobility, toileting and transfers. Amb (ambulates) with 1 assist. ... Posture is upright, gait is slightly side to side. ... Cont of B/B with assist. ..." "8/1/13 10:38 AM: ... Pt has no C/O (complaints of) pain this morning but stated that he doesn't feel good and want to talk to MD (Medical Doctor). ... Family members reported to me today that (resident 217) went LOA with family for couple hrs (hours) on 7/31/13 and was extremly (sic) shaky. Pt have unsteady gait. Pt also couldn't remember where he was with the family. I told family member that I will let MD know and cont (continue) to moniotr (sic)." "8/2/13 12:30 PM: 10:10 Resident is shacky (sic) wanting to walk home unsteady gait, sometimes not making full sentences. wants to leave yet states he is hungry and wants to eat but is upset to his stomach. ... DNP (? Nurse Practitioner) (name) was consulted and a STAT (immediate) [MEDICATION NAME] level was ordered and his [MEDICATION NAME] was D/C'd. ..." "8/2/12 1:21 PM: Late entry for Labbs (sic). Obtain CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), TSH ([MEDICAL CONDITION] Stimulating Hormone) and UA (urinalysis). D/C orders when you get results bck (back) and notify MD." "8/2/13 1:23 PM: Late entry for 8/1/12 (sic)." "8/2/13 1:24 PM: Error for note above. Late entry for labs obtain on 8/2/13." "8/2/13 7:14 PM: Received lab results on [MEDICATION NAME] for (resident 217) NP (Nurse Practitioner) notified. 2. New order to D/C [MEDICATION NAME] and recheck on 8/5/13." "8/3/13 2:49 PM: Late entry for 8/2/13 Pt 1 person assist with transfer, toileting, bed mobility and eating. Pt continent of B&B but this morning has one episode of diarrhea. ... Pt stated that he doesn't feel good and is very shaky today. PT (physical therapy) and OT (Occupational Therapy) let (sic) recommend to use walker D/T (due to) unsteady gait. NP order (sic) labs for (resident 217). Got results back for [MEDICATION NAME]. [MEDICATION NAME] D/C and they will check [MEDICATION NAME] Levels on 8/5/13. Pt has order to do UA but unable to do it. Meesage (sic) pass on night nurse. ... Pt stated that he doesn't have much apettit (sic) during this shift. ..." "8/3/13 3:07 PM: ...Pt is still very shaky using a walker for mobility. Called lab for rest of lab test that were done on 8/2, didn't receive results yet. ... Night nurse reported to me that pt was awake through the night and was walking around couple times. Pt was humming most of the day this AM shift. Pt also has therapys (sic) today with PT and she was also concerned about (resident 217). PT stated that (resident 217) is acting differently then (sic) usually (sic) and has very unsteady gait. ..." "8/4/13 7:16 AM: ...Pt was found on the floor of the Rohal (sic) Grove Dining room. Pt states that he did not fall. States that he likes to lay on the floor sometimes. ... Pt has not slept in the last 2 days. Results of labs were sent to MD and no new orders at this time. Pt has been taken off [MEDICATION NAME] until Monday the 5th when his oevels (sic) can be checked again. Pt a bit anxious this shift. Wandering around the bldg (building), and singing. ..." "8/4/13 7:17 PM: T.O. (telephone order) = [MEDICATION NAME] 0.5 mg po TID (three times daily) prn (as needed) for anxiety [MEDICATION NAME] 5mg/ml (milligrams per milliliter) IM Q 8 hrs as need it (sic) for agitation." (Note: According to the facility Medical Director, interviewed on 9/12/13, staff did not report that resident 217 was being treated for [REDACTED].) "8/4/13 9:44 PM: ... Resident alert and oriented to self this morning, resident denied pain all day long, confused unstady (sic) gait, pacing, talking to himself, tremors on his hands (sic), S/S (signs and symptoms) of anxiety, MD notified, new order of [MEDICATION NAME] in placed (sic), 1 person total assist for ADL's (Activities of Daily Living) and 1 person with transgfers (sic) and ambulation for safety, ... Incontinent of bowel and bladder, Max assistence (sic) with eating, R/T (related to) confusion, ... Behaviors creaming (sic), pacing, disruptive sounds, ..." "8/5/13 4:18 AM: Pt is alert and oriented to self in this shift. Pt was very agitated, confused and talking to himself. He has tremors on his hands, and S/S of anxiety. Pt was kept trying (sic) to get up self from bed. Placed mattress next to bed and put pt on the mattress D/T (due to) fall risk. Pt screamed in middle of night. Administered prn [MEDICATION NAME] 0.5 mg, and Pt went back to sleep. Will continue to monitor." "8/5/13 7:43 PM: Pt found at 630 AM on mattress by bed shaking uncontrollably. Pt was making consistent yelling noises. Pt was not able to respond to nurse when asked questions. Nurse pulled pt on to mattress when pt found scooting off mattress. After reviewing previous night and days information the nurse checked pt again for changes at 645 AM. CNA (Certified Nursing Assistant) assisted in pulling pt on mattress again. Pt found to have vitals of 89/41 BP (blood pressure) PR (pulse rate) 82 OX (oxygen) 88% RR (respiratory rate) 12. Pt cont to yell out and shake uncontrollably. Pt not able to respond to staff prompting or questions. Pt sent to (name of acute care hospital) by BLS (basic life support) ambulance transport around 8 AM." Review of physician progress notes [REDACTED]. No documentation could be found on the progress notes to indicate that the physician or nurse practitioner were aware that resident 217 was receiving [MEDICATION NAME]. No documentation could be found to show that the physician or nurse practitioner ordered a baseline serum [MEDICATION NAME] level to be obtained for resident 217. On 8/1/13 the facility nurse practitioner documented the following on a progress note: "... staff reports (increasing) confusion, wandering, doesn't make sense. Appropriate during interview A&O X 3 but requires constant queing (sic) to monitor conversation." Again the nurse practitioner makes no mention of the fact that resident 217 was receiving [MEDICATION NAME]. In the "Assessment/Plan" portion of the progress note, the nurse practitioner documented that labs would be checked for a possible metabolic cause, infection, electrolytes or [DIAGNOSES REDACTED] related to resident 217's change of status. On 8/2/13 the facility nurse practitioner documented the following on a progress note: "...(increased) confusion, irritability, ataxia, tremors. Labs (?) r/o (rule out) metabolic cause. Review of chart et (and) meds (medications) et discussion of meds (with) family. ? of long acting meds admin (administered) (at) hosp (hospital) et dc'd (discontinued) to facility, whereas family does not think was previously on long acting [MEDICATION NAME]. Family states has acted like this (before) when meds are of out of order ... Alert, oriented X 3 to conversation (with) ques (sic), although staff reports (increased) wandering et not aware of situation, time place." In the "Labs/x-ray results" portion of the progress note dated 8/2/13, the nurse practitioner documented "[MEDICATION NAME] 2.5, norm (normal) 0.6 - 1.2." The "Assessment/Plan" portion of the progress note dated 8/2/13 contained the following: "1. [MEDICATION NAME] toxicity - Hold [MEDICATION NAME] until 8/5/13, re (check) level et dose accordingly, monitor for s/sx (signs and symptoms) (increased) toxicity, (change) in LOC (level of consciousness). Encourage PO (by mouth) fluids. awaiting labs renal fxn (function), electrolytes - H/O (history of) [MEDICAL CONDITION]. Discussed case (with) (name of physician) et RN (Registered Nurse)." Review of the laboratory values for resident 217 revealed that the STAT [MEDICATION NAME] level ordered by the Nurse Practitioner on 8/2/13 at 10:10 AM was not obtained until 1:30 PM on 8/2/13. Resident 217's serum [MEDICATION NAME] level was 2.5 milliequivalents (mEq) per liter (L). The laboratory used by the facility listed the reference range for [MEDICATION NAME] as 0.6 to 1.2 mEq/L. The laboratory characterized resident 217's level of 2.5 mEq/L as "critical". Per documentation on the laboratory results for resident 217's [MEDICATION NAME] level on 8/2/13, a panic result was called into a facility Registered Nurse. On 8/4/13, facility staff obtained a physician's orders [REDACTED]. Review of the documentation revealed that facility staff administered two doses of both medications in an approximate 13 hour time frame. Per acute care hospital documentation, resident 217's [MEDICATION NAME] level upon admission to the Emergency Department was 2.06 mEq/L. According to the hospital admission "History and Physical" resident 217 presented to the hospital "agitated and unresponsive, disoriented and tremor right sided posturing alternating with rapid thrashing motions in all extremities." The hospital "Assessment/Plan" listed resident 217's "Active Hospital Problem" as "[MEDICATION NAME] toxicity." Resident 217 passed away on 8/9/13. On 9/5/13 at 1:07 PM, a Medical Examiner with the State of Utah's office of the Medical Examiner was interviewed. The Medical Examiner stated that resident 217's primary cause of death was [MEDICATION NAME] toxicity. On 9/3/13, the facility Administrator, Assistant Director of Nursing, and Corporate Nurse Consultant were interviewed. They stated that the facility did not have a policy in regards to drawing laboratory values for medications that required therapeutic dosing monitoring. They further stated that the laboratory values were drawn at the discretion of the facility's physician or nurse practitioner. On 9/12/13 at 7:43 AM, the facility nurse practitioner (NP) was interviewed. The NP stated that the facility did not draw routine surveillance laboratory values for residents. The NP further stated that laboratory values for medications would only be drawn when it was indicated. The NP stated that those indications would be if the resident experienced a change in condition or showed signs of toxicity to the medications. The NP stated he ordered a [MEDICATION NAME] level for resident 217 on Thursday night (8/2/13) because resident 217 had showed signs which indicated [MEDICATION NAME] toxicity. The NP stated resident 217 was alert and was encouraged to drink a lot of fluids because of the [MEDICATION NAME] toxicity. The NP stated, "I have not treated [MEDICATION NAME] toxicity. So, I contacted Dr. (Name of doctor)." The NP further stated that the medical director told him to hold the medication, monitor and recheck the level. The NP stated the facility medical director was on call over the weekend. The NP stated the facility nurses called the medical director and informed him of resident 217's behaviors. The NP stated that he had spoken with the medical director and the medical director had told him that the facility staff had not informed him (the medical director) that the resident with the behaviors was the resident who currently had [MEDICATION NAME] toxicity. The NP stated he would have done things differently if he had been informed of resident 217's behaviors. The NP further stated he would have sent resident 217 to the hospital. On 9/12/13 at 9:15 AM, the facility Medical Director (MD) was interviewed via telephone. The MD stated that resident 217 was receiving a "pretty good dose" of [MEDICATION NAME]. The MD stated that he typically ordered a [MEDICATION NAME] level to be drawn, for patients receiving [MEDICATION NAME], every three months. The MD further stated that he tried to get residents off of [MEDICATION NAME] because the blood level could change rapidly. The MD stated that residents receiving [MEDICATION NAME] needed to be monitored. The MD stated that when the facility staff contacted him on 8/4/13, the staff did not report to him that they were calling about the resident who currently had [MEDICATION NAME] toxicity. The MD stated that he was told a resident was having behaviors. The MD stated that had he been told it was the resident with [MEDICATION NAME] toxicity he would have ordered IV hydration or that the resident be sent to the hospital. The MD stated that he did not order a baseline [MEDICATION NAME] level for resident 217 because the NP did all of the admission assessments and ordered the laboratory values. B. Harm: Resident 251 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 9/11/13 resident 251's medical record was reviewed. Review of the medical record revealed the following hospital discharge instructions: "Instructions for LTAC (Long-Term Acute Care Hospital), Acute Rehab, Acute Hospital or SNF (Skilled Nursing Facility): ...1. [MEDICATION NAME] trough level to be checked am (in the morning) on 8/12/13 with results to SNF physician, 2. Redose [MEDICATION NAME] at 1.5 grams IV (Intravenous) once [MEDICATION NAME] trough is < (less than) 20 (goal trough level : 15 -20). expected dosing is 1.5 gm IV Q (every) 48 hours . Received dose am 8/11/13, 3. [MEDICATION NAME] to be completed on 9/12/13, 4. Hold [MEDICATION NAME] 8/11/13, 5. repeat INR (International Ratio) in am on 8/12/13. 