Every finding on record at Mt. Olympus Rehabilitation Center

Based on observation, interview, and record review, it was determined that, for 3 out of 23 sampled residents, the facility failed to ensure each resident had the right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part; and to make choices about aspects of his or her life in the facility that were significant to the resident. Specifically, three residents were restricted to supervised smoking and designated smoking times when they were assessed to have the functional capacity to smoke independently and one resident's request to be taken off of an antipsychotic medication was not completed as ordered. Resident identifiers: 6, 32, and 66. 1. Resident 66 was admitted [DATE] with diagnoses included major depressive disorder recurrent severe without psychotic features, other specified diabetes mellitus without complications, and nicotine dependence.Resident 66's medical record was reviewed from 6/22/26 through 6/29/26.On 6/4/26, a Safe Smoking Evaluation - V 2 was completed for Resident 66. The assessment stated that Resident 66 smoked traditional cigarettes. The assessment stated that Resident 66 was able to light her cigarettes independently, used ashtrays appropriately, held cigarettes safely at all times, was alert and attentive, was able to safely extinguish cigarettes, and required reminders to adhere to smoking area rules. Despite the level of safety indicators demonstrated by resident 66, the resident was determined to meet criteria for assisted supervised smoking. On 6/22/26 at 11:05 AM, an interview was conducted with Resident 66. Resident 66 stated that she did not like the smoking times at the facility. Resident 66 stated that whoever made the facility smoking schedule clearly did not smoke. Resident 66 stated that she liked to eat her breakfast in the morning and then have a relaxing cigarette, not the other way around like the schedule currently was. Resident 66 stated that she was told she was not allowed to smoke independently because she tried to cross the street at the facility. It should be noted that exit seeking behavior or wandering was not mentioned on the resident's Safe Smoking Evaluation - V 2 completed on 6/4/26.On 6/22/26 at 1:09 PM, an observation was made of the 1:00 PM supervised smoking session. Resident 66 was observed smoking in her wheelchair and lit and smoked her own cigarettes without assistance. 2. Resident 32 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, history of falling, muscle weakness, adult failure to thrive, chronic pain syndrome, and acquired absence of left foot.On 6/22/26 at 1:30 PM, an interview was conducted with resident 32 who stated he had no concerns about the facility except this smoking s-. Resident 32 stated he liked to smoke every 20 minutes but was no longer allowed to because the facility told him he could not have his smokes anymore because of the State. Resident 32 stated he used to be able to smoke on his own up until about three months ago.On 6/23/26 at 1:05 PM, a follow up interview and observation of resident 32 was conducted. Resident 32 was smoking a cigarette with 14 other residents in the smoking area and was being observed and assisted by the Dietary Manager (DM) and the Business Office Manager (BOM). Resident 32 stated he was going to smoke three cigarettes during this break because of the smoking time restrictions. Resident 32 was observed to be holding his cigarette and ashing away from his body; his hold on his cigarette was stable. Resident 32 finished one cigarette and asked the BOM for another one. The BOM got another cigarette and lit it for resident 32. Resident 32 stated he would be able to light his own cigarette safely if staff let him.Resident 32's medical record was reviewed 6/22/26 through 6/29/26.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15, which indicated an intact cognition.A Safe Smoking Evaluation dated 5/12/26 at 11:52 AM indicated, Chart Review Diagnosis.High Risk Diagnosis Review (1 Point Each) . It indicated he received 1 point for, Stroke with any residual weakness. It further indicated he had no, High Risk Safety Behaviors. It indicated, Physical Evaluation 1. Grip Strength Strong (0 Points) .2. Tremor Present.None (0 Points) .3. Upper extremity coordination.Mild impairment (1 Point) .4. Vision.Adequate (with or without glasses)(0 Points) .5. Mobility considerations.Wheelchair but stable (1 Point) .6. Cognitive status.Alert and Oriented x 4 (0 Points) .7. Physical Evaluation Score: 2. It further indicated, Smoking Observation.Lighting cigarette .Independent and safe (0 Points) .Ash Management.Uses ashtray appropriately (0 Points) .Handling Cigarette.Holds safely at all times (0 Points) .Attention and alertness.Alert and Attentive (0 Points) .Ability to extinguish cigarette.Safely extinguishes (0 Points) .Adherence to smoking are rules.Follows rules (0 Points) .Smoking Observation Score: 0. It indicated, Smoking Safety Determination Total Score from all assessment areas: 1. Remember to count scores from Chart Review, Physical Evaluation, and Smoking Observation Section [Total score was 3] Scoring Criteria: Any score >2 represents a High Risk for Unsafe Smoking Conditions and requires smoking assistance and/or observation to maintain safety.Smoking Safety Determination .Based on the Evaluation, the resident meets criteria for Assisted Smoking. In summary, resident 32 received 2 points for having a history of a stroke with mild impairment and 1 point for being in a wheelchair which totaled 3 points and triggered a determination of, High Risk for Unsafe Smoking Conditions and requires smoking assistance and/or observation to maintain safety, despite being observed to smoke safely.On 6/23/26 at 1:09 PM, an interview was conducted with the DM who stated when she assisted with smoking she had to watch everyone for safety and that there were a couple residents who had to use safety devices. The DM stated resident 32 had no safety issues that she was aware of.On 6/24/26 at 11:08 AM, an interview was conducted with Certified Nurse Assistant (CNA) 2 who stated when she first started working at the facility there were residents who could go out and smoke on their own. CNA 2 stated that starting in March 2026, nobody was an unsupervised smoker anymore, that it became a supervised smoking facility, and that the new smoking policy enforced smoking times. CNA 2 stated she would watch smoking but resident 36 had no safety issues she had to watch for. CNA 2 stated that resident 32 required assistance to get out of bed but was independent with bed mobility and demonstrated the ability to roll side-to-side on his own. CNA 2 stated resident 32 had left-sided weakness, but remained independent with oral hygiene tasks, such as brushing his teeth. CNA 2 further stated that the resident was alert, exhibited no forgetfulness, and was not known to display any behavioral issues or rule-breaking tendencies. CNA 2 stated resident 32 was independent with community access, possessing the cognitive ability to safely leave the facility and sign himself out.On 6/24/26 at 11:15 AM, an interview was conducted with Registered Nurse (RN) 1 who stated the facility had a supervised smoking policy and everybody had to be supervised. RN 1 stated there were no unsupervised smokers at the facility. RN 1 stated resident 32 was alert and oriented to person, place, time, and situation. RN 1 stated resident 32 could definitely smoke safely on his own. RN 1 stated resident 32 signed himself out every time he left the facility and adhered to facility rules. RN 1 stated resident 32 was able to smoke on his own before the changes and that he had no significant changes that would have made that change.On 6/25/26 at 1:21 PM, an interview was conducted with the Director of Nursing (DON) who stated resident 32 was a supervised smoker based on the evaluation because he was in a wheelchair and he had left-sided impairment. The DON stated that resident 32 maneuvered his wheelchair safely and left the faciity on his own safely. The DON stated resident 32 smoked fine on his own.3. Resident 6 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms; unspecified psychosis; delusional disorders; anxiety disorder; post-traumatic stress disorder; and rheumatoid arthritis.a. On 6/22/26 at 10:14 AM, an interview was conducted with resident 6 who stated she was allowed to go out four times a day to vape and that she had to obtain her vaping materials from staff. Resident 6 stated she was a supervised smoker because she was told she was not safe. Resident 6 stated that she had asked for some liberties last week because she was an introvert and having to smoke with a group of people was difficult and uncomfortable for her because it made her feel anxious and all of that stuff made vaping not worth it to her.On 6/24/26 at 11:33 AM, a follow-up interview was conducted with resident 6 who stated she had bought a special vape that enables her to safely use her vape on her own because she did not have to push a button to use it. Resident 6 stated she was able to follow rules and that she was forgetful but she set up a routine for herself to help remind her of what she needed to do. Resident 6 stated she felt safe when she was alone and would like to vape on her own. Resident 6 stated she was pretty independent and could walk on her own with her walker, had not had any falls at the facility, and was able to shower on her own. Resident 6 stated the times for vaping did not align with her schedule because she was a slow eater and would have to miss the smoking times that were scheduled after breakfast and lunch often or else she would not be able to finish her meals.Resident 6's medical record was reviewed 6/22/26 through 6/29/26.An admission Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15, which indicated an intact cognition.A Care Plan Report dated 5/2/26 indicated resident 6 used a vape and the Interventions were updated on 5/4/26 to include requiring supervision while vaping.A Hot Beverage Safety Evaluation dated 5/2/26 at 12:28 AM indicated she was assessed to have a total score of 0 which indicated she did not: Demonstrate an impaired orientation to person, place, or time; Have a diagnosis of Neuropathy or other neurological impairment; Demonstrate one or more of the following cognitive impairments: Poor safety awareness, impaired short-term memory, impulsiveness; or demonstrate. It indicated this assessment resulted with the determination to be able to consume hot beverages without assistance.A Safe Smoking Evaluation dated 5/4/26 at 8:33 AM indicated, Chart Review Diagnosis.High Risk Diagnosis Review (1 Point Each) . It indicated she received 1 point for, Diagnosis of Cognitive Impairment and 1 point for, Any other (active) diagnosis that may cause tremors, cognitive deficits, or impaired judgement. It further indicated she had no, High Risk Safety Behaviors. It indicated, Physical Evaluation 1. Grip Strength Strong (0 Points) .2. Tremor Present.Mild (1 Point) .3. Upper extremity coordination.Normal (0 Points) .4. Vision.Adequate (with or without glasses)(0 Points) .5. Mobility considerations.Ambulatory (0 Points) .6. Cognitive status.Mild impairment (1 Point) .7. Physical Evaluation Score: 2. It further indicated, Smoking Observation was not completed. It indicated, Smoking Safety Determination Total Score from all assessment areas: 1. Remember to count scores from Chart Review, Physical Evaluation, and Smoking Observation Section [no score was documented] Scoring Criteria: Any score >2 represents a High Risk for Unsafe Smoking Conditions and requires smoking assistance and/or observation to maintain safety.Smoking Safety Determination: .Based on the Evaluation, the resident meets criteria for Assisted Smoking. In summary: Resident 6 was designated as an assisted smoker by an evaluation based on an incomplete assessment; and according to the form, her mild cognitive impairment and tremors were counted twice and her diagnoses alone triggered a determination of, High Risk for Unsafe Smoking Conditions and requires smoking assistance and/or observation to maintain safety.On 6/24/26 at 11:15 AM, an interview was conducted with Registered Nurse (RN) 1 who stated the facility had a supervised smoking policy and everybody had to be supervised. RN 1 stated there were no unsupervised smokers at the facility. RN 1 stated resident 6 had to be supervised to vape. RN 1 stated resident 6 was alert and oriented times 3 or 4, had okay dexterity, and was able to follow the rules and stick to the smoking areas. RN 1 stated the resident left her room now and then but that she was not very social. RN 1 stated a lot of residents had been upset about the smoking policy changes.On 6/25/26 at 1:11 PM, an interview was conducted with the Administrator (ADM) who stated the corporate team had developed the new Safe Smoking Evaluation and policy around March of 2026. The ADM stated the Safe Smoking Evaluation was more detailed and if a resident triggered 2 or more points they had to be supervised. The ADM stated that anyone who was triggered as a supervised smoker by the evaluation had to be watched when they smoked so that they would be safe for smoking. The ADM stated there had been a history at the facility for residents to share smoking paraphernalia with others and that they could not hold other residents accountable for that so all smoking, vapes, tobacco, and lighters were kept by staff in a tool box. The ADM stated that once a resident got admitted , the DON completed the Safe Smoking Evaluation and was responsible for keeping it updated. The ADM stated there were currently no unsupervised residents at the facility.On 6/25/26 at 1:21 PM, an interview was conducted with the DON who stated that the nurse does the Safe Smoking Evaluation on admission and then she checked all of them with her chart checks. The DON stated that the new Safe Smoking Evaluation and policy were recently updated by facility management and that the same tool and policy was utilized for residents who used vapes. The decision of whether a resident was supervised or not was based on the evaluation tool and that if residents had certain diagnoses, the decision could definitely be based on their diagnoses only. The DON stated the decision was also based on their cognition, mobility, and physical symptoms like tremors. The DON stated she usually did the smoking observation with the resident on their first time out to smoke and would observe to see if the resident could light the cigarette safely, hold it safely and not drop it, ash it safely, and ensure the resident could get to and from the smoking area safely. The DON stated that upon admission, resident 6 did get weak and had chronic back pain but that she was getting better. The DON stated resident 6 was supervised for using her vape because of her mobility and her tremor. The DON stated she had been talking to facility management about the resident complaints about the new smoking policy and that they had been trying to compromise with residents but also wanted to ensure their safety.On 6/25/26 at 1:34 PM, an interview was conducted with the Administrator who stated when the new smoking policy rolled out they wanted to make sure that if a resident did not want to follow it that they wanted to help them find other places to go to.b. On 6/22/26 at 10:14 AM, an interview was conducted with resident 6 who stated she felt the Nurse Practitioner (NP) was not listening to her because it had been weeks since she asked to be taken off Olanzapine, but all that had happened was that the dose was lowered. Resident 6 stated she also spoke to the Medical Doctor because she was not taken off of the medication and still nothing changed. Resident 6 stated she talked to Registered Nurse (RN) 1 the night before last about changing her Olanzapine and three other medications, and nothing had happened yet. Resident 6 stated she even got a copy of her medications and went through every one of them to look at the side effects of each so she could talk to the NP. Resident 6 stated she wanted to be taken off of the Olanzapine because it made her gain weight and that she had gained 10-15 pounds. Resident 6 stated that the weight gain was not just for looks but that she had scoliosis and two neck surgeries and the added weight made the pain worse. Resident 6 stated she had bariatric surgery and that was very painful to go through and these medications made her feel insatiable and that there was nothing to do around here so she had nothing else to look forward to but meals. Resident 6 stated she could go to the gym but she was an introvert and had other issues that made it hard for her to go to the gym with other people.Resident 6 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms; unspecified psychosis; delusional disorders; anxiety disorder; and post-traumatic stress disorder.A physician's order dated 5/1/26 at 3:41 PM indicated, OLANZapine Oral Tablet 10 MG [milligrams] (Olanzapine) Give 1 tablet by mouth at bedtime for Schizoaffective disorder. A physician's order dated 5/14/26 at 1:05 PM indicated, OLANZapine Oral Tablet 7.5 MG (Olanzapine) Give 1 tablet by mouth at bedtime for MDD [Major Depressive Disorder]. It should be noted that there was no documentation of the provider signing this order.A Psychotropic Note dated 5/20/26 at 3:36 PM indicated, .- Schizoaffective disorder- OLANZapine Oral Tablet 10 MG [milligram] (Olanzapine)- D/C [discontinue] OLANZapine Oral Tablet 10 MG (Olanzapine) 10 mg PO [by mouth] Give 1 tablet by mouth at bedtime for 1 week for Schizoaffective OLANZapine Oral Tablet 10 MG (Olanzapine) 7.5 mg PO Give 1 tablet by mouth at bedtime for 1 week for Schizoaffective OLANZapine Oral Tablet 5 MG (Olanzapine) 5 mg PO Give 1 tablet by mouth at bedtime for 1 week for Schizoaffective OLANZapine Oral Tablet 2.5 MG (Olanzapine) 2.5 mg PO Give 1 tablet by mouth at bedtime for 1 week for Schizoaffective.A Medication Administration Record (MAR) dated 5/1/26 to 5/31/26 indicated resident 6 received 10 mg of Olanzapine from 5/1/26 through 5/13/26 and 7.5 mg of Olanzapine from 5/14/26 through 5/31/26.A MAR dated 6/1/26 to 6/31/26 indicated resident 6 received 7.5 mg of Olanzapine from 6/1/26 through 6/22/26.A Physician Progress Note dated 6/23/26 at 9:10 AM indicated, Patient was seen in person for follow-up in the facility. Her medication list was reviewed with her, and medication changes were discussed.olanzapine were discontinued.On 6/24/26 at 3:06 PM, an interview was conducted with RN 1 who stated resident 6 requested to speak to the doctor about stopping or tapering her Olanzapine on Saturday, 6/20/26, but she did not tell him why. RN 1 stated he called the NP that day and said the NP stated she would see the resident on Monday.On 6/25/26 at 11:52 AM, an interview was conducted with the Director of Nursing (DON) who stated that RN 1 contacted the NP on Saturday on behalf of resident 6, so the NP came in and did a medication review which resulted in resident 6's Olanzapine order being discontinued. The DON stated the Olanzapine taper documented in the psychotropic note on 5/20/26 at 3:36 PM was not an order. The DON stated the NP gave her a verbal order to decrease her Olanzapine from 10 mg to 7.5 mg on 5/14/26 instead of tapering the resident off of her Olanzapine. The DON stated that NP would send their orders and she or the MDS Coordinator would put the new orders into the medical record. The DON stated the NP put a late note into the medical record because she asked the NP to clarify her notes and orders regarding the Olanzapine taper and order. The DON stated resident 6 was supposed to be discharged on 5/20/25 but then plans changed and she was going to be staying at the facility and when that happened the NP did not want to taper resident 6 off of Olanzapine and gave the DON a verbal order to keep the dose at 7.5 mg but it was not documented anywhere. The DON stated that when the NP put in the late note from 5/20/26 on 6/24/26, that it was actually supposed to have been documented on 5/14/26 instead.

Based on interview and record review it was determined, for 3 out of 23 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, a physician visit note was not documented in the medical record, a resident's medication administration record was not accurately completed, and a physician's note was entered late in the resident's medical record. Resident identifiers: 6, 10, and 41 1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms; unspecified psychosis; delusional disorders; anxiety disorder; and post-traumatic stress disorder.Resident 6's medical record was reviewed 6/22/26 through 6/29/26.A Physician Progress Note dated 5/14/2026 at 8:20 AM was entered as a Late Entry and indicated, Patient was seen in person on 5/14. She requested discontinuation of olanzapine due to weight gain and increased appetite. I discussed with her that olanzapine is being used for schizoaffective disorder, bipolar type, and that it should not be stopped abruptly. Reviewed risks and benefits of discontinuing olanzapine in the setting of schizoaffective disorder, bipolar type, and advised against abrupt cessation. Implemented a gradual taper of olanzapine from 10 mg at bedtime for 1 week, then 7.5 mg at bedtime for 1 week, then 5 mg at bedtime for 1 week, then 2.5 mg at bedtime for 1 week. She verbalized understanding of the taper schedule and agreed to monitor for any worsening mood symptoms, psychosis, sleep disturbance, or other concerns during the dose reduction. Follow-up was recommended to reassess symptoms, tolerability, and consider alternative treatment options if needed.A Physician Progress Note dated 5/20/26 at 9:46 AM was documented on 6/24/26 at 8:47 AM that indicated, Late Entry .Patient was seen in person for follow-up in the facility. Discharge had been planned for 5/20, but this was reviewed with her and she decided to remain for long-term care. The change in disposition was discussed during the visit. Based on this change, themedication [sic] plan was reviewed and olanzapine 7.5 mg will be continued for one month. Ongoing stay and treatment plan were discussed with her in detail.On 6/25/26 at 11:52 AM, an interview was conducted with the Director of Nursing (DON) who stated that RN 1 contacted the NP on Saturday on behalf of resident 6, so the NP came in and did a medication review which resulted in resident 6's Olanzapine order being discontinued. The DON stated the Olanzapine taper documented in the psychotropic note from 5/20/26 at 3:36 PM was not an order. The DON stated the NP gave her a verbal order to decrease her Olanzapine from 10 mg to 7.5 mg on 6/14/26 instead of tapering the resident off of her Olanzapine. The DON stated that NP would send their orders and she or the Minimum Data Set (MDS) Coordinator would put the new orders into the medical record. The DON stated the NP put a late note into the medical record because she asked the NP to clarify her notes and orders regarding the Olanzapine taper and order. The DON stated resident 6 was supposed to be discharged on 5/20/25 but then plans changed and she was going to be staying at the facility and when that happened the NP did not want to taper resident 6 off of Olanzapine and gave the DON a verbal order to keep the dose at 7.5 but it was not documented anywhere. The DON stated that when the NP put in the late note from 5/20/26 that it was actually supposed to have been documented on 5/14/26 instead.2. Resident 10 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and severe dementia with psychotic disturbance.Resident 10's medical record was reviewed 6/22/26 through 6/29/26.A physician's order dated 3/4/26 at 6:00 PM indicated, May have wander guard to Left Wrist: Check for Placement and Function Q shift.A Medication Administration Record dated 6/1/26 to 6/30/26 indicated, May have wander guard to Left Wrist: Check for Placement and Function Q shift every shift for Safety -Start Date- 03/04/2026 1800 [6:00 PM]. It further indicated nurses documented a y for Day and Night on 6/1/26 through the Day on 6/8/26 and a - starting on the Night shift on 6/8/26 through the Day shift on 6/29/26.On 6/29/26 at 10:57 AM, an observation was made of resident 10 and he was wearing a wander guard on his left wrist.On 6/29/26 at 11:01 AM, an interview was conducted with Registered Nurse (RN) 2 who stated he believed resident 10 was supposed to be wearing a wander guard and that nurses verified placement by visualizing it and then documenting that on the Treatment Administration Record. RN 2 reviewed the MAR and stated a y would probably mean that he had it on, but he did not know why nurses were documenting a negative sign or dash [-] and did not know what that meant. RN 2 stated he would go assess the resident to see if he was wearing his wander guard. On 6/29/26 at 11:04 AM, an interview was conducted with the Director of Nursing (DON) who stated resident 10 had a history of wandering and that he would try to go to the doors but his wander guard would set off an alarm. The DON reviewed the MAR and stated the negative sign that was documented from 6/8/26 through 6/29/26 was concerning and that she was going to go look into it.3. Resident 41 was admitted to the facility on [DATE] with diagnoses which included other specified disorders of the brain; alcohol dependence; alcoholic polyneuropathy; and epileptic seizures related to external causes, not intractable, without status epilepticus.On 6/22/26 at 1:51 PM, an interview was conducted with resident 41 who stated that he had not received his Lyrica for a couple of weeks and did not know why but the nurses just told him that his order for Lyrica ran out. Resident 41 stated it helped him with his nerve pain.Resident 41's medical record was reviewed 6/22/26 through 6/29/26.A physician's order dated 4/30/26 at 2:29 PM indicated, Lyrica Capsule 100 MG [milligrams] (Pregabalin) .for 30 days.A Medication Administration Record (MAR) dated 5/1/26 to 5/31/26 indicated Lyrica was administered from 5/1/26 though 5/30/26 at 2:00 PM.A Physician Progress Note dated 6/5/26 at 10:23 AM indicated, .- Visit Date: 05/06/2026.Clinical Data.Neuropathy- Pregabalin [Lyrica] Oral Capsule 100 MG.It should be noted that this late note resulted in confusion as to whether resident 41 had Lyrica ordered on 6/5/26 or not.A Nurses Note dated 6/24/26 at 10:25 AM indicated, Late Entry: .New NP order for Lyrica 100mg BID (twice a day). Order placed.It should be noted that when the progress notes were reviewed this note was not in the medical record.A physician's order dated 6/26/26 at 7:00 PM indicated, Lyrica Oral Capsule 100 MG (Pregabalin).A MAR dated 6/1/26 to 6/30/26 indicated Lyrica was administered 6/24/26 through 6/29/26.On 6/29/26 at 11:16 AM, an interview was conducted with the DON who was reviewing the physicians note dated 6/5/26 at 10:23 AM for the visit on 05/06/2026 and stated when the doctor wrote their progress note it was based on what the resident should have been on. The DON stated that there were other medications in that note that the resident was not on either so she needed to call him. It should be noted that resident 41 was prescribed and administered Lyrica on 5/6/26 but not when the note was entered on 6/5/26.

Based on record review and interview, it was determined that the facility failed to maintain documentation related to staff COVID-19 vaccination that included that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and the COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Specifically, 4 staff members had no documentation that they were offered or provided Covid-19 immunizations. Staff identifiers: 1, 2, 3, and 4. On 6/29/26 at 9:00 AM, the employee records were reviewed for Staff 1, 2, 3, and 4. There was no documentation that indicated immunizations had been offered or administered to the staff members.On 6/29/26 at 2:54 PM, an interview was conducted with the Director of Nursing who stated the COVID-19 immunization was offered to all staff during the flu season but it was not documented.

Based on interview and record review, it was determined that, for 1 out of 23 sampled residents, the facility failed to ensure each resident was informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred. Specifically, one resident was on Olanzapine and there was no documentation that she was informed of the risks and benefits or treatment or treatment alternatives or options. Resident identifier: 6Resident 6 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms; unspecified psychosis; delusional disorders; anxiety disorder; and post-traumatic stress disorder.Resident 6's medical record was reviewed 6/22/26 through 6/29/26.A physician's order dated 5/1/26 at 3:41 PM indicated, OLANZapine Oral Tablet 10 MG [milligrams] (Olanzapine) Give 1 tablet by mouth at bedtime for Schizoaffective disorder. No consent form was in the medical record for Olanzapine.On 6/24/26 at 10:48 AM, an interview was conducted with the Director of Nursing (DON) who stated there was no documentation that resident 6 was informed in advance of the risks and benefits of Olanzapine or treatment alternatives.

Based on interview and record review, it was determined that for 1 of 23 sampled residents, that the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, one resident was not tapered off of Olanzapine as ordered and requested by the resident. Resident identifier: 6.On 6/22/26 at 10:14 AM, an interview was conducted with resident 6 who stated she felt the Nurse Practitioner (NP) was not listening to her because it had been weeks since she asked to be taken off Olanzapine, but all that had happened was that the dose was lowered. Resident 6 stated she also spoke to the Medical Doctor because she was not taken off of the medication and still nothing changed. Resident 6 stated she talked to Registered Nurse (RN) 1 the night before last about changing her Olanzapine and three other medications, and nothing had happened yet. Resident 6 stated she even got a copy of her medications and went through every one of them to look at the side effects of each so she could talk to the NP. Resident 6 stated she wanted to be taken off of the Olanzapine because it made her gain weight and that she had gained 10-15 pounds. Resident 6 stated that the weight gain was not just for looks but that she had scoliosis and two neck surgeries and the added weight made the pain worse. Resident 6 stated she had bariatric surgery and that was very painful to go through and these medications made her feel insatiable and that there was nothing to do around here so she had nothing else to look forward to but meals. Resident 6 stated she could go to the gym but she was an introvert and had other issues that made it hard for her to go to the gym with other people.Resident 6's medical record was reviewed 6/22/26 through 6/29/26.Resident 6 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms; unspecified psychosis; delusional disorders; anxiety disorder; and post-traumatic stress disorder.A physician's order dated 5/1/26 at 3:41 PM indicated, OLANZapine Oral Tablet 10 MG [milligrams] (Olanzapine) Give 1 tablet by mouth at bedtime for Schizoaffective disorder. A physician's order dated 5/14/26 at 1:05 PM indicated, OLANZapine Oral Tablet 7.5 MG (Olanzapine) Give 1 tablet by mouth at bedtime for MDD [Major Depressive Disorder]. It should be noted that there was no documentation of the provider signing this order.A Psychotropic Note dated 5/20/26 at 3:36 PM indicated, .- Schizoaffective disorder- OLANZapine Oral Tablet 10 MG [milligram] (Olanzapine)- D/C [discontinue] OLANZapine Oral Tablet 10 MG (Olanzapine) 10 mg PO [by mouth] Give 1 tablet by mouth at bedtime for 1 week for Schizoaffective OLANZapine Oral Tablet 10 MG (Olanzapine) 7.5 mg PO Give 1 tablet by mouth at bedtime for 1 week for Schizoaffective OLANZapine Oral Tablet 5 MG (Olanzapine) 5 mg PO Give 1 tablet by mouth at bedtime for 1 week for Schizoaffective OLANZapine Oral Tablet 2.5 MG (Olanzapine) 2.5 mg PO Give 1 tablet by mouth at bedtime for 1 week for Schizoaffective.A Medication Administration Record (MAR) dated 5/1/26 to 5/31/26 indicated resident 6 received 10 mg of Olanzapine from 5/1/26 through 5/13/26 and 7.5 mg of Olanzapine from 5/14/26 through 5/31/26.A MAR dated 6/1/26 to 6/31/26 indicated resident 6 received 7.5 mg of Olanzapine from 6/1/26 through 6/22/26.A Physician Progress Note dated 6/23/26 at 9:10 AM indicated, Patient was seen in person for follow-up in the facility. Her medication list was reviewed with her, and medication changes were discussed.olanzapine were discontinued.On 6/24/26 at 3:06 PM, an interview was conducted with RN 1 who stated resident 6 requested to speak to the doctor about stopping or tapering her Olanzapine on Saturday, 6/20/26, but she did not tell him why. RN 1 stated he called the NP that day and said the NP stated she would see the resident on Monday.On 6/25/26 at 11:52 AM, an interview was conducted with the Director of Nursing (DON) who stated that RN 1 contacted the NP on Saturday on behalf of resident 6, so the NP came in and did a medication review which resulted in resident 6's Olanzapine order being discontinued. The DON stated the Olanzapine taper documented in the psychotropic note on 5/20/26 at 3:36 PM was not an order. The DON stated the NP gave her a verbal order to decrease her Olanzapine from 10 mg to 7.5 mg on 5/14/26 instead of tapering the resident off of her Olanzapine. The DON stated that NP would send their orders and she or the MDS Coordinator would put the new orders into the medical record. The DON stated the NP put a late note into the medical record because she asked the NP to clarify her notes and orders regarding the Olanzapine taper and order. The DON stated resident 6 was supposed to be discharged on 5/20/25 but then plans changed and she was going to be staying at the facility and when that happened the NP did not want to taper resident 6 off of Olanzapine and gave the DON a verbal order to keep the dose at 7.5 mg but it was not documented anywhere. The DON stated that when the NP put in the late note from 5/20/26 on 6/24/26, that it was actually supposed to have been documented on 5/14/26 instead.

Based on observation, interview, and record review, it was determined that for 1 of 23 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible. Specifically, a resident was found to have a nicotine vape in his possession despite being assessed as requiring supervision when smoking. Resident identifier: 3. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included osteomyelitis of vertebra lumbar region, bacteremia, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, type 1 diabetes mellitus without complications, and other psychoactive substance abuse with psychoactive substance-induced mood disorder. Resident 3's medical record was reviewed from 6/22/26 through 6/29/26.On 5/8/26, a Safe Smoking Evaluation - V 2 was completed for resident 3 upon his admission to the facility. The assessment stated that resident 3 smokes 1 pack of traditional cigarettes per day and that Resident 3 met the criteria for assisted smoking. On 6/9/26, it was documented in Resident 3's care plan that resident 3 smoked cigarettes, would not smoke without supervision through the next review date, required supervision while smoking, and that resident 3's tobacco supplies were stored in the smoking box. On 6/23/26 at 9:37 AM, an interview was conducted with resident 3 for the initial survey sample pool. During the interview, resident 3 was observed to be in possession of a nicotine vape. The vape was laying on his chest throughout the interview. On 6/24/26 at 2:27 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that residents were not allowed to vape in the building as it was considered smoking. LPN 1 stated that vapes should be stored in the locked box with other smoking supplies.On 6/25/26 at 1:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that residents were not allowed to vape inside of the building. The DON was not aware that resident 3 had a vape in his possession.

Based on interview and record review, the facility did not ensure that 1 of 23 sample residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Resident identifier: 4.Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy, osteomyelitis of vertebra, streptococcus group A, pressure ulcer of the sacral region and right buttock, myocardial infarction and chronic respiratory failure. Resident 4's medical record was reviewed on 6/29/26.Resident 4's progress notes were reviewed. The progress notes indicated that resident 4 had been seen by the facility physician on the following dates after the latest admission: 3/23/265/26/26Documentation for the physician visit from April 2026 was not observed in the medical record. On 6/29/26 at 2:20 PM, an interview was conducted with the Director of Nursing (DON) who stated she was unsure how often the providers were supposed to see the residents in the facility. The DON stated the providers were the ones who kept track of who needed to be seen and when. On 6/29/26 at 2:46 PM, a follow up interview was conducted with the DON who stated the Medical Doctor (MD) for the facility told her that the residents were to be seen on admission, then at 30 days and again at 60 days. The DON stated she was told by the MD that the residents could be seen by either the physician or the nurse practitioner. The DON stated she was also told the residents should be seen one day after they were admitted or on the following Monday if the resident was admitted on a weekend. The DON stated she was unsure if resident 4 had been seen by a provider on that day but was told that the MD had the note from the visit in April but she could not provide it and it was not in resident 4's medical record.

Based on record review and interview, it was determined that for 1 of 23 sampled residents, the facility failed to ensure that each resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. Specifically, one resident opted to receive the pneumococcal immunization but it was not provided. Resident identifier: 10. Resident 10 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and severe dementia with psychotic disturbance.Resident 10's medical record was reviewed 6/22/26 through 6/29/26.An Immunization Consent dated 3/4/26 indicated resident 10 consented to, Pneumococcal Vaccine to be administered on 3/10/26.It should be noted that there was no documentation in the medical record that resident 10 received a Pneumococcal Vaccine.On 6/29/26 at 2:54 PM, an interview was conducted with the Director of Nursing (DON) who stated resident 10 did not receive his immunizations.

Based on observation, interview, and record review, it was determined for 1 out of 10 sampled residents, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident was dropped from a hoyer lift and died; the facility used a transfer sheet and not an approved Hoyer sling while transferring the resident. Resident identifier: 3. NOTICE:Notice of Immediate Jeopardy (IJ) was given verbally to the Administrator on [DATE] at 11:00 AM. The Administrator was asked to develop an immediate plan to ensure resident safety related to Hoyer lifts and Hoyer slings. PLAN:On [DATE] at 6:26 PM, the facility Administrator provided the following abatement plan for the removal of the IJ effective at [DATE] at 10:00 PM. IJ Abatement Plan [facility name redacted] F689 Free of accidents, hazards, and supervision & [and] F726 Competent Nursing StaffImmediate ActionHoyer Inspections were conducted on all facility Hoyer lifts [DATE]. Transfer sheets were disposed of [DATE]. Hoyer slings clearly labeled, others slings removed from facility to more easily distinguish from other materials on [DATE]. Facility policy for Use of Facility Equipment for Resident Care updated [DATE]. Competency checklist with return demonstration conducted for Nursing personnel currently on shift [DATE]. Abatement Plan Regional Nurse Consultant (RNC) provided education to Nursing administrative personnel on [DATE] regarding proper use of Hoyer slings and lifts with return demonstration. This training includes the Director of Nursing (DON) and Assistant Director of Nursing (ADON) The Regional Nurse Consultant (RNC) and Director of Nursing (DON) initiated training with skill competency checklists with return demonstration for Nursing Assistants (NAs) and Licensed Nurses (LN s) on current shift ([DATE] day shift) for proper use of Hoyer slings when transferring a resident using a mechanical (Hoyer) lift. A demonstration video, retrieved from the manufacturer instructions, is included in the skills training competency. Nursing Home Administrator (NHA)/designee has clearly labelled the manufacturer tags on the Hoyer slings with the date they arrived at the facility. Housekeeping educated on 10.17.2025 on proper laundering of Hoyer slings per manufacturer instructions and when slings will be discarded per manufacturer instructions, 'If sling labels are removed or no longer legible, sling must be immediately removed from use' ([Medical supply company name redacted], 2022). Nursing Home Administrator (NHA)/designee updated facility policy for Use of Facility Equipment for Resident Care updated [DATE]. The policy specifies mechanical lift slings that are not owned and approved by Mt. Olympus Rehab are not permitted for use in this facility. The updated policy specifies, 'our staff will use our facility-owned and maintained equipment to ensure compliance, safety, and quality of care. ([Facility name redacted], [DATE]). Director of Nursing (DON) or designee will continue to train and educate Nursing Assistants (NAs) and Licensed Nurses (LNs) prior to permitting nursing personnel to work their next assigned shift. As of [DATE], Licensed Nurses (LNs) and Nursing Assistants (NAs) will be educated by the Director of Nursing or designee prior to being permitted to work direct patient care for next assigned shift. Competency Check- Transferring a Resident using a mechanical liftFull Body Slings: Instructions for use ([Medical supply company name redacted])Application VideoFacility Nursing personnel (LNs, NAs) will be contacted to come to the facility to receive the training by the Regional Nurses Consultant (RNC)/designee and Director of Nursing (DON) or designee [DATE]. The Facility will train as many nursing personnel (LNs, NAs) as possible by 22:00 [10:00 PM] on [DATE]. Nursing personnel (LNs, NAs) who are unable to attend the training will receive education prior to the start of their next shift. Newly hired Nursing personnel will be educated prior to their first direct patient care shift. Regional Nurse Consultant/Designee and Director of Nursing (DON)/designee will provide training to nursing personnel (LNs, NAs) working on night shift [DATE] as they present for their shifts and prior to allowing them to work direct patient care assignments. Training will continue at the beginning of each shift until all nursing personnel (LNs, NAs) have received the training/education. Training verification will be initially measured by return demonstration and then validated by designated leadership via focused direct observation audits. Regional Nurse Consultant (RNC) to round in the facility weekly at random to spot audit facility employee knowledge, competency of utilizing Hoyer slings and lifts. After the facility is determined to be in full compliance with F689 and F726, rounding to be conducted monthly x [times] 3 months. Alleged Date/Time of IJ Abatement: [DATE] @22:00 [10:00 PM].The abatement was verified onsite by the survey team on [DATE] at 1:45 PM.Findings included:Resident 3 was admitted to the facility on [DATE] with diagnoses which included, acute gastric ulcer with hemorrhage, unspecified diastolic (congestive) heart failure, and morbid obesity. A review of resident 3's progress notes revealed:On [DATE] at 9:31 PM, Resident admitted to our facility from [name redacted] this evening at 1720 [5:20 PM], resident arrived via stretcher with [name redacted] Transportation driver brought resident to her room, and 2 CNA's [Certified Nursing Assistants] grabbed the Hoyer lift, resident had a sling underneath her, unknown if the sling was from previous facility or [name redacted]. CNA's attached the Hoyer lift, stretcher was moved from underneath the resident as they directed the Hoyer to her bed when the feet straps snapped, followed by the front straps. Resident fell onto the Hoyer legs, CNA's called for floor nurse, floor nurse arrived and witnessed resident take a few short breaths before going unconscious, CPR [Cardio Pulmonary Resuscitation] was initiated and 911 [emergency services] was called. EMT [Emergency Medical Technician] arrived on scene and called time of death at 1739 [5:39 PM].On [DATE] at 10:34 AM, a telephone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 3 was a new admission to the facility and was transported by a transport company from a different skilled nursing facility. LPN 1 stated that she was doing her evening medication pass when resident 3 arrived at the facility. LPN 1 stated that she introduced herself to resident 3 and informed resident 3 that CNA 1 and CNA 2 were going to assist her into bed and that she would be back to perform an assessment. LPN 1 stated that she then shut the door and exited the room. LPN 1 stated she went back to her medication cart and heard a yell and then a thud and ran back into resident 3's room. LPN 1 stated that resident 3 was on the floor and her body was laying across the legs of the Hoyer lift. LPN 1 stated resident 3's head was draped over one leg of the Hoyer and her feet were draped over the other leg of the Hoyer. LPN 1 stated that resident 3 was moaning and then took a couple of breaths and her eyes rolled back and resident 3's body began to shake. LPN 1 stated that resident 3's eyes became fixed and she was not breathing and had no pulse. LPN 1 stated that the Hoyer was moved out from under the resident and CPR was started. LPN 1 stated that two Registered Nurses came into the room and assisted CNA 2 with CPR. LPN 1 stated that she left the room to call 911 and the administration of the facility. LPN 1 stated that while she was on the phone with 911 dispatch she printed paperwork for resident 3 to send with Emergency Medical Services (EMS). LPN 1 stated that she handed paperwork to the first EMS personnel that came into the facility. LPN 1 stated that the first EMS personnel reviewed the paperwork and located a Physician Order for Life Sustaining Treatment form in the paperwork and it revealed that resident 3 had a Do Not Resuscitate (DNR) order. LPN 1 stated that EMS stopped performing CPR and pronounced resident 3 deceased . LPN 1 stated that police arrived at the facility and stated resident 3's room was a crime scene and would not allow anyone to enter the room. LPN 1 stated that Administrator (ADM) 1, the DON, and the ADON all arrived at the facility. LPN 1 stated that she was instructed by a police officer to write a written statement of what had occurred with resident 3. LPN 1 stated that forensics and a detective arrived at the facility and began taking pictures of the room and the sling that resident 3 had used. LPN 1 stated that she could see on the sling straps where the threading had given way on all four of the straps.On [DATE] at 10:55 AM, a telephone interview was conducted with CNA 1. CNA 1 stated that resident 3 arrived at the facility on a stretcher and had a sling underneath her. CNA 1 stated that she was just assisting CNA 2 with the new resident. CNA 1 stated that resident 3 was put on the Hoyer lift and as soon as she was moved the four straps on the sling broke. CNA 1 stated that resident 3 fell on top of the Hoyer lift legs with her upper back and her legs. CNA 1 stated that resident 3 was kind of mumbling and talking and she got LPN 1 immediately. CNA 1 stated that she just stood there and LPN 1 took care of things. CNA 1 stated that she went to the front door to tell EMS which room to go to. CNA 1 stated that she just stayed at the nurse's station in case she was needed. CNA 1 stated she gave a statement to the police. CNA 1 stated that the sling came with the resident and it was not the facility's sling. CNA 1 stated that the facility used a Hoyer lift for all of their bigger residents who weighed over 200 pounds because it was safer for the residents and the CNA's. On [DATE] at 11:20 AM, an observation of the facility's Hoyer lift was made. The Hoyer lift had a safety notice sticker attached that documented that not all slings were compatible with the lifting device. It was the policy of the medical supply company to recommend only approved slings from the medical supply company be used with the lifts supplied by the medical supply company.On [DATE] at 11:24 AM, an interview was conducted with CNA 3. CNA 3 stated that the facility had two Hoyer lifts and one sit to stand lift. CNA 3 stated that the facility had one Hoyer that weighed residents. On [DATE] at 11:28 AM, an observation and interview was conducted with CNA 4. CNA 4 stated that Hoyer slings were kept downstairs near the laundry area in the facility. CNA 4 stated that he could tell what size the sling was just by looking at it. CNA 4 stated that Hoyer sling size depended on the patient's size and what you needed to use the Hoyer lift for. CNA 4 stated that two CNA's were required to use the Hoyer lift. CNA 4 stated that if a resident came to the facility with a sling underneath them he would talk with the nurse before transferring the resident with the sling and if the nurse was okay with it then he would use the sling. CNA 4 stated he was not sure how long Hoyer slings were good for, but the opened date should be written on the tag of the sling. An observation was made of Hoyer slings near the laundry area of the facility. There were Hoyer lift slings hanging on a hook. The Hoyer slings were made from a mesh-like material and had different colors on the straps that indicated what size the Hoyer slings were. The open date on all of the Hoyer lift slings were dated [DATE]. There was one strap per corner of the sling. CNA 4 stated that you placed the sling under the back of a resident and then hooked all four straps to the Hoyer lift as there was a place for all four straps on the Hoyer lift. CNA 4 stated that he had worked at the facility for 15 years and he learned how to use the Hoyer lift when he started, but had not received any further training. On [DATE] at 11:51 PM, an interview was conducted with ADM 1 and the DON. The DON stated that resident 3 arrived at the facility via a transport company that they have used in the past. The DON stated that resident 3 came to the facility for long-term care. The DON stated that resident 3 had a sling underneath her on a stretcher. The DON stated that CNA's 1 and 2 connected resident 3 to the Hoyer lift and lifted resident 3 up and obtained a weight. The DON stated that the transport driver removed the stretcher from underneath resident 3 and once she was in the air the two straps on the bottom of the sling snapped and the resident slid down in the sling and then the top two straps broke. The DON stated that resident 3 fell onto the legs of the Hoyer lift. The DON stated that the CNAs yelled for LPN 1. The DON stated that LPN 1 witnessed the resident take a few short breaths. The DON stated that CPR was initiated by CNA 2 and LPN 1 called 911. The DON stated that EMS arrived and they took over CPR and they called the time of death at 7:39 PM. Note: This time is inconsistent with the time listed on the [DATE] progress note. ADM 1 stated that the police and medical examiner arrived. ADM 1 stated police sanctioned the room as a crime scene. ADM 1 stated that the facility did an audit of the Hoyer lifts in the building and all the equipment. ADM 1 stated the facility implemented a new policy to only use the facility's equipment, however all staff had not been informed of the new policy. On [DATE] at 9:36 AM, a telephone interview was conducted with ADM 2 [facility name redacted]. ADM 2 stated that resident 3 had been a resident at the facility, but since they were a short-term skilled nursing facility and resident 3 needed a long-term care facility she was transferred. ADM 2 stated that since resident 3 was a stretcher transport she was using a transfer sheet underneath her. ADM 2 stated that he spoke with the CNAs at his facility who helped with transferring resident 3 and they stated that they did not use a Hoyer lift and that they slid the resident to the stretcher with the transfer sheet. ADM 2 stated that resident 3 left the facility with the transfer sheet underneath her. ADM 2 stated that Hoyer slings did not leave the facility because of how expensive they were. On [DATE] at 10:34 AM, a telephone interview was conducted with the van transport driver. The transport driver stated that he arrived at [facility name redacted] to pick up resident 3 to transfer her to a different care facility. The transport driver stated that there was a blue transfer sheet underneath resident 3 when he arrived at the facility and the transfer sheet had handles on the sides. The transport driver stated that hospitals used those types of transfer sheets all the time to move residents. The transport driver stated that he spoke with resident 3 throughout the transfer and resident 3 had voiced her concerns about being afraid and falling because that was one of the reasons she had to stay at a facility. The transport driver stated that when he arrived at Mt. Olympus with resident 3, he put the stretcher close to the bed and asked CNA 1 and CNA 2 how they wanted to transfer resident 3 to the bed. The transport driver stated he informed the CNAs that they had used the slide sheet that was underneath resident 3 at the other facility to move her from the bed to the stretcher. The transport driver stated that the CNAs informed him that they would rather use the Hoyer lift to transfer the resident. The transport driver stated that CNA 1 went and got the Hoyer lift. The transport driver stated that CNA 1 stated that they should just use the sling that was already underneath resident 3. The transport driver stated that he questioned CNA 1 and told her that she should not joke about transferring the resident with a transfer sheet. The transport driver stated that CNA 1 told him that she had worked as a CNA for a really long time and that the sheet would work. The transport driver stated that he told CNA 1 that he would not argue with her, but the blue sheets were only for transfers and not for a Hoyer lift. The transport driver stated that they should just slide resident 3 and he would do most of the work. The transport driver stated that he was just looking out for resident 3 and CNA 1 responded that he could step out of the room. The transport driver stated that he asked CNA 2 if she was really going to allow this and he left the room to find a nurse. The transport driver stated that CNA 1 called him back into the room to move his stretcher because they had resident 3 lifted in the Hoyer lift. The transport driver stated that he was asked by CNA 1 to move the stretcher and CNA 2 stated that the Hoyer lift was working. The transport driver stated that he moved the stretcher and the blue sheet straps immediately broke. The transport driver stated that resident 3 fell to the ground on the Hoyer lift and that resident 3's neck was on the legs of the Hoyer lift near the wheels. The transport driver stated that he ran out of the room and tried to get as many nurses as he could. The transport driver stated that CPR was started and he took the stretcher and left the room. The transport driver stated that he was late for another pick-up and he left the facility. On [DATE] at 2:25 PM, a follow-up telephone interview was conducted with CNA 1. CNA 1 stated that the transfer sling was blue with orange tabs, and it was a lightweight fabric. CNA 1 was unable to describe the type of fabric the sling was made of, only that it was not a heavy or mesh fabric, it was very lightweight. CNA 1 described the sling as kind of like a hammock, there were tabs at the shoulders and some about mid-thigh that were used to help lift the patient. CNA 1 stated that the straps for the transfer sling appeared like they were intact and did not have any wear or tear. CNA 1 stated that the transfer sling that resident 3 came into the facility with was not a Hoyer lift sling, it was a transfer sling. CNA 1 stated that she had used those types of transfer slings in the past with the Hoyer lift and has not had any issues with them. CNA 1 stated that the facility did have these types of slings available in the facility that they had gotten from other facility transfers.On [DATE] at 5:25 PM, a telephone interview was conducted with CNA 2. CNA 2 stated that resident 3 came to the facility on a gurney and that she was responsible for the section that resident 3 was going to be in. CNA 2 stated that they knew from the report that resident 3 would require the Hoyer lift due to her size. CNA 2 stated that if a resident came to the facility with a sling underneath them, then she would use it. CNA 2 stated that resident 3 had a sling underneath her that was not unfamiliar as the facility used the same type of sling. CNA 2 stated that the sling was made from a plastic like material and that it was tarp-like. CNA 2 stated that the sling had multiple straps on the sides and two straps on each corner. CNA 2 stated they used the sling underneath resident 3 because it was familiar to them and they do not usually get admissions in the evening. CNA 2 stated she was familiar with the sling and knew it was a Hoyer sling. CNA 2 stated they looked at the straps and she told CNA 1 there was an option to use multiple straps and they did that. CNA 2 stated she personally had only used the blue ones that were tarp-like just like the one that resident 3 was on and she had never used a mesh one. CNA 2 stated that they figured because it was tarp-like that it would be good to use. CNA 2 stated that CNA 1 brought in the Hoyer lift that also weighed residents. CNA 2 stated that they put resident 3 on the Hoyer lift with four straps on each side and got a weight of 325 pounds. CNA 2 stated that she bent down to move the bed control and resident 3's oxygen tubing when the sling straps snapped and resident 3 fell on top of the Hoyer lift. CNA 2 stated that resident 3 fell over the two metal legs of the Hoyer lift and one of the legs was behind resident 3's neck and the other was on resident 3's coccyx area. CNA 2 stated that a nurse came in and they pulled resident 3 off the Hoyer legs to lay her flat on the floor and began CPR. CNA 2 stated that EMS arrived and they took over CPR. CNA 2 stated that EMS found that resident 3 was a DNR and CPR was stopped and pronounced deceased . CNA 2 stated that police officers arrived at the facility and they turned the room into a crime scene and asked her and CNA 1 how they had hooked up the straps on the Hoyer lift.On [DATE] at 9:21 AM, an interview was conducted with CNA 5. CNA 5 stated that she had been employed at the facility for about 9 years. CNA 5 stated that Hoyer slings were kept downstairs in the laundry room. CNA 5 stated that she had not received any hands-on training regarding the use of Hoyer lifts and Hoyer slings. CNA 5 stated that there were about five residents in the facility that currently used Hoyer lifts.