6. restart [MEDICATION NAME] once INR < 2.8, 7. further [MEDICATION NAME] dose adjustments per SNF physician (expected dose is approx (approximately) 3 mg (milligrams) qhs (every night)), 8. CBC with diff (differential), Chem (Chemistry) 7, ESR (Erythrocyte Sedimentation Rate), CRP (C-Reactive Protein) every Monday while on antibiotics. 9. Right upper extremity PICC (Peripherally Inserted Central Catheter) per routine care, 10. Remove PICC upon completion of antibiotics." Review of the physician's orders [REDACTED]. No documentation could be found to show that resident 251 received the [MEDICATION NAME] or the [MEDICATION NAME]. On 8/23/13 resident 251 went to a follow up appointment at a local hospital clinic. The following was documented in the "Doctor Observation/New Orders" portion of the form: "See our original D/C (Discharge) orders, ... needed to be getting [MEDICATION NAME] all this time. Resume [MEDICATION NAME] 2 mg po QHS check PT/INR (Pro-Time/International Ratio) daily. ID (Incision and Drainage) - needed to be having IV antibiotics all this time. ..." On 8/23/13, after resident 251 attended her follow-up appointment, the following physician's orders [REDACTED]. PT/INR daily." No results could be found to show what resident 251's INR was at the time the [MEDICATION NAME] was re-instated. On 8/24/13 the following physician's orders [REDACTED]. (check) PT/INR 8/28/13 Dx (diagnosis): knee repair." No documentation could be found to show facility staff checked resident 251's PT/INR before increasing the [MEDICATION NAME] dose to 3 mg. No documentation could be found to show why facility staff obtained the order to increase the [MEDICATION NAME]/[MEDICATION NAME] to 3 mg. On 8/26/13 the following physician's orders [REDACTED]. PT/INR = 2.1/32.0, 2. continue [MEDICATION NAME] 3mg po qday, 3. Re-check PT/INR on 9/2/13." No documentation could be found to show the PT/INR was done on 8/23/13, 8/24/13, or 8/25/13. On 9/2/13 the following physician's orders [REDACTED]. Review of the Laboratory values revealed that on 9/2/13 resident 251's PT/INR was PT - > (greater than) 170.0 (reference range 11-14) and INR > 13.0 (reference range of 2.0-3.5). On 9/2/13 facility staff received the following order: "D/C (discontinue) [MEDICATION NAME]. Vitamin K IM (Intramuscularly) 10mg now x (times) 1 today (now) 9/2/13 3. PT/INR on 9/3/13." On 9/3/13 the following physician's orders [REDACTED]. Re-check PT/INR on 9/413.", in addition to the following order: "9/3/13 TO: Vit K 10mg/ml injection 1x dose." Resident 251 received two doses of Vitamin K, one dose on 9/2/13 and one dose on 9/3/13 for the elevated PT/INR. On 9/18/13, Licensed Practical Nurse (LPN) 3 was interviewed. LPN 3 stated that he obtained the routine PT/INR's for residents every Monday. LPN 3 stated that if a resident was receiving antibiotics or being re-started on [MEDICATION NAME], the resident's PT/INR should have been checked daily. LPN 3 further stated that it took 3-5 days to obtain a therapeutic blood level while receiving [MEDICATION NAME] therefore the PT/INR should have been monitored more frequently until that therapeutic level was achieved. On 9/11/13 the facility Director of Nursing (DON) was interviewed. The DON stated that the facility did not draw admission laboratory values on residents regardless of the medications the residents were receiving. The DON stated that the laboratory values were drawn at the discretion of the physician and nurse practitioner. On 9/12/13 at 8:10 AM the facility NP was interviewed. The NP stated that he was not aware of the facility policy or protocol for admission laboratory values or the monitoring of PT/INR results upon admission. The NP further stated that he was aware facility staff had missed obtaining PT/INR values for resident 251 but was not aware that resident 251 had received Vitamin K due to an elevated PT/INR. C. Potential for Harm: 1. Resident 148 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/16/13 resident 148's medical

Based on interview and record review it was determined, for 3 of 51 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care. Specifically, two residents experienced a delay in being sent to the hospital and another resident experienced a delay in receiving medications that were to be given upon admission to the facility. Resident identifiers: 33, 141, and 251. Findings include: 1. Resident 141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/18/13 resident 141's closed medical record was reviewed. Review of the nurse's notes revealed the following entries: "6/27/13 10:39 PM: ... Resident resting comfortable (sic) assisted with turning and repositioning. Assisted with ADLs (Activities of Daily Living) and transfers no fall no injuries noted. Drsg (dressing) to ABD (abdomen) changed as ordered. No SOB (shortness of breath) noted resps (respirations) even unlabored no CP (chest pain) noted. ... Feeding infusing as ordered tolerates well no N/V (nausea/vomiting) noted. Meds (medications) given crushed through tube flushes easily (sic). Call light reach (sic). O2 (oxygen) per N/C (nasal canula) cont (continue) to monitor." "6/28/13 10:15 AM: ...Chest x ray and ABD x ray to eval (evaluate) tube placement. Liquids are coming out [MEDICAL CONDITION] site opening. Upon checking for tube site placement - air expels [MEDICAL CONDITION]. Feeding stopped until results of x ray." "6/28/13 7:47 PM: X ray report received: tip of MFT (Manual Feeding Tube) is in midline chest/esophagus. MFT pulled by this nurse. Pt (patient) transported via (name of ambulance company) to have tube replaced at (name of local hospital) radiology dept. (department). When pt returns he will be transferred to (different unit within the facility). Pt wife notified." Note: According to documentation resident 141 had not been assessed for tube placement by a facility staff member for approximately 12 hours. Review of the X-ray report dated 6/28/13 revealed the following "Impression: Mild [MEDICAL CONDITION] Venous Congestion. Moderate right lower lobe and large left lower lobe infiltrate and/or effusion. The [MEDICAL CONDITION] tube tip is in mid chest most likely in mid esophagus. 25 CM (centimeter) advancement and F/U (follow-up) recommended." According to the Final X-ray report, the document was faxed to the facility at 12:54 PM on 6/28/13. Upon further review, Licensed Practical Nurse (LPN) 4 "noted and reported" the findings on 6/28/13 at 2:00 PM. (It should be noted that the first entry by the nurse was at approximately 10:00 AM. The x-ray report was faxed to the facility at approximately 1:00 PM but was not noted by the nurse until 2:00 PM. According to the documentation resident 141 had been waiting 4 hours since the discovery of the medications "squirting" out of the [MEDICAL CONDITION] site.) On 9/18/13 at 9:35 AM, LPN 4 was interviewed via telephone. LPN 4 stated that she went into resident 141's room the morning of 6/28/13 to give him his medications. LPN 4 stated that when she began to administer the medications the medications came "squirting out" of resident 141'[MEDICAL CONDITION]. LPN 4 stated that she immediately shut the tube feeding off because, "We didn't want to give him (resident 141) anything because it would go straight into his lungs at this point." LPN 4 stated that she called for an X-ray stat (immediately) but kept calling the X-ray company because, "I felt like it was taking forever for them to get here." LPN 4 further stated that the X-ray company had told her they could take up to four hours to obtain a STAT x-ray. LPN 4 stated that when she received the results she was told by the facility Nurse Practitioner and the Unit Manager to send resident 141 to the radiology department to have the [MEDICAL CONDITION] tube re-inserted. LPN 4 stated that she remembered sending resident 141 to radiology department in the late afternoon. LPN 4 stated that she was not told to send resident 141 to the hospital for evaluation but to send resident 141 to the radiology department to have the tube replaced. Review of the Acute Care Hospital Documentation revealed that resident 141 presented to the Emergency Department at 9:45 PM on 6/28/13. No documentation could be found to show what time resident 141 actually left the facility or if resident 141 spent time at the radiology department before presenting to the emergency room for evaluation. The "History of Physical Report" from the Acute Care Hospital, dated 6/28/13, documented the following: "Chief Complaint: Acute [MEDICAL CONDITION]" "History of Present Illness: (Resident 141) is a 79 y/o (year old) M (male) with a PMH (past medical history) ...complicated with aspiration pneumonitis with persistent pleural effusions requiring treacheostomy and ventilator support, which was discontinued 4 days PTA (prior to admission). He who was (sic) brought to (local hospital) from Woodland Park for replacement of his NG ([MEDICAL CONDITION]) tube which had come displaced, with residual found at his prior [MEDICAL CONDITION] site. ..." "Plan: # Acute [MEDICAL CONDITION]: Possibly secondary to large plural effusions c/b (caused by) [MEDICAL CONDITION] (chronic obstructive [MEDICAL CONDITION] disorder). History of residual [MEDICAL CONDITION] concerning for aspiration of tube feeds. ..." Note: Resident 141 waited approximately 12 hours from the time the medications were observed "squirting out" of [MEDICAL CONDITION] until he was evaluated at the hospital. Additonally, facility staff were aware resident 141 had a history of [REDACTED]. 2. Resident 251 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 9/11/13 resident 251's medical record was reviewed. Review of the medical record revealed the following hospital discharge instructions: "Instructions for LTAC (Long-Term Acute Care Hospital), Acute Rehab, Acute Hospital or SNF (Skilled Nursing Facility): ...1. [MEDICATION NAME] trough level to be checked am (in the morning) on 8/12/13 with results to SNF physician, 2. Redose [MEDICATION NAME] at 1.5 grams IV (Intravenous) once [MEDICATION NAME] trough is < (less than) 20 (goal trough level : 15 -20). expected dosing is 1.5 gm IV Q (every) 48 hours . Received dose am 8/11/13, 3. [MEDICATION NAME] to be completed on 9/12/13, 4. Hold [MEDICATION NAME] 8/11/13, 5. repeat INR (International Ratio) in am on 8/12/13. 6. restart [MEDICATION NAME] once INR < 2.8, 7. further [MEDICATION NAME] dose adjustments per SNF physician (expected dose is approx (approximately) 3 mg (milligrams) qhs (every night)), 8. CBC with diff (Complete Blood Count with differential), Chem (Chemistry) 7, ESR (Erythrocyte Sedimentation Rate), CRP (C-Reactive Protein) every Monday while on antibiotics. 