Based on observation, interview, and record review, the facility did not ensure that nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, Certified Nursing Assistants (CNA)'s had not been educated on the correct way to use a Hoyer lift, approved Hoyer slings, and how to identify a transfer sheet. Additionally, a resident was dropped from the Hoyer lift while on a transfer sheet and died. Resident identifier: 3. NOTICE:Notice of Immediate Jeopardy (IJ) was given verbally to the Administrator on [DATE] at 11:00 AM. The Administrator was asked to develop an immediate plan to ensure resident safety related to Hoyer lifts and Hoyer slings. PLAN:On [DATE] at 6:26 PM, the facility Administrator provided the following abatement plan for the removal of the IJ effective at [DATE] at 10:00 PM. IJ Abatement Plan [facility name redacted] F689 Free of accidents, hazards, and supervision & [and] F726 Competent Nursing StaffImmediate ActionHoyer Inspections were conducted on all facility Hoyer lifts [DATE]. Transfer sheets were disposed of [DATE]. Hoyer slings clearly labeled, others slings removed from facility to more easily distinguish from other materials on [DATE]. Facility policy for Use of Facility Equipment for Resident Care updated [DATE]. Competency checklist with return demonstration conducted for Nursing personnel currently on shift [DATE]. Abatement Plan Regional Nurse Consultant (RNC) provided education to Nursing administrative personnel on [DATE] regarding proper use of Hoyer slings and lifts with return demonstration. This training includes the Director of Nursing (DON) and Assistant Director of Nursing (ADON) The Regional Nurse Consultant (RNC) and Director of Nursing (DON) initiated training with skill competency checklists with return demonstration for Nursing Assistants (NAs) and Licensed Nurses (LN s) on current shift ([DATE] day shift) for proper use of Hoyer slings when transferring a resident using a mechanical (Hoyer) lift. A demonstration video, retrieved from the manufacturer instructions, is included in the skills training competency. Nursing Home Administrator (NHA)/designee has clearly labelled the manufacturer tags on the Hoyer slings with the date they arrived at the facility. Housekeeping educated on 10.17.2025 on proper laundering of Hoyer slings per manufacturer instructions and when slings will be discarded per manufacturer instructions, If sling labels are removed or no longer legible, sling must be immediately removed from use ([Medical supply company name redacted], 2022). Nursing Home Administrator (NHA)/designee updated facility policy for Use of Facility Equipment for Resident Care updated [DATE]. The policy specifies mechanical lift slings that are not owned and approved by Mt. Olympus Rehab are not permitted for use in this facility. The updated policy specifies, our staff will use our facility-owned and maintained equipment to ensure compliance, safety, and quality of care ([Medical supply company name redated], [DATE]). Director of Nursing (DON) or designee will continue to train and educate Nursing Assistants (NAs) and Licensed Nurses (LNs) prior to permitting nursing personnel to work their next assigned shift. As of [DATE], Licensed Nurses (LNs) and Nursing Assistants (NAs) will be educated by the Director of Nursing or designee prior to being permitted to work direct patient care for next assigned shift. Competency Check- Transferring a Resident using a mechanical liftFull Body Slings: Instructions for use ([Medical supply company name redacted])Application VideoFacility Nursing personnel (LNs, NAs) will be contacted to come to the facility to receive the training by the Regional Nurses Consultant (RNC)/designee and Director of Nursing (DON) or designee [DATE]. The Facility will train as many nursing personnel (LNs, NAs) as possible by 22:00 [10:00 PM] on [DATE]. Nursing personnel (LNs, NAs) who are unable to attend the training will receive education prior to the start of their next shift. Newly hired Nursing personnel will be educated prior to their first direct patient care shift. Regional Nurse Consultant/Designee and Director of Nursing (DON)/designee will provide training to nursing personnel (LNs, NAs) working on night shift [DATE] as they present for their shifts and prior to allowing them to work direct patient care assignments. Training will continue at the beginning of each shift until all nursing personnel (LNs, NAs) have received the training/education. Training verification will be initially measured by return demonstration and then validated by designated leadership via focused direct observation audits. Regional Nurse Consultant (RNC) to round in the facility weekly at random to spot audit facility employee knowledge, competency of utilizing Hoyer slings and lifts. After the facility is determined to be in full compliance with F689 and F726, rounding to be conducted monthly x [times] 3 months. Alleged Date/Time of IJ Abatement: [DATE] @22:00 [10:00 PM].The abatement was verified by the survey team on [DATE] at 1:45 PM.Findings included:Resident 3 was admitted to the facility on [DATE] with diagnoses which included, acute gastric ulcer with hemorrhage, unspecified diastolic (congestive) heart failure, and morbid obesity. A review of resident 3's progress notes revealed:On [DATE] at 9:31 PM, Resident admitted to our facility from [facility name redacted] this evening at 1720 [5:20 PM], resident arrived via stretcher with [facility name redacted] Transportation driver brought resident to her room, and 2 CNA's [Certified Nursing Assistants] grabbed the Hoyer lift, resident had a sling underneath her, unknown if the sling was from previous facility or [facility name redacted]. CNA's attached the Hoyer lift, stretcher was moved from underneath the resident as they directed the Hoyer to her bed when the feet straps snapped, followed by the front straps. Resident fell onto the Hoyer legs, CNA's called for floor nurse, floor nurse arrived and witnessed resident take a few short breaths before going unconscious, CPR [Cardio Pulmonary Resuscitation] was initiated and 911 [emergency services] was called. EMT [Emergency Medical Technician] arrived on scene and called time of death at 1739 [5:39 PM].On [DATE] at 10:34 AM, a telephone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 3 was a new admission to the facility and was transported by a transport company from a different skilled nursing facility. LPN 1 stated that she was doing her evening medication pass when resident 3 arrived at the facility. LPN 1 stated that she introduced herself to resident 3 and informed resident 3 that CNA 1 and CNA 2 were going to assist her into bed and that she would be back to perform an assessment. LPN 1 stated that she then shut the door and exited the room. LPN 1 stated she went back to her medication cart and heard a yell and then a thud and ran back into resident 3's room. LPN 1 stated that resident 3 was on the floor and her body was laying across the legs of the Hoyer lift. LPN 1 stated resident 3's head was draped over one leg of the Hoyer and her feet were draped over the other leg of the Hoyer. LPN 1 stated that resident 3 was moaning and then took a couple of breaths and her eyes rolled back and resident 3's body began to shake. LPN 1 stated that resident 3's eyes became fixed and she was not breathing and had no pulse. LPN 1 stated that the Hoyer was moved out from under the resident and CPR was started. LPN 1 stated that two Registered Nurses came into the room and assisted CNA 2 with CPR. LPN 1 stated that she left the room to call 911 and the administration of the facility. LPN 1 stated that while she was on the phone with 911 dispatch she printed paperwork for resident 3 to send with Emergency Medical Services (EMS). LPN 1 stated that she handed paperwork to the first EMS personnel that came into the facility. LPN 1 stated that the first EMS personnel reviewed the paperwork and located a Physician Order for Life Sustaining Treatment form in the paperwork and it revealed that resident 3 had a Do Not Resuscitate (DNR) order. LPN 1 stated that EMS stopped performing CPR and pronounced resident 3 deceased . LPN 1 stated that police arrived at the facility and stated resident 3's room was a crime scene and would not allow anyone to enter the room. LPN 1 stated that the Administrator (ADM) 1, DON, and the ADON all arrived at the facility. LPN 1 stated that she was instructed by a police officer to write a written statement of what had occurred with resident 3. LPN 1 stated that forensics and a detective arrived at the facility and began taking pictures of the room and the sling that resident 3 had used. LPN 1 stated that she could see on the sling straps where the threading had given way on all four of the straps.On [DATE] at 10:55 AM, a telephone interview was conducted with CNA 1. CNA 1 stated that resident 3 arrived at the facility on a stretcher and had a sling underneath her. CNA 1 stated that she was just assisting CNA 2 with the new resident. CNA 1 stated that resident 3 was put on the Hoyer lift and as soon as she was moved the four straps on the sling broke. CNA 1 stated that resident 3 fell on top of the Hoyer lift legs with her upper back and her legs. CNA 1 stated that resident 3 was kind of mumbling and talking and she got LPN 1 immediately. CNA 1 stated that she just stood there and LPN 1 took care of things. CNA 1 stated that she went to the front door to tell EMS which room to go to. CNA 1 stated that she just stayed at the nurse's station in case she was needed. CNA 1 stated she gave a statement to the police. CNA 1 stated that the sling came with the resident and it was not the facility's sling. CNA 1 stated that the facility used a Hoyer lift for all of their bigger residents who weighed over 200 pounds because it was safer for the residents and the CNA's. On [DATE] at 11:28 AM, an observation and interview was conducted with CNA 4. CNA 4 stated that Hoyer slings were kept downstairs near the laundry area in the facility. CNA 4 stated that he could tell what size the sling was just by looking at it. CNA 4 stated that Hoyer sling size depended on the patient's size and what you needed to use the Hoyer lift for. CNA 4 stated that two CNA's were required to use the Hoyer lift. CNA 4 stated that if a resident came to the facility with a sling underneath them he would talk with the nurse before transferring the resident with the sling and if the nurse was okay with it then he would use the sling. CNA 4 stated he was not sure how long Hoyer slings were good for, but the opened date should be written on the tag of the sling. An observation was made of Hoyer slings near the laundry area of the facility. There were Hoyer lift slings hanging on a hook. The Hoyer slings were made from a mesh-like material and had different colors on the straps that indicated what size the Hoyer slings were. The open date on all of the Hoyer lift slings were dated [DATE]. There was one strap per corner of the sling. CNA 4 stated that you placed the sling under the back of a resident and then hooked all four straps to the Hoyer lift as there was a place for all four straps on the Hoyer lift. CNA 4 stated that he had worked at the facility for 15 years and he learned how to use the Hoyer lift when he started, but had not received any further training. On [DATE] at 11:51 PM, an interview was conducted with ADM 1 and the DON. The DON stated that resident 3 arrived at the facility via a transport company that they had used in the past. The DON stated that resident 3 came to the facility for long-term care. The DON stated that resident 3 had a sling underneath her on a stretcher. The DON stated that CNA's 1 and 2 connected resident 3 to the Hoyer lift and lifted resident 3 up and obtained a weight. The DON stated that the transport driver removed the stretcher from underneath resident 3 and once she was in the air the two straps on the bottom of the sling snapped and the resident slid down in the sling and then the top two straps broke. The DON stated that resident 3 fell onto the legs of the Hoyer lift. The DON stated that CNAs yelled for LPN 1. The DON stated that LPN 1 witnessed the resident take a few short breaths. The DON stated that CPR was initiated by CNA 2 and LPN 1 called 911. The DON stated that EMS arrived and they took over CPR and they called the time of death at 7:39 PM. Note: This time is inconsistent with the time listed on the [DATE] progress note. ADM 1 stated that the police and medical examiner arrived. ADM 1 stated police sanctioned the room as a crime scene. ADM 1 stated that the facility did an audit of the Hoyer lifts in the building and all the equipment. ADM 1 stated the facility implemented a new policy to only use the facility's equipment, however all staff had not been informed of the new policy. On [DATE] at 9:36 AM, a telephone interview was conducted with ADM 2 [facility name redacted]. ADM 2 stated that resident 3 had been a resident at the facility, but since they were a short-term skilled nursing facility and resident 3 needed a long-term care facility she was transferred. ADM 2 stated that since resident 3 was a stretcher transport she was using a transfer sheet underneath her. ADM 2 stated that he spoke with the CNAs at his facility who helped with transferring resident 3 and they stated that they did not use a Hoyer lift and that they slid resident 3 to the stretcher with the transfer sheet. ADM 2 stated that resident 3 left the facility with the transfer sheet underneath her. ADM 2 stated that Hoyer slings did not leave the facility because of how expensive they were. On [DATE] at 10:34 AM, a telephone interview was conducted with the van transport driver. The transport driver stated that he arrived at [facility name redacted] to pick up resident 3 to transfer her to a different care facility. The transport driver stated that there was a blue transfer sheet underneath resident 3 when he arrived at the facility and the transfer sheet had handles on the sides. The transport driver stated that hospitals used those types of transfer sheets all the time to move residents. The transport driver stated that he spoke with resident 3 throughout the transfer and resident 3 had voiced her concerns about being afraid and falling because that was one of the reasons she had to stay at a facility. The transport driver stated that he put the stretcher close to the bed and asked CNA 1 and CNA 2 how they wanted to transfer resident 3 to the bed. The transport driver stated he informed the CNAs that they had used the slide sheet that was underneath resident 3 at the other facility to move her from the bed to the stretcher. The transport driver stated that the CNAs informed him that they would rather use the Hoyer lift to transfer the resident. The transport driver stated that CNA 1 went and got the Hoyer lift. The transport driver stated that CNA 1 stated that they should just use the sling that was already underneath resident 3. The transport driver stated that he questioned CNA 1 and told her that she should not joke about transferring the resident with a transfer sheet. The transport driver stated that CNA 1 told him that she had worked as a CNA for a really long time and that the sheet would work. The transport driver stated that he told CNA 1 that he would not argue with her, but the blue sheets were only for transfers and not for a Hoyer lift. The transport driver stated that they should just slide resident 3 and he would do most of the work. The transport driver stated that he was just looking out for resident 3 and CNA 1 responded that he could step out of the room. The transport driver stated that he asked CNA 2 if she was really going to allow this and he left the room to find a nurse. The transport driver stated that CNA 1 called him back into the room to move his stretcher because they had resident 3 lifted in the Hoyer lift. The transport driver stated that he was asked by CNA 1 to move the stretcher and CNA 2 stated that the Hoyer lift was working. The transport driver stated that he moved the stretcher and the blue sheet straps immediately broke. The transport driver stated that resident 3 fell to the ground on the Hoyer lift and that resident 3's neck was on the legs of the Hoyer lift near the wheels. The transport driver stated that he ran out of the room and tried to get as many nurses as he could. The transport driver stated that CPR was started and he took the stretcher and left the room. The transport driver stated that he was late for another pick-up and he left the facility.On [DATE] at 2:25 PM, a follow-up telephone interview was conducted with CNA 1. CNA 1 stated that the transfer sling was blue with orange tabs, and it was a lightweight fabric. CNA 1 was unable to describe the type of fabric the sling was made of, only that it was not a heavy or mesh fabric, it was very lightweight. CNA 1 described the sling as kind of like a hammock, there were tabs at the shoulders and some about mid-thigh that were used to help lift the patient. CNA 1 stated that the straps for the transfer sling appeared like they were intact and did not have any wear or tear. CNA 1 stated that the transfer sling that resident 3 came into the facility with was not a Hoyer lift sling, it was a transfer sling. CNA 1 stated that she had used those types of transfer slings in the past with the Hoyer lift and has not had any issues with them. CNA 1 stated that the facility did have these types of slings available in the facility that they have gotten from other facility transfers.On [DATE] at 5:25 PM, a telephone interview was conducted with CNA 2. CNA 2 stated that resident 3 came to the facility on a gurney and that she was responsible for the section that resident 3 was going to be in. CNA 2 stated that they knew from the report that resident 3 would require the Hoyer lift due to her size. CNA 2 stated that if a resident came to the facility with a sling underneath them, then she would use it. CNA 2 stated that resident 3 had a sling underneath her that was not unfamiliar as the facility used the same type of sling. CNA 2 stated that the sling was made from a plastic like material and that it was tarp-like. CNA 2 stated that the sling had multiple straps on the sides and two straps on each corner. CNA 2 stated they used the sling underneath resident 3 because it was familiar to them and they did not usually get admissions in the evening. CNA 2 stated she was familiar with the sling and knew it was a Hoyer sling. CNA 2 stated they looked at the straps and she told CNA 1 there was an option to use multiple straps and they did that. CNA 2 stated she personally had only used the blue ones that were tarp-like just like the one that resident 3 was on and she had never used a mesh one. CNA 2 stated that they figured because it was tarp-like that it would be good to use. CNA 2 stated that CNA 1 brought in the Hoyer lift that also weighed residents. CNA 2 stated that they put resident 3 on the Hoyer lift with four straps on each side and got a weight of 325 pounds. CNA 2 stated that she bent down to move the bed control and resident 3's oxygen tubing when the sling straps snapped and resident 3 fell on top of the Hoyer lift. CNA 2 stated that she fell over the two metal legs of the Hoyer lift and one of the legs was behind resident 3's neck and the other was on resident 3's coccyx area. CNA 2 stated that a nurse came in and they pulled resident 3 off the Hoyer lift legs to lay her flat on the floor and began CPR. CNA 2 stated that EMS arrived and they took over CPR. CNA 2 stated that EMS found that resident 3 was a DNR and CPR was stopped and pronounced deceased . CNA 2 stated that police officers arrived at the facility and they turned the room into a crime scene and asked her and CNA 1 how they had hooked up the straps on the Hoyer lift.On [DATE] at 9:21 AM, an interview was conducted with CNA 5. CNA 5 stated that she had been employed at the facility for about 9 years. CNA 5 stated that Hoyer slings were kept downstairs in the laundry room. CNA 5 stated that she had not received any hands-on training regarding the use of Hoyer lifts and Hoyer slings. CNA 5 stated that there were about five residents in the facility that currently used Hoyer lifts. On [DATE] at 9:22 am, an interview was conducted with CNA 6. CNA 6 stated that she had training on the Hoyer lift but it had been a couple years. [NAME] stated that she had worked at the facility for 40 years. CNA 6 stated there might have been another training since that she had missed but she was unsure. On [DATE] at 9:36 AM, an interview was conducted with CNA 7. CNA 7 stated that he had training a couple days ago on the Hoyer lift policies. On [DATE] at 10:22 AM, an interview was conducted with CNA 8. CNA 8 stated the last hands on Hoyer lift training was about a month ago. CNA 8 stated when the facility got new Hoyer slings the staff had to visualize the new slings and sign off that they saw them.

Based on interview and record review, it was determined for 1 of 38 sampled residents, that the facility did not notify a representative of the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the move in writing. Specifically, when a resident was discharged to the hospital, the Ombudsman was not notified. Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included peripheral vascular disease, chronic obstructive pulmonary failure, type 2 diabetes mellitus with diabetic neuropathy, left and right leg above knee amputation, adjustment disorder with mixed anxiety and depressed mood, and hypertension. Resident 21's medical record was reviewed on 5/6/24 through 5/9/24. The medical record revealed resident 21 was discharged to the hospital for a change in condition on 2/18/24. Resident 21 was readmitted to the facility on [DATE]. A Hospital Progress Note dated 2/18/24 at 10:07 AM, indicated resident was admitted for Acute Hypoxic Respiratory Failure. On 5/8/24 at 2:31 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that the facility did not notify the Ombudsman when resident 21 was admitted to the hospital in February. The RA further stated that she was not aware that she needed to inform the Ombudsman when a resident was transferred to the hospital or discharged from the facility, and had not been doing so.

Based on interview and record review, the facility did not ensure that 4 of 38 sample residents were provided adequate supervision and assistance devices to prevent accidents. Specifically, residents had a wanderguard placed without a physician order or assessment. In addition, residents were able to elope from the facility multiple times without additional interventions put into place. Resident identifiers: 120, 121, 125, and 127. Findings include: 1. Resident 120 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, memory deficit, schizophrenia, psychosis, Addison's disease, and diabetes mellitus. Resident 120's medical record was reviewed from 5/6/24 through 5/9/24. On 10/6/24, resident 120's Brief Interview for Mental Status (BIMS) on the Minimum Data Set (MDS) assessment was an 8, indicating moderate cognitive impairment. Resident 120's care plan was reviewed. A care plan dated 10/7/23 indicated that the resident was at risk for impaired safety related to Wandering. HE HAS IMPAIRED INSIGHT. A Wandering Risk Scale quarterly assessment for resident 120 was completed on 10/6/23. The assessment indicated that resident 120 could not follow instructions, and was at a high risk to wander. Resident 120's progress notes were reviewed and revealed the following: a. On 10/29/23, pt (patient) agitated. wanted wander guard off, says he was told he only had to wear it for a couple of days. arguing with staff. Quieter after meds (medications) taken and pt had a slice of pizza. b. On 11/1/23 at 12:26 AM, At change of shift (approx (approximately) [6:00 PM]) nurses informed Resident was outside (wanderguard removed by resident) and attempting to climb over fence in rear of the premises. CNA (Certified Nursing Assistant) had also informed ADON (Assistant Director of Nursing) who contacted Nurse while he was responding to the situation. Nurse and Guardian . spoke with Resident at length, attempting to convince him to come inside. Resident told Guardian he might rather be injail (sic) . However, he decided to return inside with staff. PRN (as needed) Ativan prepared, but Resident did not want to accept shot. c. On 11/1/23 at 6:50 AM, At approximately [5:40 AM] Resident was noted missing. He was last seen just before that time. Nurse organized a search, both inside and outside the building. On search, noted that part of the rear fence was broken out. [Note: No physician's order or assessment for the resident's wanderguard was located in the resident's medical record, even though staff had placed a wanderguard on the resident per documentation in the progress notes.] On 5/9/24 at 9:45 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 120 had a wanderguard placed but he took it off repeatedly. The DON stated that resident 120 was delusional about the reasons a wanderguard had been placed on him. The DON stated that she was unsure if there was a specific wanderguard assessment, and that there should be a physician's order for a wanderguard to be placed on a resident. The DON stated that resident 120's guardian wanted the wanderguard placed, so facility staff followed the guardian's wishes. The DON stated that after the first time resident 120 left the facility, she was unsure if the wanderguard was placed on the resident again. The DON stated that after the resident left the faciity on [DATE] the second time, he was later located and taken to a different facility. The DON stated that if a resident repeatedly removed their wanderguard, staff would try a different intervention to ensure a resident's safety, however she was unsure if any other interventions were attempted for resident 120. The DON confirmed that resident 120 was on a one to one status with facility staff when he eloped from the facility on 11/1/23. The DON stated that on 11/1/23, the staff member, Certified Nursing Assistant (CNA) 1 left resident 120 to walk into the kitchen but came right back and the resident was gone. On 5/9/24 at 11:55 AM, an interview was conducted with CNA 1. CNA 1 stated that on 11/1/23 he was supposed to be with resident 120 on a one on one basis. CNA 1 stated that he entered the kitchen to get some ice water for another resident, closed the door, and left resident 120 by the door of the kitchen. CNA 1 stated that resident 120 was supposed to be standing next to the door of the kitchen. CNA 1 stated that when he opened the kitchen door to exit the kitchen, resident 120 was gone. CNA 1 stated that he had only closed the door for like 8 seconds. CNA 1 stated that resident 120's wanderguard was on at the time the resident eloped, because they had put it on because he kept trying to escape. CNA 1 stated that resident 120 had removed the wanderguard two or three times prior to 11/1/23. On 11/1/23, the facility submitted a form 358 to the State Survey Agency (SSA). The form documented that on 11/1/23 at 5:45 AM, a facility nurse went to check on resident 120 and was unable to locate him. On 11/2/2023 at 1:35 PM, a phone call was placed to the facility. A conversation was completed with the Resident Advocate (RA). The RA confirmed the Resident had not returned to the building but stated that they had received a phone call from him this morning requesting a ride back to the facility from the homeless shelter. When facility staff arrived at the shelter, the resident was gone. The facility gave the shelter and the police their contact information in case he returned so they could take him back to the facility. The RA stated that due to the Resident's health history, he was placed under guardianship. The RA stated that when the Resident was admitted , he did not want to stay. The RA stated the resident was doing well until his roommate had to go to the hospital. The facility staff and his guardian feel this triggered the resident and made him want to leave. The Resident was assessed as needing a wander guard upon admission but did not want to wear it and had taken it off multiple times and liked to trigger the door alarms. The RA confirmed the Resident did not have a wander guard in place when he eloped on 11/1/2023 because he took it off. The RA stated the guardian stated it was not uncommon for the resident to leave a facility, and he had a history of doing this but always showed back up. The RA stated that approximately three minutes before the resident eloped, an aide was with him walking the building because he was having trouble sleeping. The aide left the resident to get ice for another resident, and when he returned, the resident was gone. The RA stated staff immediately called administration and the police, who all began searching for the Resident. 2. Resident 121 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, vascular dementia, traumatic brain hemorrhage, cognitive communication deficit, and anxiety disorder. Resident 121's medical record was reviewed from 5/6/24 through 5/9/24. On 9/11/23, resident resident 121's BIMS on the Admission MDS assessment was an 8, indicating moderate cognitive impairment. The MDS also indicated the the resident had wandered 1 to 3 days in the look back period. The MDS triggered behaviors on the Care Area Assessment Summary, however no wandering care plan was developed until 9/29/23. It should be noted that this was after the resident had eloped multiple times. Resident 121's care plan was reviewed. A care plan dated 9/29/23 indicated that the resident was an elopement risk/wanderer that eloped on 9/29/23 r/t (related to) Impaired safety awareness, Resident wanders aimlessly, resident wanting to just get out of here. A Wandering Risk Scale quarterly assessment for resident 121 was completed on 9/4/23. The assessment indicated that resident 121 was at a low risk to wander. Resident 121's progress notes were reviewed and revealed the following: a. On 9/10/23, Very restless and agitated today. Redirected and reoriented frequently paranoid. Exited facility 2 times today and brought back. The nurses note did not give additional details about the 2 elopements from the facility that were referenced. b. On 9/23/23 at 8:52 AM, Very agitated and restless difficult to redirect. Attempting to walk to road. c. On 9/23/23 at 2:58 PM, LCSW (Licensed Clinical Social Worker) provided emotional support. He was tearful . reports feelings of uncertainty with not being able to leave the building. d. On 9/23/23 at 2:58 PM, Continues to wander. e. On 9/23/23 at 4:19 PM, Displays paranoia startles easily. Becomes agitated when people invade his personal space. f. On 9/23/23 at 10:18 PM, Resident continued agitated and exit-seeking behavior. This Nurse needed to run out to stop Resident from either trying to get on bus at bus stop in front of facility, and then to stop him from heading east on sidewalk, on two separate incidents. Resident has been checked on frequently by Nurse and by CNA staff. Staff acted to dissuade him from entering Lobby or trying to leave building via front door. Resident set off alarms at more than one of the other doors, [NAME] on bar but not know the code. g. On 9/29/23 at 7:39 PM, At [5:15 PM] resident was not in his room to receive his dinner. floor nurse and CNA's, initiated Building check. Resident was last seen at [4:45 PM] by the lobby. Resident was not located after the building wide check.Floor nurse received call at [5:45 PM] from paramedics resident was found a few blocks from facility, no injuries noted. Resident was agitated . performing 15 minute checks. h. On 9/30/34 at 12:02 AM, Resident continued to attempt to leave numerous times until resident agreed to let the CNAs get him in bed . i. On 10/3/23, Resident continues on one on one supervision for behaviors. Resident restless and impulsive. On 9/29/23, the facility submitted a form 358 to the State Survey Agency, indicating that the resident had eloped at 4:50 PM, and was found outside the facility by a concerned citizen. On 5/8/24 at 10:36 AM, an interview was conducted with the RA. The RA stated that resident 121 had repeatedly removed his wanderguard, and that he had broken at least three. The RA stated that there was not order for resident 121 to have a wanderguard. [Note: No physician's order or assessment for the resident's wanderguard was located in the resident's medical record, even though staff had placed a wanderguard on the resident per documentation in the progress notes.] No information could be located in resident 121's medical record to indicate other interventions the facility had implemented in order to prevent the resident from eloping, after the resident was able to remove his wanderguard. On 5/9/24 at 9:45 AM, an interview was conducted with the facility DON. The DON stated that she remembered that resident 121 had been placed on one on one a few times but was unable to describe other interventions that had been put into place to prevent resident 121 from eloping again. 3. Resident 125 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, delusional disorder, pneumonia, severe protein calorie malnutrition, psychoactive substance abuse, and altered mental status. Resident 125's medical record was reviewed from 5/6/24 through 5/9/24. An MDS assessment dated [DATE] revealed the resident had a BIMS of 9, indicating moderate cognitive impairment. On 5/27/23, a wander risk assessment for resident 125 indicated that she was a low wander risk. On 5/28/23, a care plan was developed for resident 125 indicating that she was at risk for impaired safety related to Wandering. On 6/5/23, a wander risk assessment for resident 125 indicated that she was a high wander risk. Resident 125's progress notes were reviewed and revealed the following: a. On 5/31/23, resident 125 later escorted back into Mt. Olympus by [name of local transport company] guard, pt had gotten on the bus wanting to get to Seattle. Pt room close to nurse station, staff monitoring pt as closely as possible. b. On 6/12/23 at 11:48 PM, Staff discovered Resident absent from the facility. The lat apparent time that she was seen was approximately an hour ago. Another Resident reported to staff that he had seen her crossing the street to bus stop. c. On 6/13/23, the resident returned from the hospital, and Wanderguard placed on right ankle and working . d. On 7/2/23, Day nurse (2 July 2023) reported Resident had removed wanderguard at some point. Resident has awakened and left her room from time to time, and staff are being watchful for attempts to leave. [Note: No physician's order or assessment for the resident's wanderguard was located in the resident's medical record, even though staff had placed a wanderguard on the resident per documentation in the progress notes.] No information could be located in resident 125's medical record to indicate other interventions the facility had implemented in order to prevent the resident from eloping, after the resident was able to remove her wanderguard. 4. Resident 127 was admitted on [DATE] with diagnoses that included heart failure, palliative care, senile degeneration of brain, degenerative disease of nervous system, dementia, major depressive disorder, bipolar, and anxiety. Resident 127's medical record was reviewed from 5/6/24 through 5/9/24. On an annual MDS assessment dated [DATE], staff indicated that resident 127's BIMS was unable to be determined because the resident was severely cognitively impaired. On 10/11/22, a care plan was developed that indicated resident 127 is a wanderer r/t (related to) History of attempts to leave facility unattended, Impaired safety awareness. [Note: The care plan had not been updated since 10/11/22, even though resident 127 had eloped or attempted to elope multiple times after that.] On 2/10/23, resident 127's wander risk assessment indicated that the resident was a high risk to wander, due to poor safety awareness and cognition as well as a history of wandering the facility. The assessment also indicated that the resident was unsafe for independent community visits. Resident 127's progress notes were reviewed and indicated the following: a. On 4/14/23, Pt confused at times. Tries to wander out of building, wander guard on and working . b. On 5/16/23 at 4:05 PM, Res (resident) Was very anxious today and trying to escape. c. On 5/16/23 at 5:00 PM, Res had been trying to leave the building all day. As the day went on he was getting more nervous and agitated. I administered scheduled doses of lorazepam and called Hospice to get PRN lorazepam ordered as well. Offered several different ways to help Rescalm (sic) down in addition to PRN anti-anxiety medications including calling family, watching TV, eating snacks, listening to music, walking with resident. Res had Wander guard on and it was working throughout the day when he would approach a door. Around 1700 (5:00 PM) I moved Res to the dining area so that he could be occupied by eating dinner. I left as the kitchen staff were setting a place for him. not too much longer, around 1730 (5:30 PM) the police arrived the [resident 127] sic saying they had found him around 2700 E. Talking with nursing staff, Wander guard alarm was not heard. Administered additional PRN dose of Ativan and helped res settle in bed. Preformed (sic) skin check and found no new open areas. Advised Nursing staff to keep a very close eye on him andto (sic) monitor if his wander guard is working appropriately next time he gets up. Res was tired and quick to fall to sleep once returning to facility. On the facility submitted a form 359 to the State Survey Agency regarding the incident on 5/16/23. The facility determined that the front doors were malfunctioning [name of company] is repairing and servicing door on 5/24/23. d. On 6/12/23, Pleasant, mostly cooperative. Wander-Guard D/T (due to) exit-seeking behavior during the daytime into the early evening.Resident sleeping restfully at present, but attempted to go out the front door x2 early in the shift, and was stopped by staff and wanderguard device. e. On 7/16/23, Resident is alert and oriented x 1, is able to follow some of simple command (sic) at times, mood is stable, had episode of exit seeking, stopt (sic) by set off alarm of the door by a wander guard which is placed on his ankle, refused to eat breakfast at times, ate lunch and dinner, ate double tray at times. Resident has pain to knees, worse on right knee currently, has difficult time to walk. Staffs (sic) encouraged resident to use w/c (wheelchair) and call for help to assist him to use toilet, but resident is unableto (sic) redirect, had an episode of setting on the floor when was walking self to use toilet noted . f. On 8/17/23, Resident is alert and oriented x 1, is able to follow some of simple command (sic) at times, mood is stable, had episode of exit seeking, stop by set off alarm (sic) of the door by a wander guard which is placed on his ankle . [Note: No physician's order or assessment for the resident's wanderguard was located in the resident's medical record, even though staff had placed a wanderguard on the resident per documentation in the progress notes.] No information could be located in resident 127's medical record to indicate other interventions the facility had implemented in order to prevent the resident from eloping. [Cross refer to F657]

Based on observation and interview it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 38 sampled residents, a staff member was observed to touch a resident medications with bare hands with each medication administration. Also medications were dropped on and in the medication cart and then administered to the residents Findings include: On 5/8/24 at 8:20 AM, during morning medication pass the following was observed: a. At 8:32 AM Registered Nurse (RN) 2 was observed to not use hand hygiene prior to starting medication pass. RN 2 was observed to use her right index finger to retrieve a medication placed in the medication cup in error. After RN 2 had stuck her finger into the cup she was observed to then remove her finger and obtain a spoon to retrieve the medication from the cup. RN 2's finger was observed to have already touched the medications and sides of the medication cup. b. At 8:36 AM RN 2 was observed to obtain a tablet from a bottle with her bare fingers and place the tablet on the pill cutter. RN 2 was observed to cut the medication, pick up half of the tablet with bare fingers and place the half tablet into the medication cup. The medication cup was then administered to a resident. On 5/8/24 at 8:40 AM, an interview was conducted with RN 2. RN 2 stated hand hygiene was done when passing medications and medications were not supposed to be touched with bare hands to keep them clean for the residents. On 5/9/24 at 9:17 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses are expected to use hand hygiene when administering medications. The DON stated the nurses are not supposed to touch the medications, and if they do they are expected to start the medication pass over for that resident. The DON stated medication pass education needed to be completed.