9. Right upper extremity PICC (Peripherally Inserted Central Catheter) per routine care, 10. Remove PICC upon completion of antibiotics." Review of the physician's orders [REDACTED]. No documentation could be found to show that resident 251 received the [MEDICATION NAME] or the [MEDICATION NAME]. On 8/23/13 resident 251 went to a follow up appointment at a local hospital clinic. The following was documented in the "Doctor Observation/New Orders" portion of the form: "See our original D/C (Discharge) orders, ... needed to be getting [MEDICATION NAME] all this time. Resume [MEDICATION NAME] 2 mg po QHS check PT/INR (Pro-Time/International Ratio) daily. ID (Incision and Drainage) - needed to be having IV antibiotics all this time. ..." On 8/23/13, after resident 251 attended her follow-up appointment, the following physician's orders [REDACTED]. PT/INR daily." No results could be found to show what resident 251's INR was at the time the [MEDICATION NAME] was re-instated. (Note: Resident 251 was admitted with bacteremia [MEDICAL CONDITION] yet was not receiving the prescribed antibiotic therapy.) On 8/24/13 the following physician's orders [REDACTED]. (check) PT/INR 8/28/13 Dx (diagnosis): knee repair." No documentation could be found to show facility staff checked resident 251's PT/INR before increasing the [MEDICATION NAME] dose to 3 mg. No documentation could be found to show why facility staff obtained the order to increase the [MEDICATION NAME]/[MEDICATION NAME] to 3 mg. On 8/26/13 the following physician's orders [REDACTED]. PT/INR = 2.1/32.0, 2. continue [MEDICATION NAME] 3mg po qday, 3. Re-check PT/INR on 9/2/13." No documentation could be found to show the PT/INR was done on 8/23/13, 8/24/13, or 8/25/13. On 9/2/13 the following physician's orders [REDACTED]. Review of the Laboratory values revealed that on 9/2/13 resident 251's PT/INR was PT - > (greater than) 170.0 (reference range 11-14) and INR > 13.0 (reference range of 2.0-3.5). On 9/2/13 facility staff received the following order: "D/C (discontinue) [MEDICATION NAME]. Vitamin K IM (Intramuscularly) 10mg now x (times) 1 today (now) 9/2/13 3. PT/INR on 9/3/13." On 9/3/13 the following physician's orders [REDACTED]. Re-check PT/INR on 9/413.", in addition to the following order: "9/3/13 TO (telephone order): Vit K 10mg/ml injection 1x dose." Resident 251 received two doses of Vitamin K, one dose on 9/2/13 and one dose on 9/3/13 for the elevated PT/INR. On 9/18/13, LPN 3 was interviewed. LPN 3 stated that he obtained the routine PT/INR's for residents every Monday. LPN 3 stated that if a resident was receiving antibiotics or being re-started on [MEDICATION NAME], the resident's PT/INR should have been checked daily. LPN 3 further stated that it took 3-5 days to obtain a therapeutic blood level while receiving [MEDICATION NAME] therefore the PT/INR should have been monitored more frequently until that therapeutic level was achieved. On 9/11/13 the facility Director of Nursing (DON) was interviewed. The DON stated that the facility did not draw admission laboratory values on residents regardless of the medications the residents were receiving. The DON stated that the laboratory values were drawn at the discretion of the physician and nurse practitioner. On 9/12/13 at 8:10 AM, the facility NP was interviewed. The NP stated that he was not aware of the facility policy or protocol for admission laboratory values or the monitoring of PT/INR results upon admission. The NP further stated that he was aware facility staff had missed obtaining PT/INR values for resident 251 but was not aware that resident 251 had received Vitamin K due to an elevated PT/INR. The NP stated that he had reviewed resident 251's medical record and resident 251 was not admitted with an order to receive IV [MEDICATION NAME]. The NP further stated that he was unsure why facility staff were to obtain a [MEDICATION NAME] trough, when resident 251 was "not receiving [MEDICATION NAME]". 3. Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 9/16/13 resident 33's medical record was reviewed. There were no nurses notes between 7/26/13 and 8/10/13. Review of resident 33's nurse's notes revealed the following entries: a. On 8/10/13 at 5:06 PM, a nurse assessment indicated that resident 33's bowels were "subject to impaction. . . Pain is about 6 on a scale of 0-10. . ." b. On 8/10/13 at 6:30 PM, "PT's (patient's) abdomen is hard and distended. PT states no BM (bowel movement) for three days. Hypoactive bowel sounds heard in all four quadrants. [MEDICATION NAME], half a bottle of mag [MEDICATION NAME] (Magnesium [MEDICATION NAME]) administered. PT still has not had BM. PT states pain 7 on a scale of 0-10 in abdominal area. Report given to night nurse to follow up on possible impaction". (Note: According to the August 2013 MAR indicated [REDACTED]. In addition, resident 33 received Senna 8.6mg at 10:30 PM and [MEDICATION NAME] 4mg at 8:47 AM and 6:19 PM. There was a follow up note at 2:23 PM after [MEDICATION NAME] Suppository was administered that medication was not effective, as resident 33 had not had a bowel movement.) c. On 8/11/13 at 2:34 AM, "PT assessed for impaction. There was no stool that was found. PT refused to take a (sic) enema. PT took 10mg [MEDICATION NAME]. No BM yet. Will continue to monitor." (The August 2013 MAR indicated [REDACTED].) d. On 8/12/13 at 3:19 PM, "PT has a hard, distended abdomen. PT reports she has been having BMs the last few days, but they are small and hard. PT given oral laxatives and stool softeners. No results. NP (Nurse Practitioner) notified and PT given enema. Still awaiting results at this time." (The August 2013 MAR indicated [REDACTED]. A follow up nurses note at 11:47 PM noted no BM.) e. On 8/12/13 at 3:23 PM, "TO Mineral Oile (sic) order noted." f. On 8/12/13 at 4:21 PM, "PT has not had significant BM, PT given enema, dig stim (digital stimulation), and suppository. Small amount of watery feces and significant ammount (sic) of gas expelled. Will continue bowel protocol until results." (The August 2013 MAR indicated [REDACTED].) g. On 8/13/13 at 2:52 PM, "Pt stated that she has not had good amount of BM for 4 days. PT's stomach was very distended and hard. Notified MD (medical director) and DON. Got order for enema and digital stim (stimulation). Pt went to bathroom for (sic) multiple times in this shift, but PT still does not have good amount of BM. Administered 17mg of [MEDICATION NAME], 30ml of Milk of Mag, suppository and digital stim. When performed digital stim, PT had a lot of gas. VS (vital signs): T (temperature): 96.0, BP (blood pressure): 142/91, P (pulse): 125. Will continue to monitor." (The August 2013 MAR indicated [REDACTED].) h. On 8/14/13 at 12:49 PM "Spoke with Nurse Practitioner regarding no BM for PT. TO: [MEDICATION NAME] 30ml every 2 hours TO: Ducolax 5mg twice a day TO: 10mg [MEDICATION NAME] Suppository TO: Enema twice a day TO: Mag [MEDICATION NAME] until BM TO: [MEDICATION NAME] 10mg, TID (three times per day) x (for) 3 days TO: NG ([MEDICAL CONDITION]) tube and suction." i. On 8/14/13 at 4:17 PM "NP, (Name of Nurse Practitioner), notified of possible bowel obstruction. New TOs given. Educated patient regarding NG tube. Advised decompression of stomach, administration of bowel meds through tube. Pt refused NG tube. Pt refused NG tube despite education stating it hurt her throat. Pt refused enema because she wanted to attend casino royale. Administered [MEDICATION NAME] 30ml, po, 1 (to) 2 hours. Administered 2 Ducolax po. No mag [MEDICATION NAME] available in the facility. . . supply director notified of need for mag [MEDICATION NAME]'s stomach is hard and distended. PT is diaphoretic and in pain of 7 on scale of 0-10 located in stomach, knees, back. PT has only passed watery diarrhea, no fecal matter has been passed today. Will continue with bowel medications and new orders. . . ABD (abdominal) plate ordered for today." (The August 2013 MAR indicated [REDACTED].) j. On 8/14/13 at 6:51 PM, "Administered Mag [MEDICATION NAME] in apple juice. Pt only took a few sips and refused more..." k. On 8/14/13 at 6:57 PM "TO: abdominal plate to rule out ileus per (name removed), NP. D/C (discharge) order when results reported to NP/DR. ABD plate performed 8/14 at 1700 (5:00 PM). Suppository administered per order..." (Note: A TO was signed by facility nurse at 1:30 PM for abdominal plate. There was a 3.5 hour delay from the time the order was obtained until the abdominal plate was performed.) l. On 8/15/13 at 2:19 AM "Patient was currently being treated for [REDACTED]. Report from am nurse was that she had been in extreme discomfort, having difficulty consuming mag [MEDICATION NAME] and [MEDICATION NAME] and (Name of NP) was aware with orders to keep encouraging bowel treatment until she had bowel movements. At 1900 (7:00 PM) patient was not taking mag [MEDICATION NAME] well for me either and refused to consume it without thining (sic) it down significantly with apple juice. Attempts made to encourage drinking mag [MEDICATION NAME] without diluting in order to decrease so much intake was not successful. Mixed in apple juice, she only consumed about 30 cc (cubic centimeter) and had som (sic) emesis each time. At 2000 (8:00 PM) she did manage to consume the [MEDICATION NAME]. She was in extreme pain refused other HS (night time) meds at that time. Abdomen extremely distended and hard. Patient was yelling in discomfort and I asked CNA (certified nursing assistant) to obtain VS." m. On 8/15/13 at 2:36 AM, "At 2000 (8:00 PM) patient in discomfort from pain, color was grey (sic), lips blue. Saturation checked and was 64%. O2 (oxygen) applied at 6L (6 liters) to bring sat (saturation) to 95%. BP 191/104 P 136 RR 30. Ambulance called and she was taken to (name of local hospital) hospital.... At 0200 (2:00 AM) Update from (name of local hospital) hospital obtained. She was admitted to (room in hospital) with [DIAGNOSES REDACTED]. They are obtaining a GI (gastrointestinal) consult to evaluated (sic) her in the AM." A form titled "Long Term Care Progress Note" completed by facility NP was dated 8/14/13 revealed, a. "History: H/O (history of) severe constipation...Reported to MD on 8/12/13, advised to give PRN (as needed) laxatives ordered. MD called again 8/12/13 @ (at) noc (night) with orders for stimulation by RN (registered nurse) and continued admin (administration) of meds. On 8/13/13 digital exam." b. "Nursing Concerns: Moderate to lower abd cramping. c. "Abd: Marked distension, BS (bowel sounds) hyperactive, 1+ tympany." d. "psych: anxious, contancherous" e. "Assessment/Plan: See meds as ordered 8/14/13. F/U (follow up) with abd plate, if sig (significant) illeus (sic) will transport to ED (emergency department)." A physician progress notes [REDACTED]. [DIAGNOSES REDACTED]." (Note: There was no treatment plan documented to resolve the above [DIAGNOSES REDACTED]. A care plan developed on 7/14/10 revealed a problem of "Resident does have hx of bowel problems. Has went (sic) to hospital to have colon decompressed." There were no obtainable goals for resident 33 on the care plan. One approach revealed, "will monitor residents bowel movements (and) BS (bowel sounds), stomach distress." (Note: There was no indication the care plan was updated.) A form titled "Final X-ray Report" revealed results were faxed to the facility on [DATE] at 11:30 PM. The findings revealed, "Comparison is made with 7/10/11. There is marked colonic dilatation consistent with ileus or obstruction. The small bowel loops are unremarkable. There is no soft tissue mass or significant pathologic calcification. There is a large amount of rectal stool present." The form further revealed, "Impression: Significant distention of colon, most likely represents obstruction or ileus. Clinical attention and f/u advised. The findings are worse than 7/10/11." On 9/18/13 at 10:30 AM, an interview was conducted with resident 33. Resident 33 stated that the nurses tried to give her two enemas but the enemas did not work. Resident 33 stated she thought the nurses were giving her a lot of laxatives. An observation was made of resident 33 during the interview. Resident 33 had a distended abdomen and was moaning. (Note: It should be noted that resident 33 exhibited symptoms of an obstruction on 8/10/13, but did not receive an xray to rule out the obstruction until 8/14/13 at 5:00 PM, three hours before the resident was sent to the local hospital due to a change in vital signs and increased pain.) Resident 33 was admitted to a Long Term Acute Care (LTAC) hospital from the local hospital on [DATE]. The notes from the LTAC revealed that resident 33 "...was admitted to (local hospital) on 8/14/13 with colonic pseudoobstruction secondary to constipation. She presented with abdominal pain and massively dilated colon. Over the next several days, she was treated with a bowel regimen, decompressive colonoscopy on 8/15/13 and 8/22/13, neostigmine x2, and [MEDICATION NAME] x (sic). GI and Colorectal Surgery Services were both consulted and followed the patient throughout her hospitalization . The patient declined surgical intervention and it was deemed she was overall to have a poor prognosis. Hospice was recommended but also declined by the patient and her family and it was felt that they wanted to pursue ongoing medical management of her condition. She developed [MEDICAL CONDITION] with rapid ventricular response and was placed on a [MEDICATION NAME] drip. One week into her hospitalization , she was placed on TPN (total [MEDICATION NAME] nutrition) for nutritional therapy when it was felt that her obstruction was not improving and she could not take internal nutrition. . ."