Based on interviews and record review, the facility did not develop and implement a baseline care plan for 2 of 38 sample residents that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, a care plan was initiated 7 days after admission for two residents. Resident identifiers: 55 and 167. Findings include: 1. Resident 55 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, dysphagia, difficulty walking, reduced mobility, repeated falls, dementia, visual hallucinations, major depressive disorder and neuromuscular dysfunction of the bladder. Resident 55's medical record was reviewed on 5/6/24. The care plans developed for resident 55 were reviewed. The 48 hour care plan was not developed until 2/15/24, this was 7 days after admission. 2. Resident 167 was admitted to the facility on [DATE] with diagnoses which included right hip osteoarthritis, chronic lymphocytic leukemia of b-cell type, morbid obesity, type II diabetes, chronic obstructive pulmonary disease, muscle weakness and hypertension. Resident 167's medical record was reviewed on 5/6/24. The care plans developed for resident 167 were reviewed. The 48 hour care plan was not developed until 4/30/24, this was 7 days after admission. On 5/09/24 at 9:23 AM, an interview was conducted with the Director of Nursing (DON). The DON stated when a resident was admitted there is an assessment that should be done by the admitting nurse that would populate the baseline care plan. The DON stated after a week the Minimum Data Set (MDS) coordinator would do the comprehensive care plan. The DON stated if the resident did not have that admission assessment completed then it would not populate the baseline care plan. The DON stated the nursing administration were in charge of making sure the base line care plans were completed. The DON stated there was not an admission assessment completed for either resident 55 or 167 so neither had a baseline care plan completed.

Based on interview and record review, the facility did not ensure that care plans for 2 of 38 sample residents were developed within 7 days after the completion of the comprehensive assessment, or revised by the interdisciplinary team after each assessment. Resident identifiers: 121 and 127. Findings include: 1. Resident 121 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, vascular dementia, traumatic brain hemorrhage, cognitive communication deficit, and anxiety disorder. Resident 121's medical record was reviewed from 5/6/24 through 5/9/24. On 9/11/23, resident resident 121's BIMS on the Admission MDS assessment was an 8, indicating moderate cognitive impairment. The MDS also indicated the the resident had wandered 1 to 3 days in the look back period. The MDS triggered behaviors on the Care Area Assessment Summary, however no wandering care plan was developed until 9/29/23. It should be noted that this was after the resident had eloped multiple times. Resident 121's care plan was reviewed. A care plan dated 9/29/23 indicated that the resident was an elopement risk/wanderer that eloped on 9/29/23 r/t (related to) Impaired safety awareness, Resident wanders aimlessly, resident wanting to just get out of here. A Wandering Risk Scale quarterly assessment for resident 121 was completed on 9/4/23. The assessment indicated that resident 121 was at a low risk to wander. Resident 121's progress notes were reviewed and revealed the following: a. On 9/10/23, Very restless and agitated today. Redirected and reoriented frequently paranoid. Exited facility 2 times today and brought back. The nurses note did not give additional details about the 2 elopements from the facility that were referenced. b. On 9/23/23 at 8:52 AM, Very agitated and restless difficult to redirect. Attempting to walk to road. c. On 9/23/23 at 2:58 PM, LCSW (Licensed Clinical Social Worker) provided emotional support. He was tearful . reports feelings of uncertainty with not being able to leave the building. d. On 9/23/23 at 2:58 PM, Continues to wander. e. On 9/23/23 at 4:19 PM, Displays paranoia startles easily. Becomes agitated when people invade his personal space. f. On 9/23/23 at 10:18 PM, Resident continued agitated and exit-seeking behavior. This Nurse needed to run out to stop Resident from either trying to get on bus at bus stop in front of facility, and then to stop him from heading east on sidewalk, on two separate incidents. Resident has been checked on frequently by Nurse and by CNA staff. Staff acted to dissuade him from entering Lobby or trying to leave building via front door. Resident set off alarms at more than one of the other doors, press on on bar but not know the code. g. On 9/29/23 at 7:39 PM, At [5:15 PM] resident was not in his room to receive his dinner. floor nurse and CNA's, initiated Building check. Resident was last seen at [4:45 PM] by the lobby. Resident was not located after the building wide check.Floor nurse received call at [5:45 PM] from paramedics resident was found a few blocks from facility, no injuries noted. Resident was agitated . performing 15 minute checks. h. On 9/30/34 at 12:02 AM, Resident continued to attempt to leave numerous times until resident agreed to let the CNAs get him in bed . i. On 10/3/23, Resident continues on one on one supervision for behaviors. Resident restless and impulsive. On 9/29/23, the facility submitted a form 358 to the State Survey Agency, indicating that the resident had eloped at 4:50 PM, and was found outside the facility by a concerned citizen. On 5/8/24 at 10:36 AM, an interview was conducted with the RA. The RA stated that resident 121 had repeatedly removed his wanderguard, and that he had broken at least three. The RA stated that there was not order for resident 121 to have a wanderguard. [Note: No physician's order or assessment for the resident's wanderguard was located in the resident's medical record, even though staff had placed a wanderguard on the resident per documentation in the progress notes.] No information could be located in resident 121's medical record to indicate other interventions the facility had implemented in order to prevent the resident from eloping, after the resident was able to remove his wanderguard. On 5/9/24 at 9:45 AM, an interview was conducted with the facility DON. The DON stated that she remembered that resident 121 had been placed on one on one a few times but was unable to describe other interventions that had been put into place to prevent resident 121 from eloping again. 2. Resident 127 was admitted on [DATE] with diagnoses that included heart failure, palliative care, senile degeneration of brain, degenerative disease of nervous system, dementia, major depressive disorder, bipolar, and anxiety. Resident 127's medical record was reviewed from 5/6/24 through 5/9/24. On an annual MDS assessment dated [DATE], staff indicated that resident 127's BIMS was unable to be determined because the resident was severely cognitively impaired. On 10/11/22, a care plan was developed that indicated resident 127 is a wanderer r/t (related to) History of attempts to leave facility unattended, Impaired safety awareness. [Note: The care plan had not been updated since 10/11/22, even though resident 127 had eloped or attempted to elope multiple times after that.] On 2/10/23, resident 127's wander risk assessment indicated that the resident was a high risk to wander, due to poor safety awareness and cognition as well as a history of wandering the facility. The assessment also indicated that the resident was unsafe for independent community visits. Resident 127's progress notes were reviewed and indicated the following: a. On 4/14/23, Pt confused at times. Tries to wander out of building, wander guard on and working . b. On 5/16/23 at 4:05 PM, Res (resident) Was very anxious today and trying to escape. c. On 5/16/23 at 5:00 PM, Res had been trying to leave the building all day. As the day went on he was getting more nervous and agitated. I administered scheduled doses of lorazepam and called Hospice to get PRN lorazepam ordered as well. Offered several different ways to help Rescalm (sic) down in addition to PRN anti-anxiety medications including calling family, watching TV, eating snacks, listening to music, walking with resident. Res had Wander guard on and it was working throughout the day when he would approach a door. Around 1700 (5:00 PM) I moved Res to the dining area so that he could be occupied by eating dinner. I left as the kitchen staff were setting a place for him. not too much longer, around 1730 (5:30 PM) the police arrived the [resident 127] sic saying they had found him around 2700 E. Talking with nursing staff, Wander guard alarm was not heard. Administered additional PRN dose of Ativan and helped res settle in bed. Preformed (sic) skin check and found no new open areas. Advised Nursing staff to keep a very close eye on him andto (sic) monitor if his wander guard is working appropriately next time he gets up. Res was tired and quick to fall to sleep once returning to facility. On the facility submitted a form 359 to the State Survey Agency regarding the incident on 5/16/23. The facility determined that the front doors were malfunctioning [name of company] is repairing and servicing door on 5/24/23. d. On 6/12/23, Pleasant, mostly cooperative. Wander-Guard D/T (due to) exit-seeking behavior during the daytime into the early evening.Resident sleeping restfully at present, but attempted to go out the front door x2 early in the shift, and was stopped by staff and wanderguard device. e. On 7/16/23, Resident is alert and oriented x 1, is able to follow some of simple command (sic) at times, mood is stable, had episode of exit seeking, stopt (sic) by set off alarm of the door by a wander guard which is placed on his ankle, refused to eat breakfast at times, ate lunch and dinner, ate double tray at times. Resident has pain to knees, worse on right knee currently, has difficult time to walk. Staffs (sic) encouraged resident to use w/c (wheelchair) and call for help to assist him to use toilet, but resident is unableto (sic) redirect, had an episode of setting on the floor when was walking self to use toilet noted . f. On 8/17/23, Resident is alert and oriented x 1, is able to follow some of simple command (sic) at times, mood is stable, had episode of exit seeking, stop by set off alarm (sic) of the door by a wander guard which is placed on his ankle . [Note: No physician's order or assessment for the resident's wanderguard was located in the resident's medical record, even though staff had placed a wanderguard on the resident per documentation in the progress notes.] No information could be located in resident 127's medical record to indicate other interventions the facility had implemented in order to prevent the resident from eloping. On 5/9/24 at 9:45 AM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that the care plans for residents 121 and 127 had not been developed and/or revised in a timely manner. [Cross refer to F689]

Based on interview and record review it was determined, for 1 of 38 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, a resident's blood pressure (B/P) medication was administered outside of physicians ordered parameters. Resident identifier: 4. Findings include: Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, traumatic subdural hemorrhage, severe protein calorie malnutrition, type II diabetes, dysphagia, chronic kidney disease stage 3, hypothyroidism, gastro-esophageal reflux disease and hypertension. Resident 4's medical record was reviewed on 5/6/24. Review of resident 4's physician orders revealed the following: a. Chlorthalidone Oral Tablet give 12.5 mg (milligrams) by mouth one time a day for HTN (hypertension). Hold for systolic less than 110. b. Amlodipine Besylate Oral tablet 5 MG Give 1 mg by mouth one time a day for hypertension. Hold for systolic less than 110. Review of resident 4's March, April and May 2024 Medication Administration Records (MARs) revealed the following: c. Chlorthalidone 12.5 mg was administered when it should have been held for a blood pressure of 102/65 on 3/17/24. d. Amlodipine 5 mg was administered when it should have been held for a blood pressure of 105/62 on 4/7/24. e. Chlorthalidone 12.5 mg was administered when it should have been held for a blood pressure of 96/68 on 5/5/24. On 5/8/24 at 8:06 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated some residents have blood pressure parameters that the physician has ordered. RN 1 stated the nurses are supposed to check the residents blood pressure to make sure it is at an ok level before administering their blood pressure medications so their blood pressure does not drop too low. On 5/9/24 at 9:26 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility did have blood pressure parameters that were ordered by the physician and the nurses were expected to follow those parameters when administering medications. If the blood pressure was under the parameter the nurses were expected to hold the medication, make the physician aware and await further orders. The DON stated there are parameters in place to keep the residents safe.

Based on observation and interview, the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles and included appropriate accessory instructions and the expiration date when applicable. Specifically, narcotics were repackaged into the narcotic medication cards. Findings include: On 5/8/24 at 8:35 AM, an observation was made of the facility medication cart for the Quail hallway serving rooms 31 - 42. The following medication was located inside: a. A medication card which held Tramadol 50 mg (milligrams) had the back of pockets numbered 10 and 20 taped, there was a white tablet observed to be in each of the pockets. On 5/8/24 at 8:45 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that 2 nurses are supposed to waste narcotics, and they are usually placed in the sharps container then both nurses sign the narcotic book. RN 2 stated the narcotics are not supposed to be taped back into the narcotic card. On 5/9/24 at 9:17 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses are expected to waste narcotics with another nurse and sign it as completed in the narcotic book. The DON stated the nurses are not supposed to re-tape any medication back into the medication cards as this could increase the chance of infection and the wrong medication being placed in the medication card.