Based on interview and record review it was determined that the facility failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, facility administration were aware that the facility laboratory procedures and medication monitoring were ineffective. Additionally, residents experienced a delay in receiving treatment and/or medications, which resulted in hospitalization for two residents. Facility administration failed to properly assess and correct the identified concerns. The deficient practice identified for resident 217 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for resident 33, 141, and 251 was found to have occurred at a Harm level. Resident identifiers: 33, 141, 217, and 251. Findings include: 1. The facility administration failed to protect residents from undue adverse medication consequences with a lack of monitoring and a lack of timely and appropriate monitoring for drug titration. This failure resulted in a finding of immediate jeopardy for one resident, and harm for a second resident. Resident identifiers: 217 and 251. (Cross refer to F329) 2. The facility administration failed to ensure that residents received services to attain their highest practicable physical, mental, and psychosocial well being. This failure resulted in a finding of harm for three residents. Resident identifiers: 33, 141, and 251. (Cross refer to F309) 3. The facility administration failed to maintain a quality assessment and assurance committee that identified quality of care concerns and implemented plans of action to correct the identified concerns. (Cross refer to F490)

Based on interview and record review it was determined that the facility failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, facility administration were aware that the facility laboratory procedures and medication monitoring were ineffective. Additionally, residents experienced a delay in receiving treatment and/or medications, which resulted in hospitalization for two residents. Facility administration failed to properly assess and correct the identified concerns. The deficient practice identified for resident 217 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for resident 33, 141, and 251 was found to have occurred at a Harm level. Resident identifiers: 33, 141, 217, and 251. Findings include: 1. The facility administration failed to protect residents from undue adverse medication consequences with a lack of monitoring and a lack of timely and appropriate monitoring for drug titration. This failure resulted in a finding of immediate jeopardy for one resident, and harm for a second resident. Resident identifiers: 217 and 251. (Cross refer to F329) 2. The facility administration failed to ensure that residents received services to attain their highest practicable physical, mental, and psychosocial well being. This failure resulted in a finding of harm for three residents. Resident identifiers: 33, 141, and 251. (Cross refer to F309) 3. The facility administration failed to maintain a quality assessment and assurance committee that identified quality of care concerns and implemented plans of action to correct the identified concerns. (Cross refer to F520)

Based on observation, interview and record review, it was determined the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practical physical, mental, and psychological well-being in accordance with the comprehensive assessment and care plan for 1 of 49 sample residents. Specifically, resident 270's pain level was not reassessed and addressed with the attending physician for 15 days. Findings include: Resident 270 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 2/12/13 at 8:43 AM, resident 270 was interviewed. Resident 270 was asked if she had any discomfort such as pain or hurting with no relief. Resident 270 stated that she had pain from her [MEDICAL CONDITION], pain in her hands and pain in her left ankle from her surgical procedure. Resident 270 stated that her pain was really bad but that medications sometimes relieved it. Resident 270 stated that the pain prevented her from attending activities. Resident 270's medical record was reviewed on 2/12/13. Review of the admission Minimum Data Set (MDS) Assessment with an assessment reference date of 2/5/13, revealed that the facility staff assessed resident 270 as having a Brief Interview for Mental Status (BIMS) of 11. The facility staff assessed resident 270 has having: (a) little interest or pleasure in doing things, feeling down, depressed, or hopeless; (b) feeling bad about herself; and (c) had thoughts that she would be better off dead for 2-6 days during the reference assessment. The facility staff assessed resident 270 as having pain frequently which made it hard for her to sleep at night with a pain rating of an 8 (scale of 1-10 with 10 being the worst). The facility staff did not document if the pain was mild, moderate, severe, or very severe. On 1/29/13, a care plan for pain was developed. The facility staff documented the problem as "(Resident 270) admits with a L (left) ankle fracture impairing her mobility, putting her at risk for falls, impaired skin integrity and pain". The goals developed included "...(Resident 270) will have no untreated s/sx (signs or symptoms) of pain TNR (to next review)". The approaches developed to achieve that goal included: (1) "Assisted (resident 270) with all transfers and ambulation. Provide up to extensive two person assist for all ADL (activities of daily living), transfer and mobility activities; (2) Monitor (resident 270's) pain q (every) shift. Give pain medication as requested/ordered. Notify physician of increase in pain or pain not controlled by curren (sic) regimen...." Review of the initial admission orders Question resident about presence of pain or burning including pressure points. Monitor all pain each shift using a 0 (equals) none/10 (equals) worst possible...." A "Pain Evaluation" was completed by an unknown staff member (the pain evaluation was not signed or dated as to who completed the evaluation or when the evaluation was completed). The pain evaluation documented the location of pain to be in the joint with an potential underlying cause of pain being a fracture. The facility staff member documented a present pain rating of "2" ("hurts a little bit (mild))" with the worst the pain was at an "8" ("hurts a whole lot (excruciating))". The facility staff member documented an acceptable level of pain to be at a "2" ("hurts a little bit (mild)"). The facility staff further documented that resident 270 verbalized the pain and that the pain interfered with her enjoyment of life and her physical activity. The "E (electronic) - Medication Administration Record" for January and February 2013 were reviewed. The facility licensed nurses were to "Question (resident 270) about presence of pain or burning including pressure points, monitor all pain each shift using a 0 (equals) none / 10 (equals) worst possible. ..." The facility licensed nurses (LN) documented resident's 270's pain level as follows: 1. 1/29/13 at 10:00 PM: "7" - The LN did not document where resident 270's pain was or characteristics of the pain such as dull, sharp or stabbing and did not document administering any pain medication despite the pain rating of "7". 2. 1/30/13 at 10:00 AM: "6" - The LN did not document where resident 270's pain was or characteristics of the pain such as dull, sharp or stabbing and did not document administering any pain medication despite the pain rating of "6". 3. 1/31/13 at 10:00 AM: "8" - The LN did not document where resident 270's pain was or characteristics of the pain such as dull, sharp or stabbing and did not document administering any pain medication despite the pain rating of "8". 4. 2/1/13 at 8:11 AM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 5. 2/1/13 at 10:00 AM: "10". 6. 2/1/13 at 10:24 AM: The LN documented "Follow up (Administered: 1024 AM, 2/1/13; [MEDICATION NAME] 7.5/325 1-2 each PO Q 4 H PRN) Medication follow up - ...Medication was effective". (Note: The LN documented administering [MEDICATION NAME] at 8:11 AM without a pain rating. At 10:00 AM, the LN documented a pain rating of 10, almost two hours after administering the [MEDICATION NAME]. Additionally, the LN documented that the [MEDICATION NAME] was "effective" 24 minutes after receiving a pain rating of 10, without administering additional medications). 7. 2/1/13 at 10:00 PM: "1". 8. 2/2/13 at 8:30 AM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 9. 2/2/13 at 9:01 AM: The LN documented "Follow up (Administered 9:01 AM, 2/2/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...Medication was "effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 10. 2/2/13 at 10:00 AM: "8". The LN did not document what interventions were implemented to resolve resident 270's pain. (Note: The LN documented at 9:01 AM, that resident 270 had "effective" results after administering [MEDICATION NAME] to resident 270 at 8:30 AM.) 11. 2/2/13 at 5:28 PM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 12. 2/2/13 at 6:51 PM: The LN documented "Follow up (Administered 6:51 PM, 2/2/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - (blank). (Note: The LN did not document whether the [MEDICATION NAME] administered at 5:28 PM was effective or ineffective.) 13. 2/2/13 at 10:00 PM: "1". 14. 2/3/13 at 5:14 AM: The LN documented "5/14 AM, 2/3/13 (Administered: 5/34/AM, 2/3/13; [MEDICATION NAME] 650 mg PO q 4 H PRN) Medication Follow up - ...(blank). (Note: The LN did not document where resident 270's pain was or the characteristics of the pain.) 15. 2/3/13 at 6:48 AM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 16. 2/3/13 at 7:20 AM: The LN documented "...Follow up (Administered 7:20 AM, 2/3/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 17. 2/3/13 at 10:00 AM: "5". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain. 18. 2/3/13 at 8:08 PM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 19. 2/3/13 at 8:45 PM: The LN documented "...Follow up (Administered 8:45 PM, 2/3/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 20. 2/3/13 at 10:00 PM: "4". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain. 21. 2/4/13 at 1:24 AM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 22. 2/4/13 at 2:20 AM: The LN documented "...Follow up (Administered 2:20 AM, 2/4/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 23. 2/4/13 at 8:26 AM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 24. 2/4/13 at 9:01 AM: The LN documented "...Follow up (Administered 9:01 AM, 2/4/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 25. 2/4/13 at 10:00 AM: "5". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain despite being "effective" one hour prior. 26. 2/4/13 at 12:50 PM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 27. 2/4/13 at 3:30 PM: The LN documented "...Follow up (Administered 3:30 PM, 2/4/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 28. 2/4/13 at 5:17 PM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 29. 2/4/13 at 6:35 PM: The LN documented "...Follow up (Administered 6:35 PM PM, 2/4/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 30. 2/4/13 at 10:00 PM: "4". The LN did not document administering any pain relieving medications and did not document what interventions were implement to resolve resident 270's pain despite being "effective" 3 1/2 hours prior. 31. 2/5/13 at 4:23 AM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 32. 2/5/13 at 5:38 AM: The LN documented "...Follow up (Administered 5:38 AM, 2/5/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 33. 2/5/13 at 8:26 AM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 34. 2/5/13 at 9:29 AM: The LN documented "...Follow up (Administered 9:29 AM, 2/5/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 35. 2/5/13 at 10:00 AM: "5". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain despite being "effective" 1/2 hour prior. 36. 2/5/13 at 12:44 PM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. The LN did not document whether the [MEDICATION NAME] was effective or ineffective. 37. 2/5/13 at 8:16 PM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. Additionally, the LN did not document whether the [MEDICATION NAME] was effective or ineffective. 38. 2/5/13 at 8:47 PM: The LN documented "...Follow up (Administered 8:47 PM, 2/5/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 39. 2/5/13 at 10:00 PM: "4". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain despite being "effective" 1 hour and 15 minutes prior. 40. 2/6/13 at 10:00 AM: "5". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain. 41. 2/6/13 at 12:05 PM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 42. 2/6/13 at 12:38 PM: The LN documented "...Follow up (Administered 12:38 AM, 2/6/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 43. 2/7/13 at 7:40 PM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 44. 2/7/13 at 8:29 PM: The LN documented "...Follow up (Administered 8:29 PM, 2/6/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 45. 2/6/13 at 10:00 PM: "5". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain despite having pain relief 1 1/2 hours prior. 46. 2/7/13 at 1:39 AM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 47. 2/7/13 at 3:11 AM: The LN documented "...Follow up (Administered 3:11 AM, 2/7/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 48. 2/7/13 at 5:52 AM: The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 49. 2/7/13 at 6:24 AM: The LN documented "...Follow up (Administered 6:24 AM, 2/7/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 50. 2/7/13 at 10:00 AM: "5". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain despite having pain relief 3 1/2 hours prior. 51. 2/7/13 at 10:00 PM: "1". 52. 2/8/13 at 6:44 AM: "7". The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 53. 2/8/13 at 7:26 AM: The LN documented "...Follow up (Administered 7:26 AM, 2/8/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 54. 2/8/13 at 10:00 AM: "7". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain despite having pain relief 2 1/2 hours prior. 55. 2/8/13 at 10:00 PM: "1". 56. 2/9/13 at 7:31 AM: "7". The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 57. 2/9/13 at 9:23 AM: The LN documented "...Follow up (Administered 9:23 AM, 2/9/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 58. 2/9/13 at 10:00 AM: "6". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain despite having pain relief 1/2 hour prior. 59. 2/9/13 at 10:00 PM: "5". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain. 60. 2/10/13 at 10:00 AM: "8". The LN did not document administering any pain relieving medications and did not document what interventions were implement to resolve resident 270's pain. 61. 2/10/13 at 10:00 PM: "5". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain. 62. 2/11/13 at 1:25 AM: "4". The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 63. 2/11/13 at 2:50 AM: The LN documented "...Follow up (Administered 2:50 AM, 2/11/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 64. 2/11/13 at 7:05 AM: "5". The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 65. 2/11/13 at 7:35 AM: The LN documented "...Follow up (Administered 7:35 AM, 2/11/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 66. 2/11/13 at 10:00 AM: "5". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain despite being effective 2 1/2 hours prior. 67. 2/11/13 at 11:24 AM: "6". The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 68. 2/11/13 at 11:45 AM: The LN documented "...Follow up (Administered 11:45 AM, 2/11/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 69. 2/11/13 at 4:02 PM: "5". The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 70. 2/11/13 at 4:40 PM: The LN documented "...Follow up (Administered 4:40 PM, 2/11/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 71. 2/11/13 at 7:59 PM: "4". The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 72. 2/11/13 at 8:00 PM: The LN documented "...Follow up (Administered 8:00 PM, 2/11/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 73. 2/11/13 at 10:00 PM: "5". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain despite being effective 2 hours prior. 74. 2/12/13 at 1:37 PM: "5". The LN documented administering [MEDICATION NAME] 7.5/325 1-2 tablets. The LN did not document where resident 270's pain was or the characteristics of the pain such as dull, sharp or stabbing. 75. 2/12/13 at 2:07 AM: The LN documented "...Follow up (Administered 2:07 AM, 2/12/13; [MEDICATION NAME] 7.5/325 1-2...) Medication follow up - ...medication was effective". (Note: The LN did not document a pain rating or how it was determined the [MEDICATION NAME] was "effective".) 76. 2/12/13 at 10:00 AM: "4". The LN did not document administering any pain relieving medications and did not document what interventions were implemented to resolve resident 270's pain. Review of the "Departmental Notes" revealed the facility licensed nursing staff documented the following: 1. 1/30/13 at 1:49 AM: "...No C/O (complaints of) pain, discomfort, or SOB (shortness of breath). ..." (Note: Resident 270 was assessed on 1/29/12 at 10:00 PM as having a pain rating of "7".) 2. 1/31/13 at 10:55 PM: "...Resident c/o some pain and discomfort pain meds given as ordered. ..." 3. 2/1/13 at 4:38 PM: "...Rst (resident) c/o in (sic) lower leg. PRN given with good effect. ..." (Note: The LN did not document how resident 270's pain medication was assessed as being effective.) 4. 2/2/13 at 4:50 PM: "Rst c/o in low leg. PRN given with good effect as well as [MEDICATION NAME] for anxiety. ..." (Note: The LN did not document how resident 270's pain medication was assessed as being effective.) 5. 2/4/13 at 12:04 AM: "...Medicated as ordered for pain with good relief verbalized. ..." (Note: The LN did not document how resident 270's pain medication was assessed as being effective.) 6. 2/5/13 at 11:36 PM: "...Medicated as ordered for pain with good relief verbalized. ..." (Note: The LN did not document how resident 270's pain medication was assessed as being effective.) 7. 2/7/13 at 10:03 PM: "...Resident c/o some pain and discomfort pain meds given as ordered. ..." (Note: The LN did not document how resident 270's pain medication was assessed as being effective.) 8. 2/8/13 at 9:28 AM: "...She complains of pain at a 7-8, pain meds given PRN. ..." (Note: The LN did not document if/how resident 270's pain medications were effective.) 9. 2/12/13 at 10:56 AM: "...Pt. uses [MEDICATION NAME] 7.3 (sic)/325 for pain. Pt needs pain managed by nsg (nursing staff). ..." 10. 2/12/13 at 11:58 AM: "...Spoke with pt and family in her room about pain level. Pt. and family state they feel her pain meds (medications) are stable and controlled with [MEDICATION NAME] 7.5 and don't feel like it needs to be increased at this time. ..." On 2/12/12, the facility Nurse Practitioner (NP) evaluated resident 270. The NP documented: "...Staff reports not participating in therapy (secondary to) c/o (complaints of) pain. Pain described as shooting pain, throughout extremities. C/O numbness tingling. ...When (questioned) re (about) c/o pain states feels like she goes to (sic) long (without) meds '6 or 12' hours. Plus staff review records, meds consistently given q 4h (every 4 hours). ...Assessment/Plan: (1) Acute or chronic pain - stable. Continue PRN [MEDICATION NAME] 7.5 1-2 q 4h PRN. (2) [MEDICAL CONDITION] - [MEDICATION NAME] indicated for [MEDICAL CONDITION] will follow. ..." The facility Policy and Procedure for "Pain Assessment (and) Management " was reviewed. The "Pain Assessment (and) Management " policy and procedure documented: "Guidelines: It is the goal of the facility that all residents will be assessed for pain, interventions implemented to reduce or relief pain, and effectiveness of interventions re-evaluate in a timely manner. ...Considerations: In conjunction with established guidelines of standards of practice, provision of resident centered care and services will be implemented to address and manage pain and to support each resident ' s highest practical level of functioning. 1. Resident will be assessed for pain upon admission by completing the Initial Pain Assessment ((facility) form 316). This assessment will assist with the identification of contributing factors and characteristics associated with the resident's pain, including Pain for resident with Advanced Dementia (PAINAD). The completed assessment will be utilized for the development of an individualized pain management regimen. The resident/responsible party and his/her physician will be consulted as possible to establish appropriate goals and approaches. Both pharmacological and non-pharmacological interventions will be implemented as applicable. ... 2. A numerical 0-10 pain scale shall be utilized as the standardized method for assessing pain intensity. A visual scale, depicting faces which corresponds with the 0-10 scale, shall be utilized for residents with impaired cognition or communication deficits. ... 3. Pain will be assessed by the licensed nurse each shift, and with any PRN medication administration. This information will be recorded in the HER (Electronic Health Record) on the MAR (Medication Administration Record). ...As applicable, the resident ' s physician will be notified and a revised pain management regimen requested. The physician will be notified if at any time the resident does not experience adequate pain control with administration of ordered [MEDICATION NAME] and applicable non-pharmacological interventions. ... " On 2/12/13 at 2:45 PM, Registered Nurse (RN) 2 was interviewed related to resident 270's pain management. RN 2 stated that she believed that resident 270's pain was being managed. RN 2 stated that she would ask the resident if she was in pain and at what level (scale of 0-10). RN 2 stated that she would administer PRN medications to resident 270 if she complained of pain rated at a 6-9. She further stated that she would follow up with the resident approximately 1/2 hour after the PRN medication was administered and ask if the medication was effective. On 2/12/13 at 3:20 PM, RN 2 was observed while conducting an interview with resident 270. Resident 270 was asked if she was in pain. Resident 270 stated that she was. The resident was asked where she (resident 270) would rate her pain on a scale of 1-10. Resident 270 responded with a "7". Resident 270 further stated that she didn't feel like doing much when she was in excruciating pain. RN 2 stated that resident 270 had [MEDICATION NAME] administered at noon, 3 1/2 hours prior to when the interview was conducted. RN 2 then proceeded to educate resident 270 about the potential need for obtaining a new order for a different pain medication to provide additional pain control. Resident 270 stated that her family had felt like she was getting adequate pain control. RN 2 responded to resident 270 that she would discuss the concern with resident 270's family. On 2/13/13 at 8:55 AM, Physical Therapist Assistant (PTA) 1 was interviewed. PTA 1 stated that resident 270's level of pain decreased her participation in therapies. On 2/13/13 at 9:05 AM, Certified Nurse Assistant (CNA) 2 was interviewed. CNA 2 stated that resident 270 frequently complained of pain in the morning. On 2/13/13 at 9:35 AM, the NP was interviewed. The NP stated that he was not notified of resident 270's pain until 2/12/13. He stated that when he interviewed resident 270, she stated that she wanted to be "pain free", which the NP stated was "unrealistic". The NP further stated that the facility licensed nurses should have notified him when resident 270 had complaints of pain rated above 7.