Based on observation, interview, and record review it was determined, for 9 out of 41 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident received second degree burns to the face, scapula area, and thigh when his oxygen cannula ignited while smoking a cigarette unsupervised. Additionally, multiple residents who were identified as requiring staff supervision while smoking were observed smoking without staff present, and residents were not assessed for their smoking assistance/supervision needs. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Another resident sustained a skin tear when he was not secured in the transportation van. This example was cited at a harm level. Resident identifiers: 4, 17, 18, 47, 56, 77, 134, 181, and 231. NOTICE On 2/9/23 at 2:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that residents were evaluated for smoking safety, that interventions were identified, and that monitoring for safe smoking was implemented. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON), and the Corporate Resource Nurse (CRN), and they were informed of the findings of IJ pertaining to F689 for residents 4, 17, 56 and 134. On 2/13/23, the facility provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 2/13/23 at 6:15 PM: The facility seeks to ensure that each resident is free from accidents hazards and that each resident receives adequate supervision and assistive devices to prevent accidents. Immediate Interventions: Resident 17: Resident was assessed and found to require full assistance with smoking. He was placed on supervised smoking program where staff will assist him out to the smoking area (without his oxygen) and the staff will light his cigarette, stay and supervise him, extinguish cigarette and assist him back into the facility. If Resident 17 is observed asking for smoking materials from others, nursing staff will redirect him. A Smoking Assistance Form will be initiated by the Licensed Nursing Staff on 2/10/23 to provide guidance for staff to ensure they provide the appropriate level of assistance when he wishes to smoke. This form will be stored in the Smoking Binder at the Nurses Station for CNA's [Certified Nurse Assistants] and other staff to know what level of assistance to provide. The Care Plan will be updated on 2/10/23 to match the interventions contained on the Smoking Assistance Form. Resident 56 Resident will be assessed quarterly and as needed to ensure his smoking plan meets his cognitive/physical level. He currently has been assessed as needing supervision with smoking. Resident 56 chews tobacco most of time. The IDT [Interdisciplinary Team] will review the resident's condition by 2/10/2023 to ensure Resident 56 is safe to have his own smoking materials and has an appropriate place to secure the materials. A Smoking Assistance Form will be initiated by the Licensed Nursing Staff on 2/10/23 to provide guidance for staff to ensure they provide the appropriate level of assistance when he wishes to smoke. This form will be stored in the Smoking Binder at the Nurses Station for CNA's [sic] and other staff to know what level of assistance to provide. When the resident expresses desire to smoke, monitoring will be provided based on the level of assistance indicated on the Smoking Assistance Form. Resident 4 A new smoking evaluation was completed using the Smoking Safety Evaluation in Point Click Care, and Resident 4 was found to require supervision while smoking. The staff will assist the resident outside without oxygen, staff will light cigarette, stay and supervise them, extinguish cigarette, and assist them back into facility. A Smoking Assistance Form will be filled out by the Licensed Nursing Staff on 2/10/23 to provide guidance for staff to ensure they provide the appropriate level of supervision and assistance while smoking. This form will be stored in the Smoking Binder at the Nurses Station. The resident's care plan was updated to reflect the required level of assistance. Resident 134 A new smoking evaluation was completed using the Smoking Safety Evaluation in Point Click Care, and Resident 134 was found to require supervision while smoking. The staff will assist the resident outside without oxygen, staff will light cigarette, stay and supervise them, extinguish cigarette and assist them back to facility. A Smoking Assistance Form will be filled out by the Licensed Nursing Staff on 2/10/23 to provide guidance for staff to ensure they provide the appropriate level of supervision and assistance while smoking. This form will be stored in the Smoking Binder at the Nurses Station. The Resident's care plan was updated to reflect the required level of assistance. Facility Plan to ensure compliance quickly Nursing Home Administrator/Designee reviewed the facilities smoking policy and began education with all staff about facility smoking policy and how to identify those who require supervision and how to support residents who wish to start smoking to ensure safety starting 2/9/23. Investigation began to determine which residents are unsafe to smoke without supervision. A smoking evaluation was done on 2/9/2023 of all residents who smoke to ensure the facility has identified all residents who have physical/cognitive decline that may indicate the need for assistance. Physical Therapy physically assessed the identified residents for safety and mobility. Careplans were updated to include the required smoking supervision. All current facility residents smoking evals [sic] have been updated by Director of Nursing /Designee from the past three months to ensure that residents have appropriate interventions in place for their smoking status. All residents who smoke will be evaluated quarterly and with changes in condition that affects residents mobility, ROM [Range of Motion], changes in LOC [Level of Consciousness], new oxygen orders by licensed nurse using smoking evaluation, and will be reviewed by IDT team. Ad-Hoc QAPI [Quality Assurance and Performance Improvement] to be held on 2/10/2023 with the IDT to discuss the identify smoking program and additional areas as needed for improvement. Smoking Binder: Residents who smoke will have a Smoking Assistance Form located in the Smoking Binder at the Nurses Station. The assisted smoking times and staff assignments that will supervise the smoking sessions will be located in the binder. Updates to the residents who are on program as well as new admits will be updated in the book by social services as soon as possible. The forms will be updated quarterly and as needed, based on the results of the Smoking Safety Evaluation in Point Click Care and other information gathered by the IDT as indicated. Securement of Smoking Materials: For Residents who are determined to be unsafe to store their own smoking materials, the supplies will be stored in the Nurses Medication Cart and utilized under the supervision of the staff during smoking times. All independent smokers will be reviewed by 2/10/2023 by IDT/designee to ensure they have safe/secure place to store their smoking materials. When Residents have a Desire to Start Smoking: All residents will be educated on admission if they wish to start smoking at any time, to speak with the nurse. If a resident is observed to smoking (or who expresses the desire to be smoking) in-between the annual/quarterly reviews, staff will initiate a smoking safety evaluation to determine the resident's physical/cognitive level and any assistance that is needed. The facility smoking policy will be reviewed with them and documentation will be included in the medical record at that time to review the education provided. Sharing Smoking Materials: Residents who smoke will be educated on admission that sharing of smoking materials is not allowed. If residents require assistance with smoking, the facility will store their smoking materials to ensure safety. Residents who are assessed to be independent will have a safe place to secure their own materials. If they are found to be sharing smoking materials, the IDT will be notified and adjustments to the smoking plan will be made to ensure safety. Supervised Smoking: Staff will receive education starting on 2/9/2023 about how to properly monitor resident's needs based on their evaluation. Each resident who requires assistance will have a Smoking Assistance Form in the Smoking Binder that will inform staff on what assistance is needed for each resident. Resident Evaluation/Criteria for Evaluation: The initial smoking evaluation is to be done on admission and quarterly, documented in the Smoking Safety Evaluation using Point Click Care. This assessment will also be initiated on Changes of Condition. If a resident who smokes triggers for Physical Deficits, a Therapy Screen for smoking safety will be initiated. Therapy will report back to the IDT with any recommendations for smoking safety. These recommendations will be included in the Plan of Care and in the Smoking Binder to ensure CNA's [sic] are aware of the interventions. Changes of Condition: All residents who smoke who experience a Change of Condition will be evaluated with for changes in mobility, ROM, changes in LOC, new oxygen orders, etc. This assessment will be initiated by the licensed nurse using the Smoking Safety Evaluation in Point Click Care. Other disciplines will be involved in the evaluation as indicated based on the initial assessment findings. Oversight: The Director of Nursing/Designee will be responsible for ensuring that Smoking Safety evaluations are completed timely and are accurate, by periodically reviewing the assessment schedule. If concerns are identified, they will be brought to the QA [Quality Assurance] Committee for further discussion and protocol revision. Findings included: IMMEDIATE JEOPARDY 1. Resident 17 was admitted on [DATE] with diagnoses that included but not limited to encephalopathy, type 2 diabetes mellitus with neuropathy, congestive heart failure, major depressive disorder, mild cognitive impairment, obstructive sleep apnea, hypertension, sensorineural hearing loss, and tobacco use. On 2/06/23 at 2:06 PM, an interview was conducted with resident 17. Resident 17 stated that he lit his cigarette while he had his oxygen on, and it caught on fire. Resident 17 stated that it taught him a lesson not to have the oxygen on while smoking. Resident 17 stated that at the time of the accident he did not have staff accompany him while smoking. Resident 17 stated that now staff go out with him while he smoked. Resident 17 stated that at the time of the accident he had his lighter and cigarettes with him in his room. Resident 17 stated that the facility started the smoking apron a few days ago, for what reason, I don't know. Resident 17 stated that his nose and right cheek was hurting from the burns, and that he was also burned on his back. On 2/6/23, resident 17's medical records were reviewed. On 12/6/22, resident 17 had a physician's order initiated for oxygen per nasal cannula at a rate of 4 to 5 liters/minute continuously for Chronic Obstructive Pulmonary Disease (COPD). Resident 17's progress notes revealed the following: a. On 1/27/23 at 12:38 PM, the note documented that resident 17 was awake and alert and the oxygen saturation was 94% on room air [RA]. Resident 17 was sent to the local area emergency room [ER] for evaluation. b. On 1/27/23 at 3:42 PM, the note documented that resident 17's physician was notified about a change in condition. The physician gave new orders for resident 17 to be on room air and oxygen was to be applied if oxygen saturations dropped below 88% or with any shortness of breath. c. On 1/27/23 at 5:22 PM, the note documented, Returned from ER awake alert no sob [shortness of breath] on RA sat 91%. Face and hands cleaned with lotion on skin. Small burn on To small burns [sic] on right upper back all oTA [open to air]. No c/o [complaints of] pain asking for a cigarette before he was in bed. Explained to resident he will be on assisted smoking and will be taken out by staff at scheduled times. Call light within reach also instructed to call for assist getting out of bed. States he understands. No new orders from ER. d. On 1/27/23 at 11:00 PM, the 72 Hour Event Charting documented, Type of Event: Burns from smoking Interventions: Pt [patient] being monitored frequently. O2 [oxygen] checked Q [every] 4 hrs [hours], Duoneb tx [treatment] Q 6 hrs and VS [vital signs] Q 6 hrs x [times] 3 days. Resident Reaction to Interventions: Pt needs reminding that he has no cigarettes and no smoking r/t [related to] burns. Pain Management: Tylenol and Tramadol for pain as ordered. Improvement/Decline: ongoing e. On 1/29/23 at 10:00 PM, the 72 Hour Event Charting documented that resident 17 needed reminders that he had no cigarettes and was forgetful. f. On 1/31/23 at 3:18 PM, the skin/wound note documented, NP [Nurse Practitioner] in today and Reasessed [sic] partial thickness burn, noted Right and left external nasal area and partially in nostril and upper mouth, noted some dry red scab and brown scabs and noted small amount of crusted areas, c/o pain 3/10 and NP ordered lidocaine 2% to apply for pain management and effective, also to cleanse with NSS [normal saline solution] crusted areas and apply bacitracin with zinc to affected areas. Noted Right shoulder partial thicknes [sic] burn from smoking with dry red scabs, measurement 10cm[centimeter] x [by] 2.5cm x 0cm, no oozing noted, no s/s [signs and symptoms] of infection noted and denies pain. Clarified treatment with NP and in placed [sic], to apply bacitracin with zinc bid [two times a day]. Right thigh small partial thickness burn with red dry scab with a measuremnt [sic] of 2cmx1cmx0cm, denies pain and no s/s of infection, clarified treatment in placed [sic], to apply bacitracin with zinc bid and in placed [sic]. Also to monitor for s/s of infection q shift. Edcated [sic] and encouraged resident to call for help or to follow scheduled plan on smoking to be assisted. Resident verbalizes understanding and will continue to monitor. g. On 2/3/23 at 8:42 AM, the note documented, Wander guard applied to right ankle for residents [sic] safety. Resident continues to ask for cigarettes frequently reoriented to facility smoking times. Burns much improved denies any pain. No sob sat on RA 91%. On 12/12/22, a Minimum Data Set (MDS) Admission Assessment for resident 17 indicated that resident 17's Brief Interview for Mental Status (BIMS) score was 12, indicating a moderate cognitive impairment. The assessment did not have documentation for short-term memory [STM] or long-term memory [LTM] impairments. On 12/13/22, the weekly nursing summary documented that resident 17's mental status was poor memory. On 12/15/22, the skilled daily review documented that resident 17 had short-term memory impairment. On 1/21/23, the Smoking Safety Evaluation documented a diagnosis of neuropathy or neurological impairment which scored resident 17 as a 1. A score of 1 on the assessment indicated that resident 17 may require set-up assistance with smoking. The evaluation further documented that resident 17 could smoke independently, could safely have smoking paraphernalia on person, and was educated on safe smoking. Additional comments documented, Pt using FWW [forward wheeled walker] to assist with ambulation to smoke shack, pt doing well coming in and out independently during shift, res [resident] is free to keep cigaretes [sic] and lighter at this time, res educated on safe smoking. The assessment was initiated on 1/21/23 and was locked on 2/5/23 at 11:04 PM. On 1/19/23 at 1:00 PM, a St. Louis University Mental Status (SLUMS) Examination for detecting cognitive impairments was conducted. Resident 17 scored a 20 out of 30, which would indicate a cognitive level consistent with Dementia. On 1/27/23, the Smoking Safety Evaluation documented a diagnosis of neuropathy or neurological impairment. Resident 17 demonstrated one or more of the following cognitive impairments: Poor safety awareness, impaired STM [short term memory], impulsiveness, had a history of unsafe smoking practices, and demonstrated non-compliance with smoking policy (i.e., smoking in designated areas only, appropriate disposal of cigarettes, etc.). The assessment scored the resident 4-6 points which would indicate that resident 17 was unable to smoke independently and required supervision while smoking. Additional comments documented, Pt lit cigarette while his O2 was on in his nose, causing burns. Cigarettes and lighter will be kept in nursing cart for pt and pt is required to be on assisted smoking program. Staff educated on assistive smoking and the times are posted in pt room. Pt educated and verbalizes understanding. Offer pt lozenges, patch, gum to help, res refuses any interventions at this time. The evaluation was signed and locked on 2/5/23 at 11:13 PM. On 1/27/23 at 12:37 PM, resident 17's incident report documented, Called by CNA to assist a resident outside smoking on ramp outside bldg. Found [resident 17] on the ramp. Nasal cannula was on fire in residents lap and side of w/c [wheelchair] was also burning. The incident report documented burns to the right finger and right shoulder. The report documented predisposing factors as confused, gait imbalance, and impaired memory. On 1/30/23, the incident report documented that the resident was educated on assisted smoking times, supervision required, PRN (as needed) use of lozenges for smoking cessation, and that cigarettes and lighter must be kept at nurse's station. On 1/27/23, the Hospital History and Physical documented a second degree, partial thickness burns of resident 17's face. The triage note documented that resident 17 was transferred to the emergency room due to smoking a cigarette while on baseline 4 liters of oxygen per nasal cannula (NC). The NC caught on fire and singed the tubing approximately 1.5 to 2 feet. Right sided nasal/cheek and right scapula blisters. Soot present in bilateral nares and dusting of soot to top of tongue. Patient arrived with second-degree burns to nares bilaterally, breathing was unlabored. Patient with singed nares and secondary burn to right upper lip and cheek, no evidence of oropharyngeal involvement. On 12/6/22, resident 17 had a care plan created for tobacco use. The interventions identified were to instruct resident 17 about smoking risks and hazards and about cessation aids that were available (initiated on 2/5/23); instruct resident about facility policy on smoking locations, times, and safety concerns (initiated on 12/6/22); notify charge nurse immediately if suspected violated smoking policy (initiated on 2/5/23); observe clothing and skin for burns (initiated on 2/5/23); required supervision for smoking (initiated on 1/28/23); and resident's tobacco supplies were stored at the nursing cart (initiated on 1/28/23). On 2/6/23, resident 17 had a care plan created for SMOKES CIGARETTES. The goal identified was that resident 17 would not smoke without supervision through the review date. The interventions identified were to instruct resident 17 about smoking risks and hazards and about smoking cessation aids that were available (initiated on 2/6/23); instruct resident 17 about the facility policy on smoking: locations, times, safety concerns (initiated on 2/6/23); monitor oral hygiene (initiated on 2/6/23); and resident 17 required SUPERVISION while smoking (initiated on 2/6/23). On 2/7/23 at 1:07 PM, an observation was made of resident 17 during a supervised smoke break. Resident 17 was accompanied on the smoke break by CNA 6. Resident 17 was observed wearing a smoking apron. Resident 17 ambulated to the nurse's station with the use of a walker and CNA 6 obtained a cigarette from Licensed Practical Nurse (LPN) 4. CNA 6 then accompanied resident 17 to the back smoking patio. Upon exit of the facility, resident 17's wander guard triggered an alarm that had to be silenced by the staff. CNA 6 handed resident 17 the cigarette and lit it for him. An immediate interview was conducted with CNA 6. CNA 6 stated he was to watch resident 17 while he smoked because he had an accident a few weeks ago, so now he had to be supervised with smoking. CNA 6 stated that resident 17 came outside with an oxygen tank and he lit himself on fire. CNA 6 stated that prior to the accident resident 17 was not supervised with smoking. Resident 17 was observed to discard the cigarette on the ground next to him. Resident 17 ambulated back inside the facility after smoking one cigarette. On 2/8/23 at 10:30 AM, an interview was conducted with LPN 4. LPN 4 stated that the licensed nurse was supposed to complete a smoking assessment upon admission for each resident. LPN 4 stated that the smoking assessment was contained within the admission paperwork, but if the document was not there it may not be completed. LPN 4 stated that the smoking assessment upon admission was not consistently being completed by the nursing staff. LPN 4 stated that upon admission residents were assessed for cognition and any memory deficits. LPN 4 stated that they were supposed to go outside with the resident while they smoked to see if they were safe while they smoked. LPN 4 stated that the smoking assessment asked if the resident was aware and could smoke safely. LPN 4 stated that the smoking assessment was now located in the electronic medical records under the additional admission assessment and was not included in the admission package paperwork. LPN 4 stated that resident 17 initially resided in a different hallway upon admission. LPN 4 was observed to review resident 17's records and stated that a smoking assessment was completed on 1/27/23 and he was admitted on [DATE]. LPN 4 stated that resident 17 should have had a smoking assessment completed when he was admitted because he was a smoker upon admission. LPN 4 stated that resident 17 was alert and oriented times 3 to 4 to person, place, and situation. LPN 4 stated that resident 17 did not have good safety awareness. LPN 4 stated for example residents were not supposed to smoke with oxygen on. LPN 4 stated that resident 17 had used supplemental oxygen since admission and he was a smoker since admission. LPN 4 stated that they had that issue before with the smokers, they did not want to leave their oxygen inside while they smoked. LPN 4 stated that this worried them because the oxygen will blow everything up. LPN 4 stated that according to what was reported resident 17 was right by the door going out to the smoking patio when the accident occurred. If he was down in the smoking patio no one would see him. LPN 4 stated that a hospice CNA walked by and went to help resident 17 when the accident occurred. We were lucky that he was right here by the door. LPN 4 stated that they were not sure how the facility enforced not allowing residents to take their oxygen outside, lots of people do it. LPN 4 stated that the residents would fight you if you tried to not allow oxygen tanks outside on the smoking patio. They can't survive without the oxygen. LPN 4 stated that they were providing treatment for resident 17's burns. On 2/8/23 at 10:46 AM, an interview was conducted with the Wound Care Nurse (WCN). The WCN stated that she provided wound care on Mondays, Tuesdays, and Wednesday. The WCN stated that resident 17 had burns on both nares, the top lip, the right posterior shoulder, and on the right thigh. The WCN stated that they were partial thickness burns and were almost healed. On 2/8/23 02:28 PM, an interview was conducted with Nursing Assistant (NA) 3. NA 3 stated she was not sure which residents smoked and was getting to know the residents because she was new. NA 3 stated residents mostly smoked in the back and staff checked on residents while they were smoking. NA 3 stated staff kept resident 17's cigarettes because he smoked them too fast. NA 3 stated resident 17 had not had any accidents with smoking. NA 3 stated that resident 17 liked to smoke constantly and finished his boxes of cigarettes. NA 3 stated that resident 17 did not have any accidents while smoking, just that he smoked too many. NA 3 stated that they attempted to lower the number of cigarettes that resident 17 smoked. NA 3 stated that resident 17 was on supplemental oxygen. NA 3 stated that she had not supervised the residents while they were smoking. On 2/8/23 at 4:16 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the process for the smoking assessment was that the admitting nurse should complete the assessment to determine if the resident was safe to smoke. The DON stated that the nurse should inquire if the resident was a current or previous smoker. The DON stated that the assessment was part of the electronic medical records and was not part of the admission packet. The DON stated that the smoking assessment should also be completed quarterly. The DON stated that once the admitting nurse had determined the resident's smoking status they should complete the smoking assessment. The nurses should just know to do it upon admission. The DON stated that the smoking safety evaluation was the same for admission and quarterly. The DON stated that if the assessment was not locked with a date, it could still have modifications made to the assessment. If you don't lock it additional information could be added at any time. The DON stated that the aides were told if there was someone who needed to be assisted with smoking. The DON stated the nurse will tell them which residents needed to be supervised, and what type of supervision was needed. The DON stated that the nurse did not initiate a care plan from the smoking evaluation, but the unit manager should pick that up and initiate the care plan on a 48-hour chart check. The DON stated that resident 17 was able to ambulate with the use of a walker, but on the day of the accident resident 17 took his wheelchair outside. The DON stated that resident 17's wheelchair had an oxygen tank on it. The DON stated that at the time of the accident resident 17 had his smoking materials with him, cigarettes and a lighter. The DON stated that resident 17 would utilize a walker or wheelchair for a mobility device and that the wheelchair was equipped with an oxygen tank. The DON stated that she was aware of one incident prior to the accident when resident 17 went outside to smoke with his supplemental oxygen. The DON stated that they educated resident 17 not to have the oxygen tank outside while smoking even if it was turned off. The DON stated that she would have to look at resident 17's medical records to determine if he had any STM or LTM deficits that would impair his ability to recall the education that was provided. The DON stated that she believed that resident 17's accidental burn was reported to the state, but that the Administrator was responsible for doing that. The DON stated that after resident 17 sustained the burns they provided education to the staff, had a smoker meeting with residents and staff, and showed them resident 17's burned wheelchair. The DON stated that they educated the residents and staff that the oxygen tanks were not allowed outside while smoking. The DON stated that she also provided education to the licensed nurses that a smoking assessment had to be completed with every resident. The DON stated prior to the accident the smoking assessment was only completed for residents that were smokers. The DON stated that she did not have any IDT notes for each residents smoking assessment. The DON stated that the smoking assessment was reviewed with all department heads, and they covered who was safe or not. The DON stated that if the resident was evaluated as safe to independently smoke, they could keep their smoking materials with them. The DON stated that they would discuss with the residents monthly not to give smoking materials or lighters to other residents in the smoke shack. On 2/08/23 at 4:47 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the smoking policy was smokers who needed to be supervised could smoke generally whenever they wanted except after hours, and only in the designated smoking area. The ADM stated that they made sure that residents had cigarettes when they wanted them and any restrictions such as supervised, they had staff availability for them with supervision. The ADM stated that for residents who could not afford cigarettes they provided them. The ADM stated that residents knew the rules about no smoking inside the rooms or inside the building. The ADM stated that if residents could not make those decisions, then they held their cigarettes and supervised them when they smoked. The ADM stated that the nursing staff assessed the residents to determine who was safe to independently smoke and who needed supervision. The ADM stated that at the time of the accident resident 17 did not have in his possession his cigarettes but was able to ambulate. The ADM stated that resident 17 did not have any physician orders for alarms then either. The ADM stated that resident 17 went outside with his oxygen on and bummed a cigarette off another resident. The ADM stated that at the time of the accident resident 17's cigarettes were stored with the nurse. We don't know who he got the cigarette from. The ADM stated that when resident 17 went outside to smoke he stayed right on the landing outside the doors. The ADM stated that if the resident was supervised during smoking, then he was escorted down to the smoke shack. The ADM stated that at the time of the accident resident 17 was not a supervised smoker. The ADM stated that after the accident with resident 17 they had a meeting with all the residents who smoked and reminded them the dangers of sharing cigarettes. The ADM stated that the staff were provided education on the smoking policy after the incident and the plan was to do it during the shift change with reminders. The ADM stated that he did not report the incident to the state agency (SA). The ADM stated that he asked the Assistant Director of Nursing (ADON) if the incident needed to be reported, and the ADON was responsible to document all the details of the incident. The ADM stated that if the incident was not abuse then he delegated it to staff to investigate. The ADM stated that if it was abuse related, he would be the person responsible for reporting it to the SA. The ADM stated that he assumed that the ADON documented it all and reported anything to the state if it needed to be reported. On 2/8/23 at 5:12 PM, an interview was conducted with the ADON. The ADON stated that the nurse who admitted the resident was responsible for filling out a smoking assessment. The ADON stated that the smoking assessment was included in the admission packet paperwork. The ADON stated that all residents, except for one, go outside to smoke in the smoke shack. The ADON stated that they had several residents who used oxygen and smoked. The ADON stated that those residents knew that they were to leave the oxygen at the exit door or in their room while they smoked. The ADON sta [TRUNCATED]

Based on observation, interview, and record review the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies; and regularly review and analyze data, including data collected under the QAPI (Quality Assurance and Performance Improvement) program, and act on available data to make improvements. Specifically, deficient practices identified during the survey included repeat deficiencies in the areas of prevention of accident hazards, physician notification in changes of condition, quality of care related to hospice services, resident's free from unnecessary medications, and maintaining laboratory reports in the resident records. Resident identifiers: 4, 11, 17, 18, 20, 31, 32, 47, 56, 68, 77, 134, 181, and 231. Findings included: 1. Based on observation, interview, and record review it was determined, for 9 out of 41 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident received second degree burns to the face, scapula area, and thigh when his oxygen cannula ignited while smoking a cigarette unsupervised. Additionally, multiple residents who were identified as requiring staff supervision while smoking were observed smoking without staff present, and residents were not assessed for their smoking assistance/supervision needs. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Another resident sustained a skin tear when he was not secured in the transportation van. This example was cited at a harm level. Resident identifiers: 4, 17, 18, 47, 56, 77, 134, 181, and 231. [Cross-refer F689] 2. Based on interview and record review, it was determined, the facility did not immediately consult with the resident's physician when there was need to alter the residents treatment. Specifically, for 1 out of 41 sampled residents, the facility nursing staff did not notify the provider when a resident's blood sugar (BS) was greater than the indicated amount as per the physician order. Resident identifier: 47. [Cross-refer F580] 3. Based on interview and record review it was determined, for 1 out of 41 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices. Specifically, hospice communication notes were not contained within the resident's medical records and staff reported difficulty with communication between the hospice providers. Resident identifier 32. [Cross-refer F684] 4. Based on interview and record review it was determined, for 4 of 41 residents sampled, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, residents' medications were not administered or held per the physician ordered parameters. Resident identifier: 11, 31, 32, and 47. [Cross-refer F757] 5. Based on interview and record review, it was determined, the facility did not file in the resident's clinical record laboratory (lab) reports that were dated and contained the name and address of the testing laboratory. Specifically, for 3 out of 41 sampled residents, a resident that had a UA completed did not have the sensitivity report at the facility or filed in their medical record. In addition, a resident that had a Troponin and Creatine Kinase (CK) ordered for chest pain did not have the report at the facility or filed in their medical record, and a resident that had an influenza nasal swab ordered did not have the report at the facility or filed in their medical record. Resident identifiers: 11, 20, and 68. [Cross-refer F775] It should be noted that deficient practice was identified in the following areas during the facility's recertification survey in 2021: F-582, F-584, F-600, F-610, F-644, F-655, F-656, F-740, F-758, F-842, and F-880. The deficient practices identified, for the above mentioned areas, during the current recertification survey were the same areas of concern identified on the last recertification survey. 38031 On 2/14/23 at 1:39 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the QAPI meeting was held one time a month. The ADM stated that they had agenda items that were discussed every time. The ADM stated that they identified issues that needed to be focused on, or areas that they felt needed improvement. The ADM stated then they would look at any associated documentation, convert it to an action plan for improvement and then assign it to a staff to track and look at performance indicators. The ADM provided examples of falls and infection control that were discussed in QAPI. The ADM stated that all the department heads were present during the meeting to ensure that they covered all topics that may affect resident care. The ADM stated that the medical director attended one time per quarter, but he planned on having him attend the meetings monthly. The ADM stated that they would re-assess any items at the following meeting, and any items that were being tracked would have daily flash meeting discussions. The ADM stated that the daily flash meeting was 30 to 40 minutes long, and all department heads attended the daily flash meetings including human resources and therapy. The ADM stated that any deficiencies identified from survey were put through the QAPI process and they would identify what needed to be reviewed and improved. The ADM stated that the practice moving forward would be to review deficiencies in QAPI the meetings. 33215

Based on record review and interview, it was determined, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1 out of 41 sampled residents, a resident who attempted suicide in the facility was not receiving behavioral health services when there were multiple recommendations for behavioral health services prior to the incident. Resident identifier: 134. Findings included: Resident 134 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include nontraumatic chronic subdural hemorrhage, chronic pulmonary edema, pneumonia unspecified organism, epilepsy, acute and chronic respiratory failure, dementia, other specified peripheral vascular diseases, adult failure to thrive, plantar fascial fibromatosis, muscle weakness, repeated falls, multiple fractures of ribs, right side, subsequent encounter for fracture, dysphagia (oropharyngeal phase), vitamin B deficiency, vitamin D deficiency, alcohol dependence in remission, post-traumatic stress disorder (PTSD), major depressive disorder, anxiety disorder, suicidal ideations, and obesity. A record review was conducted on 2/7/23. The most recent quarterly Minimum Data Set assessment completed on 12/7/22 revealed the following; a. Resident 134 answered Yes to Feeling down, depressed, or homeless for 2-6 days. b. Resident 134 answered Yes to Feeling tired or having little energy for 7-11 day. c. Resident 134 answered Yes to Poor appetite or overeating for 2-6 days. d. Resident 134 answered Yes to Trouble concentrating on things, such as reading the newspaper or watching television for 7-11 days. e. Resident 134 answered Yes to Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual for 7-11 days. On 1/18/23 at 2:46 PM, a Nurses Note stated CNA [Certified Nursing Assistant] this am to check Res [resident] B/P [blood pressure], Res tongue protruding making gurgling noises, no nasal cannula in place, Res pointed at neck and found his 02 [oxygen] tubing wrapped around his neck several times knotted in different areas, nurse in with scissors cut cannula off. Res vitals taken 02 put in place. [Ambulance] called to ambulate to hospital for medical and psych [psychological] eval [evaluation]. Prior to resident 134's suicide attempt on 1/18/23, a progress note from 1/3/23 at 4:45 PM, stated .Resident is a vet [veteran] and has reported suffering multiple traumatic events during time of service . Per LEVEL 2 [preadmission screening resident review]: resident would benefit from SRS [specialized rehabilitation services] program. Resident 134's Preadmission Screening Resident Review (PASRR) Level II completed on 10/12/22, was reviewed. The PASRR's recommendation for specialized services for mental illness treatment stated, Pt [patient] would benefit from supportive therapy through SRS or other service while at SNF [Skilled nursing facility]. Resident 134's Care Plan dated 11/3/22, prior to being hospitalized due to a suicide attempt, included the following; a. The Focus area stated, PASRR Level 2 of MDD [major depressive disorder] recurrent, and PTSD chronic was initiated 11/5/22. b. The Goal stated, Resident's emotional needs will be met through the review date. was initiated 11/6/22. c. The Interventions/Tasks stated, Recommendations per Level 2 PASRR: Recommendations for services to be provided by the Nursing Facility: PT [physical therapy], OT [occupational therapy], medication management, assistance with ADLS [activities of daily living], would care and, Recommendation for Specialized Services for mental illness treatment: Pt would benefit from supportive therapy through SRS or other services while at SNF was initiated 11/5/22. [Note: The recommendations for behavioral health services were found in resident 134's progress notes, PASRR II, and in the care plan prior to resident 134's suicide attempt.] On 2/8/23 at 11:13 AM, an interview with the Resident Advocate (RA) was conducted. The RA reported that the previous social worker, who worked from July 2022 to January 2023, did not refer any residents to any behavioral health services. The RA reported that resident 134 was not receiving behavioral health services while at the facility prior to the resident attempting suicide. The RA reported that resident 134 was supposed to be referred and evaluated for behavioral health services. The RA stated that unfortunately resident 134 was sent to the hospital due to a suicide attempt before the facility was able to set the resident up with behavioral health services. The RA stated that resident 134 had since returned and the facility started 15-minute checks for the resident. The RA stated that resident 134 was moved to a room directly across from the nurses station. The RA stated since resident 134 had returned from the hospital, she was working on resident 134's behavioral health services referral. On 2/9/23 at 9:14 AM, a follow up interview was conducted with the RA. The RA stated that she had been making referrals for behavioral health services for residents since the previous social worker stopped working at the facility. The RA stated that she was visiting with residents daily, made referrals to behavioral health services as needed, and met with staff to go over any behavioral concerns of residents to provide the necessary care. On 2/9/23 at 2:20 PM, an interview with resident 134 was attempted. Resident 134 declined the interview. On 2/13/23 at 10:01 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that she believed that resident 134 had been seen by behavioral services prior to his suicide attempt on 1/18/22. The DON stated that she would provide a copy of resident 134's referral with the date. The DON stated that the PASRR II recommendations should have gone to the social worker and all of the recommendations should have happened. A document titled Specialized Rehabilitation Services (SRS) Referral Packet for resident 134 was reviewed. The date of the referral for behavioral health services was 2/9/23, which was after resident 134 returned from the hospital due to his suicide attempt.