Based on observation, interview and record review, it was determined the facility did not ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 49 sample residents. Specifically, (1) Resident 102 sustained multiple falls which resulted in a displaced olecranon process which resulted in surgical intervention; and (2) Resident 52 did not have a safety alarm in place as care planned. Resident identifiers: 52 and 102. Findings include: 1. Resident 102 was admitted to the facility on [DATE] and readmitted on [DATE] and 10/11/12 with [DIAGNOSES REDACTED]. Resident 102's medical record was reviewed on 2/14/13. Review of the significant change Minimum Data Set (MDS) Assessment completed by the facility staff on 8/22/12, revealed that resident 102 was assessed as a BIMS (Brief Interview of Mental Status) of 15. The facility staff assessed resident 102 as requiring limited assistance with a one person physical assist for transfers, ambulation in her room/corridor, and toileting. Resident 102 was further assessed as not being stable and required assistance for stabilization when moving from a seated to a standing position, walking, turning around, moving on and off toilet, and for surface-to-surface transfers. The facility staff further assessed resident 102 as having a walker. A Care Area Assessment (CAA) for falls triggered. The facility staff documented that the care area would be addressed in a care plan. Review of the care plans developed for resident 102 revealed a care plan for "Impaired mobility" which was developed on 7/12/12. The problem area documented was "I have impaired balance and use an (sic) FWW (front wheeled walker) for ambulation. I have COPD (Chronic Obstructive Pulmonary Disease) and experience SOB (shortness of breath) with exertion and I fatigue easily. I receive psychotropic medication daily and PRN (as needed). I have weakness deconditioning and pain". The goals developed included: "(1) I will have no adverse effects r/t (related to) my antianxiety medication use through next review; and (2) I will have no adverse effects r/t my antidepressant medication through next review". The approaches that were developed to achieve those goals included: "(1) Assist me with transfers and ambulation, as needed. Monitor me for fatigue and SOB; (2) Ensure my call light is in reach and answered promptly; (3) Encourage my use of proper foot wear and assistive devices, as appropriate; (4) Labs as ordered; (5) Hospice per MD (medical doctor) order DT (due to) end of life process; and (6) motion mat to bed". The facility staff documented additional interventions which included: "(1) Pt. (patient) R (refused) motion mat et (and) personal alarm (Note: The intervention was not dated); (2) Pt. R (refused) room move to closer to nurses station, family in agreement (Note: The intervention was not dated); (3) X-ray per order, Family R (refused) hospital care as patient does not want to go to hospital (Note: The intervention was not dated); (4) 9/14/12: UA (urinalysis) to RO (rule out) UTI (urinary tract infection); (5) Notify family of R (refusal) of alarm et motion mat (Note: The intervention was not dated); (6) 9/23/12: Room clear of clutter; (7) 9/28/12: Hospice in to sit (with) pt. safety mat (if) pt. allows; (8) 9/29/12: Pt. et family want comfort measures only; (9) 10/6/12: Pt. to be 1:1 (one on one) as needed; and (1) Hospice to GIP (General In-Patient) for comfort et pain management". Review of the physician's orders [REDACTED]. a. 9/14/12: "obtain urine sample via clean cath for UA to rule out UTI". b. 9/21/12: "Phenergan 25 mg (milligrams) PO (by mouth) q (every) 6 hrs (hours) PRN N (nausea)/V (vomiting)". c. 9/27/12: "Cipro 250 mg PO BID (twice a day) for 10 days for UTI. ..." d. 9/29/12 at 2:35 AM: "obtain x-ray on L (left) elbow r/t pain to rule out fracture". e. 9/30/12: Roxinol 20 mg/ml. Give 5-20 mg q (every) 1 (hour) SL (sublingual) PRN pain". f. 9/30/12: "Motion mat to bed and w/c (wheelchair) at all times for safety. Check for function and placement every shift". g. 10/1/12: "Lortab 5 mg PO QID (four times a day) PRN". h. 10/2/12: "Tylenol 650 (milligrams) PO q 6 PRN. NTE (not to exceed) 4 g (grams) in 24 (hours)". i. 10/4/12: "Norco 5/325 PO QID RT (increased) pain L elbow fracture. j. 10/4/12: "Ativan 1 mg PO BID RT (increased) anxiety". k. 10/6/12: "TO (telephone order): Obtain portable x-ray of L elbow RT fall". l. 10/6/12: "Discharge pt. to (local hospital) ER (emergency room ) RT elbow fracture". Review of the facility electronic "Departmental Notes", the revised care plans, the "Long Term Care-Provider Note (physician notes), the "Hospice Nursing Clinical Note", the hospice "Care Coordination Notes" and the laboratory values revealed the following: a. 9/10/12 at 8:22 PM: "Pt. didn't have her noticine pach (sic) today the streng (sic) was not available fax the right streng (sic) to pharmacy". b. 9/13/12 at 4:42 AM: "CNA (certified nurse assistant) reported to nurse that pt was snoking (sic) cigarette in room with o2 (oxygen) present. Room has strong odor of cigarette. Pt gave nurse a cup of water with 2 cigarette buds (sic) and took lighter from room. Pt informed that she was not allowed to smoke in room". c. 9/13/12 at 3:490 PM: "upon assessment pt has no ss (signs of symptoms) of injury, no cigarette's found in room. md order for UA. Pt. has been added to q 15 min (minute) checks to ensure no unsafe smoking behavior, explained to pt that staff can help her to smoking area and assist her back. spoke with family to explain that the nurse need (sic) to be given all smoking supplies to ensure pt safety. pt. also state she does not want to smoke she wants to continue with the smoking cessation patch, cont (continue) with poc (plan of care). pt has not smoked in several weeks until this incident". d. 9/14/12 at 12:42 PM: "Resident has been under Q 15min (15 minute) checks for the last 24 hours with no new incident to note. Resident remains in her room at this time able to make needs and wants known. No complaint of pain or discomfort noted at this time. Resident is cooperative with cares. Will continue to monitor". On 9/14/12 (the time of the visit was not documented), the hospice nurse documented: "...NEUROLOGICAL: Oriented to person. PSYCHOLOGICAL: Depressed, forgetful. MUSCULOSKELETAL: Weakness, balance/gait abnormal, limited mobility/ROM (range of motion). PAIN: Denies. ...denies burning with urination or painful urination. Pt. has had (increased) confusion with a smoking episode in her room recently RT (increased) confusion. Order to obtain UA for UTI. Ruling out UTI. ..." e. 9/15/12 at 1:35 AM: "Resident fell around 1830 (6:30 PM) 9/14/12 bruise on left side of forehead, minor abrasion on right knee, resident was calling for help when CNA and nurse walked in resident was face down on floor. Resident said she tried to walk without her walker and lost her balance. Assessment done and neuro (neurological) checks being completed. MD notified around 1845 (6:45 PM) also left message at (name removed) phone number. Resident is A&O (alert and oriented) X 3 (person, place and time). ...Resident is resting in bed with call light within reach. No complaints of pain, will continue to monitor". f. 9/16/12 at 5:20 PM: "Pt. (complains of) anxiety she requested a Ativan med (medications) were effective nurse asked her how she was feeling she stated that she still (sic) sore from the fall. She stay (sic) in her room all day today she stated that maybe tomorro (sic) she will do some activities". g. 9/16/12 at 5:32 PM: "UA labs (sic) results colony count (greater) 100,000 gram negative rods reported to (physician). No new orders yet". h. 9/17/12 at 1:39 AM: "97.6 (temperature), 116 (pulse), 20 (respirations), 118/68 (blood pressure), 94% (oxygenation) on RA (room air). Pt alert and oriented. Neurologically intact. Pt c/o HA (headache) that started last night and voice she feels it may be a result of the fall. Tyl (tylenol) given with good results. There is bruising on the left side of fore head (sic) no other injuries noted. Pt is able to verbalize needs well. No other issues at this time. Pt slept well this shift. WCTM (will continue to monitor)". i. 9/17/12 at 11:50 PM: "VS: (temperature) 97.5, (pulse) 89, (respirations) 16, (blood pressure) 121/62, (oxygen saturation) 94% O2. Resident has been in bed all evening. ..." Review of the laboratory values from the urinalysis obtained on 9/14/12 had a colony count of greater than 100,000 CFU (colonoy-forming units)/ML (milliliters) of gram negative rods. The laboratory values were documented by the laboratory company as being faxed to the facility on [DATE] at 8:20 AM. j. 9/18/12 at 9:58 AM: "VS: (temperature) 96.9, (pulse) 99, (respirations) 20, (blood pressure) 111/54, (oxygen saturation) 94 RA. No c/o pain. Pt c/o anxiety; meds given whole without difiuclty (sic). Pt. encouraged to push call light when in need of assistance r/t previoius fall on 9/14. Call light in reach WCTM (will continue to monitor)". On 9/18/12 (no time documented), the hospice nurse documented: "...NEUROLOGICAL: Oriented to person. PSYCHOLOGICAL: Confused, drowsy, forgetful. SKIN: abrasion R (right) knee, L forehead bruising. MUSCULOSKELETAL: Weakness, balance/gait abnormal, limited mobility/ROM, assistive/device, fall precautions maintained. PAIN: Denies. ...Patient experiencing (increased) weakness reported by CNA (name removed), unsteady gait, w/c & walker @ (at) bedside. Pt. had a fall 9/14/12 bruising to left forehead, pt. lost balance abrasion R knee. On 9/20/12 from 12:15 PM to 12:45 PM, the hospice nurse documented: "...NEUROLOGICAL: Oriented to person. PSYCHOLOGICAL: Confused, depressed, forgetful. SKIN: Bruise on L forehead, bruises on L forearm. MUSCULOSKELETAL: Weakness, balance/gait abnormality, limited mobility/ROM, Assistive/Device, Fall precautions maintained. PAIN: Denies. Last fall 1 1/2 weeks ago. According to staff, pt. spends most of her day sleeping. (increased) weakness, poor appetite. ..." On 9/21/12 at 3:30 PM, the hospice nurse documented: "...NEUROLOGICAL: Oriented to Person/Place/Time. PSYCHOLOGICAL: Confused, drowsy, forgetful. SKIN: Bruises R top of foot, R knee X 2, R UE (upper extremity), L forehead. MUSCULOSKELETAL: Weakness, balance/gait abnormal, limited mobility/ROM, Grip strength (equal), assistive/device, fall precautions maintained. PAIN: Denies. ...Pt. currently