Based on observation, interview and medical record review, it was determined for 3 of 43 sample residents, that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, one resident was transferred via use of a sliding board by a CNA (Certified Nursing Assistant) who had received no training for the transfer. In addition, observations were made of a laundry chute that was unlocked and unattended, two chemicals were found in an unlocked and unattended housekeeping closet and multiple oxygen tanks were found to be stored near an exit doorway as well as empty and full oxygen tanks being stored in the same closet. Resident identifiers: 7, 56 and 37. Findings include: HARM 1. Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 at 4:30 PM, an interview was conducted with resident 37. Resident 37 stated that she had had a fall from an inappropriate transfer which resulted in a right tibia/fibula fracture. On 4/26/18 resident 37's medical record was reviewed. Nursing progress notes revealed the following entries: a. 1/24/18 at 15:04 (3:04 PM), CNA (Certified Nursing Assistant) notified nurse for assistance with resident on floor. CNA states that during transfer when patient was on the bed that she was not quite far enough on the bed when slide board was removed and pt (patient) slid from bed to floor and landed on her buttocks and did not hit her head. Vitals taken and within normal limits. Pt assess (sic) before transfer and pt is able to bend knees and toes have good ROM (range of motion) with a minor increase in pain. Pt is also able to move bottom half of legs with some difficulty but normal ROM for patient. Pt transferred back into bed and skin check done with a little patch of [DIAGNOSES REDACTED] to knee and no other injuries noted. ROM continues to be normal for patient when assessed in bed. Patient continues to c/o (complain of) minor increase pain to right lower leg, [MEDICATION NAME] 5-325 mg (milligrams) administered and tolerated well. MD notified of fall and [DIAGNOSES REDACTED] to knee and increase in pain. No new orders at this time. ADON (Assistant Director of Nursing) notified. Resident is comfortable in bed at this time and will continue to monitor. b. 1/24/18 at 17:56 (5:56 PM), (Recorded as Late Entry on 1/26/18 at 23:59 (11:59 PM), Continue to check on patient often, Pt states pain medications are helpful for right leg pain. No changes to ROM or pain noted at this time. Pt appears comfortable in bed at this time and eating dinner. Will continue to monitor. c. 1/25/18 at 5:50 AM, Alert and oriented x (times) 3. Res reports ongoing UTI (urinary tract infection) symptoms. F/U (follow up) UA (urinalysis) at lab at this time. Midline remains in place at RUE (right upper extremity) flush without difficulty. One person ext. (extensive) ass (assistance) with brief changes. No s/s (signs/symptoms) injuries r/t (related to) recent fall. No increased pain r/t fall. VS (vital signs) = WNL (within normal limits). No changes noted. d. 1/25/18 at 1800 (6:00 PM), Resident is resting in bed and denies pain r/t the witness (sic) fall on 01/24/18, no skin issue noted or reported during this shift, IV (intravenous) Tigecycline administered per ordered (sic), the IV line is in place and with IV dressing intact on right arm, flushed with NS (normal saline) without problems, VS taken with (temperature) 97.3, (pulse) 67, (respirations) 16, (blood pressure) 111/66 and O2 (oxygen) sats (saturations) 92%, fluids applied and encouraged. e. 1/26/18 at 5:38 AM, IV ABX (antibiotic) infusion and flushes without difficulty. Afebrile, alert and oriented x 2 this shift. C/O pain at Rt (right) leg r/t recent fall. Reports about a 5/10 because they just changed me. No falls on this shift. No OOB (out of bed) on this shift. All PO (by mouth) meds as ordered and prn (as needed) pain medications provided and effective for pain res (sic). Res checked frequently throughout shift. Resting quietly most of Noc (night). WCTM (Will continue to monitor). f. 1/26/18 at 18:51 (6:51 PM), Resident c/o'd (complained of) increasing pain to right knee during giving nursing care, the right knee is bigger than left. It (sic) reported to (Physician 1). New order from (Physician 1) to X-ray to right knee and hip. X-ray was called in. Resident continues on IV ABX to treat UTI, no s/s of ASE (adverse side effects) noted, VS taken with (sic) T (temperature) 97.6, P (pulse) 63, R (respirations) 16, BP (blood pressure) 105/59 and O2 sats 91% on O2 3L (liters) via NC (nasal cannula). IV line is in place and with IV dressing intact to right arm, and flushed with NS without problems. g. 1/26/18 at 19:15 (7:15 PM), Received report from day nurse. Portable x-ray in rout (sic) for x-ray of Rt. hip and LOE (lower extremity). Res (Resident) is alert and oriented x 2. Res reports no pain at this time unless moved. Res informed of coming procedure. h. 1/26/18 at 22:49 (10:49 PM), X-ray results received per fax. Poss. (possible) Fx. (fracture) at RLE (right lower extremity). (Physician 1) called T.O. (telephone order) send res to E.R. (emergency room ) of choice for F/U. Daughter called, no answer, message left. Res is alert and oriented x 2. Res informed of report and trans (transport) to hospital. Res cant (sic) remember which hosp she goes to. Res reports little pain at this time. PRN pain medication given r/t transport and repositioning. Daughter just returned call and stated (Name of Hospital) is fine. i. 1/27/18 at 00:15 (12:15 AM), 2330 (11:30 PM) (Name of Ambulance) here to trans res to (Name of Hospital) for X-rays to Rt lower leg. All HS (hour of sleep) and prn pain medication provided prior to trans. j. 1/27/18 at 3:14 AM, 0300 (3:00 AM) Res returned from hospital per (Name of Ambulance). Fx confirmed at RLE. F/U appt (appointment) to be made with (Physician 2) MD. Phone (phone withdrawn) ASAP (as soon as possible). Paperwork from Hospital states this Fx is non-operative. Res is to be non-wt (weight) bearing and leg should be protected during transfers. Res is alert and oriented. Res does not want a PRN pain pill. She states she just wants to go to sleep. ABX infusing at this time. Flushed without difficulty . An X-Ray report dated 1/26/18 at 19:27 (7:27 PM) revealed that Bones: Two views were obtained with limited positioning. There is a nearly [MEDICATION NAME] oriented [MEDICAL CONDITION] right tibial metaphysis without any obvious displacement on this AP (anterior-posterior) radiograph. There is also a [MEDICATION NAME] oriented adjacent acute [MEDICAL CONDITION] right fibula but this appears to be associated with an area of old healed fracture as well. There is an old healed [MEDICAL CONDITION] fibular diaphysis .Impression: Acute nondisplaced fractures of the proximal right tibia and fibula although radiographic evaluation is limited . A facility Event Report dated 1/24/18 at 14:44 (2:44 PM) revealed that the investigation of the fall was completed on 1/25/18 and closed on 1/31/18. The Event Report revealed the following: Fall Summary: Intercepted fall (resident eased to the floor). Location of Fall: Resident Room. Shift when Occurred: Day. Activity during or just prior to fall: Transfer assisted by staff. Was fall witnessed: Yes By Whom: (CNA 1). Does resident exhibit or complain of pain related to the fall? If so, describe location. Yes, location right lower leg. On a scale of 0-10, how does resident rate intensity of pain if able or indicate based on observation. 5-6: Moderate Pain Note any injury to the head, extremities, or trunk. No injury noted. Does the resident exhibit or complain of the following: Weakness. Range of Motion: ROM X 4 without pain/limitations. Positioning of extremities: Rotation/Deformity/Shortening of Right Lower Extremity. Level of Consciousness: Alert wakefulness - Perceives the environment clearly and responds appropriately to stimuli . Speech: Clear - Distinct, intelligible words . Last toileted: 1400 (2:00 PM). Resident continence status at time of fall: Wet . Did resident complain of, experience or be observed with any of the following prior to/at time of fall: Lost strength/appeared to get weak . Were restraints/devices in use at the time of the fall: Yes - slide board . IDT Notes: Resident status prior to event (assessment): During transfer using sliding board, patient slid on the floor. No injury noted at that time. Risk Factors: MS ([MEDICAL CONDITION]); [MEDICAL CONDITIONS]; [MEDICAL CONDITION]; history of venous [MEDICAL CONDITION] and embollsm (sic); TIA ([MEDICAL CONDITION]); CKD ([MEDICAL CONDITION]); urine retention; [MEDICAL CONDITIONS]; OSA ([MEDICAL CONDITION]); [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION];[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease); hx (history) of recurrent UTIs (urinary tract infections). Use of sliding board per order. Preventive measures prior to even: sliding board use as per order. Care plan risk factors and interventions: The following areas reviewed: progress notes; orders; care plans . Resident/Staff Education: Root Cause: CNA removed sliding board thinking patient is sitting at the edge of the bed New Interventions Implemented: RP (unknown) MD informed; ROM and skin check assessment; CNA to have 1:1 with PT (physical therapy)/OT (occupational therapy) to review transfers using sliding beard (sic), care plan update. The Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 37 required an extensive 2 person assistance with transfers. The ADL Care Plan dated 7/11/16 for resident 37, revealed the following: ADL Functional/Rehabilitation Potential Impaired mobility, generalized weakness and chronic pain with ROM impairments to BLE (bilateral lower extremities). Requires extensive assistance x 1-2+ staff for transfers, bed mobility. The Goal on the ADL Care Plan revealed that (Resident 37) will receive the assistance she needs to complete all ADL's and preferred routines Q (every) shift and as needed or requested. The Approaches included, Provide extensive assist x 1-2 for bed mobility, transfers, toileting, dressing, bathing and locomotion on/off unit (NOTE: The MDS Assessment and the care plan documented a discrepancy between a two person extensive assistance by facility staff and 1-2+ person extensive assistance by facility staff.) A New Employee Orientation Checklist dated 1/15/18 for CNA 1 revealed that CNA 1 had been oriented regarding using gait belts for transferring residents safely and the proper way to use mechanical lifts such as a hoyer lift and sit to stand lift. No documentation could be located in the employee file to show that CNA 1 had been trained to safely use a sliding board for transfers. On 4/26/18, a written statement by CNA 1 was provided by the facility DON. The written statement revealed, Nurse needed (Resident 37) into bed, I was notified she was a 1 person transfer on board. We fixed her shirt for a transfer into bed, she wanted to rest. I fixed her wheelchair to (sic) close to her bed and place (sic) transfer board under her leg and on her bed. Transferred (sic) with barrer (sic) weight 100 %. She tried to help me tranfer (sic) her but got to (sic) weak, she was already on the board between her wheelchair and bed, we tried (sic) to transfer again from same position but slid forward onto my weight and slid off board. Called for help while she was barring her weight on me and no one came. No one came to help, after the fall, she slowly slid on to floor. The Inservice Training/Seminar Report regarding Slide Board Transfer Review that accompanied CNA 1's written statement was dated 1/28/18, four days after resident 37's fall from the sliding board transfer. On 4/26/18, a form that was not dated was provided by the TD for safety measures for resident 37 revealed the following: a. Precautions: falls, skin integrity b. Assistive Devices: FWW (Front Wheeled Walker), slide board, power w/c (wheelchair). c. Transfers: Ext (extensive) A (assistance) x 1 person using FWW or slide board. d. Comments: Sometimes (Resident 37) is having a weaker day than normal. She will let you know when she wants to use the slide board, instead of the FWW. On 4/26/18 at 1:00 PM, an interview was conducted with the TD. The TD stated that the undated form was some training that was provided to CNA 1 after resident 37's fall. No documentation could be located in the medical record to show that CNA 1 had been trained regarding safe practices when using a sliding board for transfers. On 4/26/18 at 1:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she heard a loud thud the day of resident 37's fall and that CNA 1 started yelling. LPN 1 stated that she went right into the room and assessed resident 37 for injuries. LPN 1 stated that the sliding board had not been placed correctly onto the bed and subsequently had become loose from the bed. LPN 1 stated that resident 37 was not on the bed far enough and started to fall and that CNA 1 lowered her to the floor. LPN 1 stated that her assessment for injuries consisted of placing her hand on resident 37's hip and then bending her right leg up and down at the knee, to see if she could feel any popping out of the hip. LPN 1 stated that she was able to know if there was a problem with her hip if there was popping out. LPN 1 stated that resident 37 was picked up off of the floor to a standing position and assisted back to bed. LPN 1 stated that the CNAs were aware of the transfer needs by resident 37 because they were in a binder at the nursing station. (NOTE: The transfer needs available in the binder were the current needs for resident 37.) LPN 1 stated that the previous paperwork for resident 37's needs had been shredded. On 4/26/18 at 2:00 PM, an interview was conducted with the Therapy Director (TD). The TD stated that therapy would change out the paperwork in the CNA binders at the nursing stations and that the paperwork was there to inform the CNA staff of the transfer needs for the residents. The TD stated that he no longer had a copy of the assistance that was required for resident 37 prior to resident 37's fall on 1/24/18. The TD provided physical therapy notes dated 12/20/18 which revealed a short term goal for resident 37 that Pt will perform sliding board transfer bed<> w/c (wheelchair) safely w (with)/CNAs and therapy. The target date for the goal was 1/16/18. The TD stated that there had not been any training provided to the CNA staff regarding sliding board transfers but that a lot of the CNAs in the facility have been here for [AGE] years and know how to do sliding board transfers. On 4/26/18 at 2:35 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 confirmed that there was paperwork that detailed the resident's needs for transfers and that the had been kept in a binder at each nursing station. RN 1 stated that all the paperwork was updated as the resident's needs changed and confirmed that the previous paperwork for resident 37's transfer needs in (MONTH) (YEAR) had been shredded. RN 1 stated that because the needs of the residents change so often, that the old paperwork was no longer needed. On 4/26/18 at 3:50 PM, an interview was conducted with the facility MDS Coordinator. The facility MDS Coordinator stated that she obtained her information from documentation from the CNA staff as well as the nursing staff to complete the MDS section G for Functional Status. The facility MDS Coordinator stated that the slide board transfer training had not been provided to the CNA staff and that the CNA staff should never have been attempting to transfer resident 37 with the slide board. The facility MDS Coordinator stated that the slide board transfer training had only been provided to the RNA (Restorative Nursing Assistant) staff. The facility MDS Coordinator confirmed that the staff member that had attempted to transfer resident 37 just prior to the fall on 1/24/18 was a CNA and that she should never have attempted the transfer with resident 37. On 4/26/18 at 4:45 PM, an interview was conducted with Resident 37. Resident 37 stated that she remembered the fall on 1/24/18. Resident 37 stated that the sliding board had not been properly placed on the bed and that when it became loose, CNA 1 pulled the sliding board out from the bed and she fell on her knee. Resident 37 stated that she had been unable to stand on her leg when the nursing staff helped her off the floor because she had severe pain in her right leg after the fall. Potential for Harm 2. Resident 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/18 resident 56's medical record was reviewed. A History and Physical (H&P) dated 12/13/18 at 1:04 PM revealed that resident 56 was admitted with altered mental status and hepatic [MEDICAL CONDITION] which was treated with [MEDICATION NAME]. Nursing progress notes revealed the following episodes of confusion and altered mental status: a) 12/19/17 at 12:47 AM, resident had critically high serum ammonia level of 140. b) 12/20/17 at 9:17 AM, staff reported that res (resident) refused breakfast this am, nurse went in to check Res and he reports that he didn't refuse breakfast .when nurse returned to the room .res yelled what after she called his name, he states that nurse was bothering him .nurse tried to recheck his BP (blood pressure) after first check was 85/50 .and he refused and started saying to 'go away.' c) 12/20/17 at 10:15 AM, (resident 56) is more confused and lethargic today d) 12/20/17 at 10:23 AM, (resident 56) couldn't recall talking to MD before nurse returned to the room. e) 12/24/17 at 1:07 PM, Resident was found standing next to the toilet .staring at the wall. facial twitching noted. Resident responded inappropriately to every other question with WHAT DO YOU WANT?! slight bilateral tremors noted BUE (bilateral upper extremities) .Nurse assisted resident to his bed requiring 1 person extensive assist f) 12/24/17 at 6:27 PM, Resident was found urinating on heating vents .when asked what he was doing residents only response was WHAT! Nurse attempted to move patient away from the area, resident began swinging his arms .Nurse assisted resident back to bed .requiring 1 person extensive assist .Due to residents cognition needs were anticipated, attempted to change his soiled clothes the resident swung his arm hitting CNA on her ribs .Resident alert and oriented to self. when asked why he hit the CNA his only response was WHAT! pupils were dilated, exhibited facial ticks, BUE involuntary tremors, Unable to follow simple commands . g) 12/28/17 at 10:14 AM, (resident) requires supervision for transfers, bed mobility, toileting and meals. h) 1/1/18 at 11:01 PM, Resident is acting exceedingly confused tonight .(resident) was repeatedly trying to get out one of the rear doors, entering the wrong door codes several times in a row, and unable to enter the appropriate code even when another resident related the proper code to him. Resident was unable to verbalize why he wanted to go outside .Resident was repeating back bits and pieces of Nurse's speech. Displayed short bursts of angry behavior, followed by laughter .Also noted rocks and mud in water, in a cup in his bathroom. Asked resident why he had that, and he stated that it was so that he could 'check up on the staff.' i) 1/1/18 at 11:14 PM, Ammonia drawn with some difficulty. Nurse and CNA escorted Lab Tech to Resident's room, given the concern about violent behavior. Resident began yelling at lab tech, but then agreed to allow draw if brought a cup of juice. Nurse quickly obtained orange juice per his request, and resident agreed to allow draw. Juice was handed to CNA Resident stated The juice is TOO CLOSE!!! and CNA held the juice farther back. Then he stated, I can't see it now! and orange juice was brought closer. At which point, (resident) grabbed juice from CNA's hand, nearly spilling it, before quickly drinking it down. CNA instructed to perform frequent checks on Residents. Nurse plans to do so as well. j) 1/2/18 at 8:50 AM, (resident) responds to questions with what .visible tremors in right hand noted. Res does not answers (sic) to questions appropriately, hen (sic) .he move his hand toward nurse as he attempted to hit her . k) 1/2/18 at 1:27 PM, Res continues to have generized (sic) tremors, not following commands, responds to voice but only answers what to questions. Res was found standing in front of the sink, holding on to top of mirror. two person extensive assist needed to get him back to his bed, when nurse attempted to give his med, he continued to move his head from left to right and then lay back down . l) 1/3/18 at 1:01 AM, Resident continues to display confused behavior .confused about time .Resident ambulated down the hall and defecated on the carpet .Now grunting and grimacing as if he is in pain, but states he does not want any medications. This is unusual behavior for this resident .CNA and Nurse making frequent and regular checks upon resident. m) 1/3/18 at 9:36 AM, Res is alert and awake to name only. when ask (sic) about situation, place or time, res stays quiet and keeps eating .visible tremors noted to bil (bilateral) hands, unsteady gait when ambulating .res has been seen getting out of bed on his own at time, staff immediately in room to help d/t fall risk. Res required two person extensive assist for transfers . n) 1/6/18 at 12:20 AM, monitoring continues r/t recent episodes of tremors/lethargy/change in mental status . o) 2/1/18 at 2:40 AM, (resident) stated he had fallen in his room .(he) stated he was getting up from chair and went down onto his bottom. asked how he went down, pt stated that his feet went out from under him and he landed on his bottom . p) 2/1/18 at 9:55 AM, (resident) appears lethargic, oriented to name only, will answer silvers when asked for the year .visible hand tremors noted .res requires supervision for transfers, bed mobility and toileting .mental status has changed from baseline . q) 2/2/18 an IDT note investigating the fall on 2/1 at 2:40 AM revealed (the resident) states his legs were weak and did not realize it until he stood up frequent visual check by LNs and CNAs due to patient intermittent confusion . r) 2/3/18 at 3:07 AM, entered room to find pt standing at door to BR (bathroom or bedroom) in a puddle of urine, noted confusion w/ pt, pt is responsive verbal/tactile stimuli, doesn't answer questions . s) 2/3/18 at 6:28 AM, (resident) continued to not answer questions . t) 2/3/18 at 6:46 PM, .patient was sitting on toilet he has eyes closed, he will answer questions when shaken but gets irritated when you shake him to answer questions . u) 2/26/18 at 9:46 AM, pt with twitching movement to bil (bilateral) hands and legs, responds to voice but unable to follow commands properly v) 2/26/18 at 6:08 PM, (resident) requires extensive assist from staff for ADL's . w) 2/27/18 at 8:34 AM, (resident) reports that yesterday 'I was out of it' x) 3/14/18 at 10:15 AM, pt appears oriented with slow mentation . y) 3/14/18 at 7:00 PM, this nurse noted that pt appeared to (sic) drowsy/sedated z) 3/14/18 at 8:56 PM, pt appears to continue w/ drowsiness/sedated behavior .told pt we were concerned and that he appeared to be behaving differently . aa) 3/18/18 at 10:31 AM, pt with slight tremors, standing in front of toilet, does note (sic) follow commands, just states to leave him alone . bb) 3/19/18 at 1:02 AM, Resident .with variable sense of time, but confusion and forgetfulness . cc) 3/23/18 at 5:22 AM, res on floor .when asked what happened, res replied what. When asked res's (sic) name, res replied what. res continued to reply what to all questions asked dd) 3/23/18 at 5:56 AM, Resident continues to appear to be drowsy/lethargic, wont grasp hands when prompted or push w/ feet when prompted . ee) 3/23/18 at 8:00 AM, Resident remained lethargic in bed .resident is incontinent of bladder, currently wearing brief Resident is unable to respond to simple questions. His only response to any question is 'What' . ff) 3/23/18 at 12:00 PM, Resident is still lethargic and unable to appropriately respond to simple questions. resident remains incontinent of bladder .needs are anticipated by staff due to cognition . gg) 3/23/18 at 7:01 PM, (resident) .does not elaborate .nor does he make eye contact Resident is exhausted and has stayed in bed the whole shift .Resident requires 1 person extensive assist with transfers, toileting, bed mobility and hygiene. hh) 3/23/18 at 10:08 PM, res appears to continue w/ drowsiness. res has been up and ambulating w/ assist to BR and back to bed. res is .providing some verbal response to questions like 'what', 'yeah' . ii) 3/30/18 at 8:16 PM, resident does not remember and is unaware of his lethargic state .Resident stated he needed to go out to buy a phone, make a stop to (Grocery Store) to buy some snacks. Resident was gone for 5 hours. leaving at 1130 and returning at 5:15 PM. Resident left again around 5:45 stated he was going to (Name of Restaurant) to get a malt shake and he has not returned . 3/30/18 at 9:13 PM, res returned to facility at approx (approximately) 2030 (8:30 PM) w/ groceries in hand . jj) 3/29/18 at 3:31 PM, Resident is lethargic and unable to follow simple instructions, When asked how he feels resident will only reply 'WHAT?!' Resident unable to swallow pills and refused to eat due to his condition. Involuntary bilateral tremors noted to BUE, Resident is B&B incontinent . kk) 4/7/18 at 12:38 PM, Pt had good sleep from 1100 am till now . ll) 4/7/18 at 4:56 PM, Pt slept most afternoon (sic) . mm) 4/7/18 at 6:00 PM, Pt was very lethargic .aid (sic) down in roommate's bed around 1700 PM. 3 staff tried to persuade Pt to go back to his own bed. Pt agreed to go back to his own bed, sat up, but could not stand up by self, refused to be touched, then refused to go back to his own bed. Pt sat in bed with eyes closed, high fall risk. Nearly half an hours (sic), staffs (sic) held Pt's arms, Pt stepped to his bed nn) 4/8/18 at 11:13 AM, Resident .had episode of lethargic (sic) and hospice came in and assessed resident. oo) 4/13/18 at 8:52 AM, pt is laying perpendicular to the bed, attempting to stand it (sic) up on his own, answers 'what' to every question, visible tremors, unable to take meds at this time d/t risk of aspiration. pt was assisted up and lay in bed properly . pp) 4/13/18 at 1:00 PM, .pt continues be (sic) lethargic, tremors, unsteady gait when ambulates. pt required two person assist to go back to bed after attempting to get up to go to the bathroom . qq) 4/19/18 at 2:28 PM, Pt has been lethargic today Pt urinated on the floor and attempted to redirect patient .Hospice states he has been having more episodes similar to this lately . rr) 4/20/18 at 8:46 AM, pt resting in bed .unable to follow commands .does not answer questions accordingly meds were held this am ss) 4/23/18 at 10:59 AM, He was comatose last Thursday and Friday . tt) 4/24/18 at 8:54 AM, Res. noted to have ST (slight tremor) to posterior left hand .Res. reports he obtained it when he passed out. Res. dose (sic) not recall when he 'passed out.' . A review of resident 56's Medication Administration Record [REDACTED]. The resident did not take medications on the following dates: a) 2/3 Not administered: due to condition. Comment: not able to wake up enough to swallow meds. b) 3/23 Not administered: due to condition. Comment: Resident lethargic unable to take meds. Notified hospice., c) 3/24 Not administered: Refused. Comment: Pt very sleepy. Hospice notified., d) 3/29 Not Administered: Due to condition. Comment: Lethargic and unable to swallow., e) 4/1 Not Administered: Due to condition. f) 4/13 Not administered: Other. Comment: Pt unable to swallow. g) 4/19, Not administered: Due to condition. Comment: resident is very drowsy; meds held. h) 4/20 Not administered: Other. Comment: clinical decision. On 4/25/18, a log of when resident 56 left the facility was obtained. The following entries were identified on the log: a) Sign out: 12/14/17 at 11:00 AM. Return: 2:20 PM b) Sign out: 12/18/17 at 2:27 PM. No return time recorded c) Sign out: 12/18/17 at 2:45 PM. Return: 4:10 PM d) Sign out: 12/30/17 at 10:35 AM. Return: 1:00 PM e) Sign out: 12/31/17 at 11:55 AM. Return: 2:15 PM f) Sign out: 1/5/18 at 12:55 PM. Return: 7:50 PM g) Sign out: 1/6/18 at 12:30 PM. Return: 4:15 PM h) Sign out: 1/8/18 at 4:10 PM. Return: 7:30 PM i) Sign out: 1/10/18 at 11:15 AM. No return time recorded j) Sign out: 1/10/18 at 1:45 PM. Return: 7:40 PM k) Sign out: 1/11/18 at 11:10 AM. Return: 6:40 PM l) Sign out: 1/12/18 at 1:15 PM. Return: 3:30 PM m) Sign out: 1/14/18 at 12:15 PM. Return: 5:55 PM n) Sign out: 1/16/18 at 12:50 PM. No return time recorded o) Sign out: 1/18/18 at 7:50 PM. No return time recorded p) Sign out: 1/19/18 at 3:20 PM. No return time recorded q) Sign out: 1/24/18 at 5:00 PM. No return time recorded r) Sign out: 1/28/18 at 12:30 PM. Return: 2:15 PM s) Sign out: 1/31/18 with no sign out or return time recorded t) Sign out: 2/11/18 at 6:15 PM. Return: 8:50 PM u) Sign out: 2/13/18 at 2:45 PM. Return: 8:20 PM v) Sign out: 3/1/18 with no sign out or return time recorded w) Sign out: 3/30/18 with no sign out or return time recorded x) Sign out: 3/30/18 with no sign out or return time recorded y) Sign out: 4/3/18 at 9:00 AM. No return time recorded z) Sign out: 4/5/18 at 11:45 AM. No return time recorded aa) Sign out: 4/5/18 at 7:40 PM. No return time recorded bb) Sign out: 4/9/18 at 9:30 AM. No return time recorded cc) Sign out: 4/11/18 at 1:40 PM. Return: 2:14 PM dd) Sign out: 4/16/18 with no sign out or return time recorded ee) Sign out: 4/22/18 at 2:30 PM. No return time recorded ff) Sign out: 4/23/18 at 2:00 PM. No return time recorded While reviewing the progress notes, it was revealed that the resident had left the facility without documenting when he left or returned on the sign out log. The following occurrences were identified in the progress notes: a) 3/21/18 at 7:25 PM, Resident left LOA (leave of absence) this morning stated he was going to (Church Property). last Pain medication was given around 8 am. resident left facility at 1045. Resident returned at 1530, stated he had a lot of fun. resident laughed and joked and stated he was in a lot of pain 10/10. administered prn pain medication granting positive results to the resident . b) 3/27/18 at 6:00 PM, pt arrived to facility after being gone a couple hours. pt stated to nurse that he fell when he was in a department store. described i (TRUNCATED)