resting in bed, denies any pain @ this time, c/o being nauseated X 2 days, feels 'sweaty' et weak. Assessment done, A&O X 3, occ. (occasional) confusion. HR (heart rate) RRR (regular rate and rhythm) (without) murmur, lungs - sl (slight) (decrease) bilat. (bilaterally) but otherwise CTA (clear to all), grips (equal) bilat. (bilaterally), (no) edema noted, pulses palp (palpated) X 4, cap (capillary) refill (less than) 3 sect (seconds), bowel sounds active X 4, remains continent of B/B (bowel and bladder), bruises noted from recent fall - top of R foot, R knee X 2., RUE (right upper extremity), L forehead, skin feels cool et clammy. Pt. noted to be spitting into garbage can. ..." On 9/22/12 (no time documented), the hospice nurse documented: "Phone call follow up. Pt. condition: Having N/V (nausea/vomiting) yesterday (with) phenergan sch. (scheduled). Spoke (with) pt. nurse. (No) vomiting today or complaints of nausea. Mainly weak/sleeping. ...Feels meds effective". k. 9/24/12 at 2:15 AM: "Pt was heard crying out for help down the hall. Upon entering the resident's room she was found lying on the floor, with her head against the closet door. Upon assessment no acute injuries were found and neurologically at baseline. Pt. was assisted to bed and room was cleared of clutter sorrounding (sic) bed and night stand. Pt. was educated about safety and requesing (sic) assistance. Initial V/S (vital signs): (temperature) 98.2, (pulse) 125, (respirations) 22, (blood pressure) 84/56, (oxygenation) 92%. Res hypotensive post fall, fluids encouraged and O2 Admin (administered) @ 2l (2 liters)/min (per minute) with good results. Lorazepam was also admin to pt an hour before fall. MD notified and unit manager, WCTM". (Note: This was the second fall that resident 102 sustained since 9/15/12.) l. 9/24/12 at 7:33 PM: "Pt has no falls today she is has (sic) c/o of a head ache (sic) but she refuse (sic) to take meds (medications) for pain she did requested (sic) Ativan for anxiety med was effective. she stay on (sic) her room most of the time she got up to go to the rest room but got back to bed. She is alert and oriented she is able to tell the nurse her needs. She is reminden (sic) to call for help and use her call light". On 9/24/12 (no time documented), the hospice nurse documented: "...NEUROLOGICAL: Oriented to person. PSYCHOLOGICAL: Confused and forgetful. MUSCULOSKELETAL: weakness, balance/gait abnormal, limited mobility/ROM, pain, assistive device, fall precautions maintained. PAIN: HA (headache) rated at a 2. Pt. weak, fatigued in bed. Denies nausea @ present. Pt. reports slight HA. Pt. had fall last night fall night (without) injury. ..." m. 9/25/12 at 12:56 AM: "Pt. has no falls today she has spends (sic) most of her time in her room she is compliant with her medication she is able to tell the nurse her needs she is reminded to use her call light if she needs help with cares. WCTM for any falls". n. 9/26/12 at 1:14 AM: "Resident continues on post-fall observation. No c/o pain or reports of falls this shift. Has been compliant with usiing call light when needing assistance. Resting comfortably in bed at this time. Will continue to monitor". On 9/26/12 (no time documented), the hospice nurse documented: "...NEUROLOGICAL: oriented to person. PSYCHOLOGICAL: depressed and forgetful. MUSCULOSKELETAL: Weakness, balance/gait abnormal, limited mobility/ROM, walker, fall precautions maintained. PAIN: Hands & legs rated at a 2. Pt. complains of frequent nausea. 'I threw up last night'. Complains of numbness of hands & feet according to staff. Pt. gets anxious often depressed. Pt. stays in her room most of the day. Sleeps on & off thru (sic) out the day. Doesn't socialize in any activities. Will speak to MD about starting ABHR (Ativan, Benadryl, Haldol, and Reglan) gel for nausea & anxiety. Poor appetite. ..." o. 9/27/12 at 6:58 PM: "Received C & S (culture and sensitivity) from (resident 102). NP (Nurse Practitioner) notified and new order as follow (sic): T.O. (telephone order) = (equals) Cipro 250 mg PO BID X 10 days r/t UTI". (Note: This order was received ten days after the culture and sensitivity results were faxed to the facility. Additionally, resident 102 had sustained two falls before the order was received to start the Cipro.) On 9/27/12, the facility nurse practitioner visited with resident 102 and documented "S (subjective): Patient is in today for: UTI. ...History: unable to obtain hx (history), memory loss, denies urinary symptoms, repeats self, poor historian. Nursing Concerns: reported (increased) agitation, confusion. ...UTI Cipro 250 mg X 10 days. ..." p. 9/28/12 at 2:46 PM: "(temperature) 98.0, (pulse) 98, (respirations) 18, (blood pressure) 96/67, (oxygen saturation) 94%. ...pt lethargic and staying in room today. No ROM problems noted. No ASE (adverse side effect) r/t fall noted. WCTM". q. 9/29/12 at 1:28 AM: "Around 2115 (9:15 PM) on 9/28/12 we heard yelling coming from resident's room. When nurse ran in there resident was lying down near the restroom door. There was blood on the floor and after assessing resident there was swelling found on back of head with about one inch laceration. Notified family also notified MD. Explained situation and was told to keep resident at facility and just do neuro checks throughout night. Bactitracin, gauze and kerlix were used for laceration. Advised resident to use call light for assistance, resident was alert and oriented as before. V/S BP (blood pressure) 87/50, P (pulse) 122, R (respirations) 18, T (temperature) 98.6, O2 (oxygen saturation) 95. Resident is resting in bed with call light within reach. Will continue to monitor". (Note: This was resident 102's 3rd fall since 9/15/12.) r. 9/29/12 at 2:40 AM: "Resident complaining of pain in left elbow related to fall. T.O. (telephone order) Obtain xray related to pain to rule out fracture". s. 9/29/12 at 2:13 PM: "...Pt. cooperative with care. L elbow pain, no ROM problems. Pt sleepy and rest in bed, pupils equal and reactive to light. No bleeding on back of head laceration noted this shift. ABX (antibiotic) given with no ASE (adverse side effects). WCTM". On 9/29/12, a new care plan was developed related to "Pt. has acute L elbow fx (fracture). Pt. and family do not want further intervention. Pt. is refusing to go to hospital. Pt. wants comfort care and pain management as she is on hospice". The goals that were developed included: "(1) Pain - resident will demonstrate relief of s/sx of pain with current regimen each time administered through next review; (2) Pain - Resident's target goal for pain control is: 3 out of 10 ie.. achieved/maintained through next review; (3) Pain - Resident will have reduced suffering through psychosocial and spiritual interventions (as) mb (manifested by) will continue to accept opportunities to openly discuss spiritual & emotional concerns/issues as desired through next review; and (4) Will have no complications thru (sic) next review". The interventions developed to achieve those goals included: "(1) Administer pain medications as ordered. Give prior to treatments, therapies or other activities identified to cause resident pain, as possible; (2) Notify physician of increased intensive or pain and/or that which is not adequately controlled with current pain regimen, as needed; (3) Hospice to assist with comfort care and pain management; (4) Monitor for s/sx constipation r/t pain medications, not relieved with current bowel regimen PRN. Encourage fluids; and (5) Elbow redness et swelling manage pain". (Note: The intervention of "Elbow redness et swelling management pain" was not dated as to when the intervention was initiated.) On 9/29/12 from 8:50 PM to 9:30 PM, the hospice company documented: "...NEUROLOGICAL: Oriented to person. PSYCHOLOGICAL: Confused, restless. SKIN: L elbow swollen. MUSCULOSKELETAL: weakness, balance/gait abnormal, grip strength weak to the left, chairbound, fall precautions maintained. PAIN: L elbow rated from 3-5. prn visit. pt. has fall X 2 (twice) in past 24 hours. X-ray done earlier after (first) fall. (Positive) for nondisplaced fx. of ulna. Pt. has become more confused et agitated. SNF (skilled nursing facility) has notified MD who ordered sling. No cast. ...Pt. given Tylenol for pain. SN (skilled nurse) will report any unrelieved pain. ..." t. 9/30/12 at 2:11 AM: "LATE ENTRY: X-Ray report. IMPRESSION: Nondisplaced fracture of olecranon process of ulna. MD notified 9/29/12 @ 0513 (5:13 AM). He texted back that sling needed". u. 9/30/12 at 2:21 AM: "Resident fell last night (9/29/12) around 1915 (7:15 PM). Received a call over the radio stating resident fell down in dining room. When approached resident was lying on floor beside her walker, CNA and nurse lifted resident up, pushed her on her walker back to her room and put her in bed. Assessment was done and no new injuries were found but her elbow was still bothering her from previous fall. V/S T 97.0, P 120, R 24, BP 91/59 when resting in bed between neuro checks resident fell again when she tried to get up, mat was placed on floor beside bed, tylenol was administered for pain. Ativan was also administered for anxiety, resident seemed more confused. Hospice was called and hospice nurse came over to see resident she said that she will try and bring sling in tomorrow when she visits. Multiple calls to family numbers were done and either voicemail picked up or somebody hung up both on 9/28 and 9/29 then around 2130 (9:30 PM) on 9/29 (resident's daughter) called and situation was explained regarding falls and injuries (head and xray fracture). Daughter said that she did want us to just keep her here and to keep resident comfortalbe. Resident is now resting in bed, ice packs on elbow. Call light within reach. Will continue to monitor". (Note: (1) Resident 102 sustained 5 falls since 9/15/12; (2) resident 102 was to receive limited assistance with transfers and ambulation with a one person physical assist according to the care plan; (3) resident 102 was ambulating with a walker independently after a new [DIAGNOSES REDACTED].) v. 9/30/12 at 9:38 AM: "(temperature) 98.5, (pulse) 103, (respirations) 20, (blood pressure) 98/67, (oxygenation) 97%. Pt A/O X 3. Cooperative with care. Pt. resident in bed this AM. Wound on back of head no pain. Skin intact and dry. L elbow red and swollen. Hospice RN (Registered Nurse) drought (sic) a sling for pt. Put sling on Pt. New order: Roxanol 20 mg/ml given 5-20 mg Q1H (every hour)SL (sublingual) PRN Pain". (Note: The sling was obtained for resident 102's fractured elbow over 24 hours after the order was received and resident 102 had sustained another fall.) w. 9/30/12 at 9:38 AM: "Motion mat to bed and w/c at all time (sic) for safety. Check for function and placement every shift". (Note: The intervention was not implemented until after resident 102 sustained five previous falls.) x. 10/1/12 at 10:00 AM: "Lortab 5mg (5 mg) PO QID (four times a day) for pain". On 10/1/12 (no time was documented), the hospice nurse documented "...NEUROLOGICAL: Oriented to person. PSYCHOLOGICAL: drowsy, forgetful. SKIN: Bruise yellowed forehead, L elbow red/edema. MUSCULOSKELETAL: weakness, balance/gait abnormal, limited mobility/ROM, pain, grip strength weak left, motion mat, assistive/device fall precautions maintained. PAIN: L elbow rated at 3. Pt. drowsy in bed, weak for assessment. States minimal pain (with) movement L elbow. L elbow swollen, red, (no) warmth, splint in place, frail, weak, mat @ beside from recent fall. Call light in place. Educated pt. to call for assist to avoid future falls. Discussed pt. status, pain, and med (medicine) regimen (with facility staff)". y. 10/2/12 at 5:01 AM: "VS: (temperature) 97.9, (pulse) 108, (respirations) 20, (blood pressure) 105/54, (oxygen saturation) 96% O2. Pt. continues to c/o moderate pain to left elbow. Managed pain effectively with PRN meds. Elbow is swollen and some bruising noted. Reminded pt. the importance of using call light. Attempted on several occasions to ambulate without assistance. Motion mat alarm was on and attended to quickly. No reports of falls this shift". z. 10/3/12 at 3:08 AM: "Pt restless this evening. Pt rolled out of bed at approximately 1120 (11:20 AM). Bed was in low position and floor mat was in place. No injuries noted. No further injuries apparent from previous fall. Pt has CO (complaints of) pain in her elbow pain. PRN medication given. Will continue to monitor". aa. 10/4/12 at 2:04 AM: "Pt continues on Cipro for UTI. Pt lethargic and drowsy. Unclear if related to infection or recent falls. Pt. was able to take pills with encouragement. Pt. appears dehydrated, sunken eye sockets, skin tents on wrists. Held Seraquil (sic) to evaluate mental status. VS T 907.3 P 116, R 16 BP 105/64 O2 88". (Note: Review of the "Physician order [REDACTED].) bb. 10/4/12 at 2:14 AM: "Pt. is lethargic and drowsy, confused at times. Pt is holding and guarding right hand and arm. Pt. looks dehydrated, encouraging fluiuds. Took pills whole with encouragement. Held Seraqul (sic) to r/t ams (unkown) and drowsiness". cc. 10/4/12 at 11:58 AM: "New order. Norco 5/325 PO QID rt increased pain left elbow fracture". dd. 10/4/12 at 2:34 PM: Pt. continues on PO ABX for UTI. No new side effects noted. Pt. CO extreme pain in elbow. As given PRN medications with little effect. The scab which was on her left elbow came off and was bleeding. Cleaned wound with wound cleanser and placed 4X4 adhesive foam dressing to site. Arm is in sling. Bed in low position. Mat on floor. Oxygen and call light in place". On 10/4/12 (no time was documented), the hospice nurse documented "...NEUROLOGICAL: Oriented to person. PSYCHOLOGICAL: confused, forgetful. SKIN: L elbow fracture red @ joint site warm to touch. MUSCULOSKELETAL: Motion mat, weakness, balance/gait abnormal, limited mobility/ROM, pain, grip strength - left weak, chairbound, assistive device, fall precautions maintained. Pain: L elbow rated at a 7. Pt. in bed c/o (increased) pain left elbow fracture, L elbow tender (with) redness & swelling @ fracture site, as well as bruising @ L wrist. Placed in sling. Educated pt. sling will help immobilize to (decrease) pain. (Facility staff member) gave Lortab & Roxanol prior to assessment. Discussed pt (increased) pain. (Physician) contacted to change Lortab to scheduled QID instead of prn. Educated pt. to use call light for assist. fall risk, mat on floor @ bedside. Assisted pt. to drink water. Obtained order for Norco 5/325 instead of Lortab from MD. ..." On 10/4/12 at 2:00 PM, the hospice nurse documented: "Discussed pt. on GIP (General In-Patient) now for 'increased" anxiety, (increased) pain, blood in urine, (increased) confusion, (decreased) ability to perform ADLs (Activities of daily Living) with (facility staff member name removed), also discussed pt status (with) need for feeding @ (at) meals as she is unable to feed self (with) decreased ROM LUE. Constant education (with) pt. rt (related to) using call light to call for assist prn. ..." ee. 10/4/12 at 5:57 PM: "New order. Ativan 1 mg PO BID rt anxiety". ff. 10/4/12 at 6:01 PM: "New order. Cleanse left elbow wound with wound cleanser gently, pat dry, apply 4X4 adhesive foam dressing. Change every 3 days and PRN". gg. 10/4/12 at 6:26 PM: "Pt. was found rolled out of bed. She was on her floor mat which was placed next to her bed. Bed was in low position and no injuries were noted. Pt. did not complain of any pain or discomforts. WCTM". hh. 10/4/12 at 6:29 PM: "(temperature) 96.0, (pulse) 110, (respirations) 18, (blood pressure) 100/68, (oxygen saturation) 93% on 3 liters N/C (nasal cannula). Pt. continues on ABX for UTI. No complaints r/t painful urination, but pt. confused aeb (as evidenced by) delusional statements. Pt. in pain, did not want to move, even to sit up to take meds. Lortab and Ativan given as scheduled. Pt. in pain and crying in AM, Roxinal (sic) given with good effect: Pt. stated that her arm still hurt but that it was bearble (sic) unless moved. When noon lortab was given, RN talked to pt about pain control. Pt. encouraged to ask for Roxinol if needed. Pt. did not seem to understand aeb unclear statements about medications and plan of care. Pt. will be monitored for signs of pain. Pt. had difficulty holding objects and has very limited rom in left arm. Pt. tried to get OOB (out of bed) this afternoon, found sitting on her mat next to bed. Pt. stated that she wanted to walk, CNA used a gait belt to help pt. ambulate in hallway. Pt. unsteady on her feet. Pt. refused breakfast. Accepted a can of ensure for lunch. Fluids encouraged. Pt. refused shower and oral cares. Bedding changed. WCTM". On 10/5/12 (no time was documented), the hospice nurse documented "... NEUROLOGICAL: Oriented to person. PSYCHOLOGICAL: Confused, drowsy, forgetful. SKIN: Bruising L (left) FA (forearm). L elbow (changed) dsg (dressing) bloody drainage. MUSCULOSKELETAL: weakness, balance/gait abnormal, limited mobility/ROM, pain, bedbound, assistive device - w/c (wheelchair), fall precautions maintained. PAIN: L elbow rated at a 6. Pt. bed sheet soiled (with) bloody drainage from L elbow, assisted CNA (name removed) to (change) sheets. Pt. refused shower. (Changed) drsg (dressing) L elbow saturated (with)serosanguineous drainage, possible bone fragment slight protrusion, pt. c/o (increased) pain 6/10. 1 ml Roxanol (20 mg) given with pain relief. Discussed pt. status & decline with (facility licensed nurse). Provided mouth care, discuss need for feeding assist RT (related to) lack of abilities to feed self. Call light in place, educated SN to give Roxanol consistently for pain relief. Left phone message (with) dtr (daughter). ..." ii. 10/6/12 at 2:07 AM: "T 97.3, P 113, R 16, BP 83/52, O2 92. Resident resident in bed, dressing to elbow changed and Roxanol was given for pain with good results, fluids being encouraged, will continue to monitor". jj. 10/6/12 at 5:03 PM: "At approximately 1200 (12:00 PM) pt was found on her floor next to her wheelchair. Pt. had no complaints of pain other than from her elbow. No other injuries were noted. VS: (blood pressure) 93/52 (pulse) 114 (respirations) 18. Pt. was alert. PERRLA (pupils equal round and reactive to light accommodation). Hand grasp was equal on both sides and strong. (MD) was notified as well as hospice. Hospice advised to push fluids and obtain portable x ray on left elbow. X ray results as as follows: Examination shows fracture of the olecranon process with approximately 3 cm (centimeter) separation from the ulna. Small amount of joint effusion noted. Radius appears intact. Fracture of the olecranon process now with displacement. Dr. (physician) notified of findings. Hospice nurse showed to assess situation and decided to discharge pt to (local hospital) ER". Review of the "History and Physical" completed by the emergency room physician on 10/6/12 documented that resident 102 "...suffers from dementia. Over the last week the patient has had several falls. Her first fall was on last Friday causing a nondisplaced fracture of the left humerus and no cast was placed. she later had a fall on last Saturday and this Wednesday. The patient was noted to have some bleeding and discharge from the left elbow and has been on IV (intravenous) vancomycin, flagyl and ciprofloxacin since. She also has a history of chronic UTI (urinary tract infections) and patient again had another fall today and repeat evaluation showed open displaced fracture. ...The patient was evaluated by orthopedics, (name removed), and cast was placed in the emergency room . ...ASSESSMENT AND PLAN: 1. status [REDACTED]. The patient will be taken to the OR (operating room) in a.m. (morning) for open reduction internal fixation. ..." On 2/14/13 at 11:30 AM, the facility Director of Nursing (DON) was interviewed related to resident 102's multiple falls resulting in the displaced fracture of the left elbow, delay in physician notification of the abnormal labs. A copy of the facility policy and procedure for falls was requested. (Note: The current DON's start date in her new position was February 2013 and the ADON (Assistant Director of Nursing) was no longer employed at the facility at the time the survey started). The DON was unable to provide information related to interventions attempted to prevent falls or why the physician was not notified of the abnormal laboratory values before the survey team exited the facility on 2/14/13 at 3:15 PM. The policy and procedure for falls was not provided to the survey team before exiting the facility on 2/14/13. On 2/17/12 at approximately 9:00 AM, the facility provided the following typed written summary of resident 102's stay at the facility from 7/12/12 through 10/6/12. The Administrator and DON