Based on observation, interview, and record review it was determined, for 2 of 45 sample residents, that the facility failed to consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when the resident experienced a significant change in the resident's physical, mental, or psychosocial status. (Residents 88 and 149). The deficient practice identified for resident 149 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for resident 88 was found to have occurred at a potential for more than minimal harm and will not be included in the Immediate Jeopardy. Resident 149 experienced a significant change in condition on the morning of [DATE]. Once the resident was found to have a significant change in condition, facility staff did not notify the resident's family for approximately four and a half hours. Additionally, facility staff did not contact the resident's physician or covering nurse practitioner for more than 10 hours after the significant change in condition. Resident 149's unresponsive status continued, without improvement, until he died , approximately 30 hours following his first noted change in condition. Resident 88 began experiencing rectal bleeding on [DATE]. Facility staff continued to administer a blood thinning medication to resident 88 despite continued rectal bleeding for 24 days. On [DATE], resident 88 was admitted to a local acute care hospital with the [DIAGNOSES REDACTED]. Facility staff assessed the increased rectal bleeding on [DATE] at 5:46 AM yet waited approximately 14 hours before notifying resident 88's family regarding the bleeding and the new physician's orders [REDACTED]. NOTICE: Notice of Immediate Jeopardy was given verbally to the Administrator on [DATE] at 3:30 PM. The Administrator was asked to develop an immediate plan to ensure residents' safety related to monitoring and assessment when residents experience a significant change in condition. PLAN: On [DATE], the Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated [DATE] stated the following: [DATE] State of Utah Department of Public Health 3760 S. Highland Dr., Suite 200 PO Box 3 Salt Lake City, UT ,[DATE] LETTER OF IJ ABATEMENT - F157 & F309 To Whom It May Concern: On [DATE]th at 14:15 p.m. (2:15 PM) Mount Olympus Rehabilitation was put in Immediate Jeopardy status in conjunction with our annual survey and specifically in association to negative outcome findings to F309 and F157. At 17:15 p.m. (5:15 PM) the facility administration team presented a plan of action to correct the Immediate Jeopardy Status. The survey team approved the plan of action. The following presents our facilities good-faith assertion and credible allegation of compliance that we have implemented the aforementioned accepted plan of correction: 1) Facility's Change of Condition policy and procedures have been reviewed for content and accuracy and facility leadership and inter-disciplinary team has affirmed that the Change of Residents Condition or Status policy and Acute Condition Changes protocol achieves and represents the professional standard of nursing care at Mt Olympus. (Attachments 1- 1A) 2) Facility has audited and reviewed all current patients for a potential acute change in mental status within the past 7 days and addressed by the facility. (Attachment 2-audit sheet) 3) Facility has audited the last 72 hours of all patients vital signs. DON (Director of Nursing) has reviewed and confirmed that all 'out of range' vital signs have been assessed for potential change of condition. Any concerns were immediately reported to attending physician by DON for appropriate follow-up. (Attachment-2, audit sheet) 4) Facility has implemented mandatory training for all staff on the new Interact Early Warning Tool Stop and Watch, which the facility will be using as an additional tool to help all staff recognize and report patient changes of condition. (Attachment 4- attendance record) (Attachment 4A- Stop and Watch tool) 5) Facility has in-serviced all current direct care licensed nurses and rehab staff on the new Matrix tool AMDA Know it All - a tool to be used for physician communication and nursing assessment needs. (Attachments 5- in-service attendance record). 6) Direct licensed care giver nurses who were unable to attend training will be trained by a trainer prior to starting shift. 7) Facility has completed retention testing with all on-duty scheduled staff to ensure knowledge base of all provided training. (Attachment 7- Retention Quiz) 8) Facility Executive Director and Director of Nursing Services met with facility Medical Director and Nurse Practitioner on [DATE]th to review best facility communication practice for all patient concerns. (Attachment 8- Provider Communication Practice Protocol) I respectfully certify that the elements in our plan of correction have been fully implemented. I allege that as of [DATE], at 3:00 PM that Immediate Jeopardy has been abated and staff trained on facility practice for recognizing and required notification for any patient change of condition. On [DATE], the surveyors confirmed the abatement of the Immediate Jeopardy situation as of [DATE]. Deficient practice with potential for more than minimal harm remained for the risk of injury. Findings include: Immediate Jeopardy: Resident 149 was admitted to the facility on [DATE] for a respite stay. Resident 149 was admitted with [DIAGNOSES REDACTED]. On [DATE] at 1:50 PM, a surveyor entered resident 149's room and observed that resident 149 was not breathing. The surveyor informed Registered Nurse (RN) 7, who assessed the resident and determined that resident 149 had died . On [DATE], resident 149's medical record was reviewed. Review of the medical record revealed the following Progress Notes entries: a. [DATE] 12:54 PM: Resident was difficult to wake up, nurse apply stimuli to try to wake up the resident with nor (sic) result vitals was taken (sic). Vital B/P (blood pressure) ,[DATE] P (pulse) 117 RR (respiratory rate) 24 O2 (oxygen saturation) 88% RA (room air). Family was contact (sic) and requested to let his (sic) sleep for rest of the day. Family stat (sic) My dad does the same think (sic) ones (sic) in a while. Family request to put oxygen. Oxygen in place showing saturation of 94% on 2L (liters). Nurse will continue monitoring. Resident is in (sic)2L nasal cannula SPO2 (oxygen saturation) 94%. Nurse will continue monitoring, By 12:00 resident had all his med (medication) without any problem. b. [DATE] 12:54 PM: Resident was difficult to wake up, nurse apply stimuli to try to wake up the resident with nor (sic) result vitals was taken (sic). Vital B/P ,[DATE] P 117 RR 24 O2 88% RA. Family was contact (sic) and requested to let his (sic) sleep for rest of the day. Family stat (sic) My dad does the same think (sic) ones (sic) in a while. Family request to put oxygen and not sent to the hospital. Oxygen in place showing saturation of 94% on 2L. Nurse will continue monitoring. Resident is in (sic) 2L nasal cannula SPO2 (oxygen saturation) 94%. Nurse will continue monitoring, By 12:00 resident had all his med (medication) without any problem. Note: The above entry was made into the electronic medical record on [DATE] at 2:51 PM. The entry was made into the medical record after resident 149 had been found expired by the state surveyor. The above statement was only changed with the addition of the family not wanting the resident to be sent to the hospital. Additionally, the nurse that made the edited entry on [DATE] was not scheduled nor was observed to be working on [DATE]. c. [DATE] 16:06 (4:06 PM): Recorded as Late Entry on [DATE] 3:02 PM: around 16:00 son called to reported (sic) they will here tomorrow (sic). Nurse reported his condition haven't change (sic) since last time we talk in the phone (sic). Continue with difficult to arouse with not responded (sic). Nurse asked one more time if his condition get worse we can send to the hospital Son state He does the same think (sic) ones (sic) in a while so let him sleep. Nurse did bedside report to the next nurse. Note: The above entry was made into the electronic medical record on [DATE] at 3:02 PM. The entry was made into the medical record after resident 149 had been found expired by the state surveyor. Additionally, the nurse that made the edited entry on [DATE] was not scheduled nor was observed to be working on [DATE]. d. [DATE] 9:02 AM: Resident continues with being non-responsive at this time, CNA (Certified Nursing Assistant) is in providing cares, oral care instruction provided by this nurse to CNA with sponge and water, unable to administer medications d/t (due to) condition, family is aware of resident's status, blood sugars continue to be elevated this AM, resident respiratory rate is regular, even at 16 RR, skin is warm, pale and dry at this time. Will continue to monitor resident, educated CNA r/t (related to) cares and repositioning. Note: The above entry was made into the electronic medical record on [DATE] at 2:04 PM. The entry was made after resident 149 was found to be expired but timed for before resident 149 had expired. e. [DATE] 13:00 (1:00 PM): RD (Registered Dietitian) delivered lunch meal tray at 1300 hours. Resident was asleep and snoring at time of delivery. Tray left at bedside at this time for availably (sic) upon waking. Nursing team informed. Note: The above entry was made into the electronic medical record on [DATE] at 2:49 PM. The entry was made after resident 149 was found to be expired but timed for before resident 149 had expired. f. [DATE] 13:55 (1:55 PM): This nurse was notified at approx (approximately) 1345 (1:45 PM) that the resident appears to not be breathing at this time. Upon assessment the resident is found to not be breathing, no apical pulse auscultated. Resident is pale and warm to the touch at that time. NP (Nurse Practitioner) notified @ (at) 1349 (1:49 PM). DON (Director of Nursing) notified. Attempts to contact the listed family members at 1350 (1:50 PM) . No answer to either numbers, voice message left to please return my call. g. [DATE] 14:41 (2:41 PM): Spoke with resident's son (name of son) at 1438 (2:38 PM), gave him a recapitation of today's cares and events. He states he will be coming in and will contact the mortuary (name of Mortuary). He states he feels guilty because he promised his dad that he could die at home, and he wanted to come and check him out this AM but didn't get in until late last night. This nurse provided comfort and reassurance to the resident's son. On [DATE] at 2:05 PM, CNA 6 was interviewed. CNA 6 stated that his work assignment for [DATE] and [DATE], during the 6 AM to 2 PM shift, included the provision of cares to resident 149. CNA 6 stated that at breakfast time on [DATE], he went to take resident 149 to breakfast but noted that resident 149 was unresponsive and was breathing fast. CNA 6 stated that he had reported resident 149's condition to the nurse. CNA 6 stated that resident 149 remained unresponsive throughout the day shift on [DATE] and was in the same unresponsive state on [DATE]. Additionally, CNA 6 stated that he had not been in resident 149's room on [DATE] since around 11:30 AM. On [DATE] at 2:05 PM, CNA 4 was interviewed. CNA 4 stated that her work assignment on [DATE] consisted of providing cares to resident 149 for the 6 AM to 2 PM shift. CNA 4 stated that resident 149 had been unresponsive for the entire 6 AM to 2 PM shift. CNA 4 stated that at or around 11:30 AM on [DATE], RN 7 had shown her how to provide oral care to resident 149. CNA 4 stated that she had tried to provide milk to resident 149 around 11:30 AM, but the milk just drooled out of resident 149's mouth. CNA 4 stated that resident 149 would not respond to anything. CNA 4 stated that she had not been in resident 149's room on [DATE] since 11:30 AM. Review of the medical record revealed the following entries: On [DATE] at 8:13 AM, a facility nurse documented resident 149's blood glucose level was 428. According to a physician order [REDACTED]. No documentation could be found to show that the physician was notified regarding resident 149's elevated blood glucose level that had been obtained on [DATE] at 8:13 AM. Review of the facility's [DIAGNOSES REDACTED]/[MEDICAL CONDITION] Protocol revealed that for blood sugars over 400, facility staff were to notify the MD (Medical Doctor). On [DATE] at 9:23 AM, nurse aide computer charting for resident 149 included documentation that no breakfast was taken. On [DATE] at 3:15 PM, a telephone interview was conducted with the facility nurse (Licensed Practical Nurse ((LPN)) 1) that made the [DATE] at 12:54 PM entry. The nurse was asked what information he had provided to resident 149's son on [DATE]. The nurse stated he informed the son that resident 149 was sleepy and difficult to arouse and that the resident had low oxygen levels. According to LPN 1, on [DATE] at 5:39 PM, LPN 1 sent a text message to the facility Nurse Practitioner, who was on-call for resident 149's attending physician. Review of the text message revealed the following: (Resident 149) being very sleepy and being so difficult to wake up him (sic). Nurse scrape his chest with not (sic) respond vital ,[DATE] P 102 RR 22 O2 97 2 L. Family state hi (sic) does that ones (sic) in a while. Any action at this time? The nurse practitioner responded via text by asking for resident 149's code status. The nurse replied via text that the resident's code status was Do Not Resuscitate/Do Not Intubate. The nurse practitioner responded via text to monitor. Note: No information was provided regarding the resident's morning blood glucose level that was greater than 400. Additionally, it should be noted that the text message was sent to the Nurse Practitioner nine and a half hours after the high blood glucose level was obtained and the resident was noted to be unresponsive. On [DATE] at 7:47 PM, a facility nurse documented that resident 149's blood glucose level was 469. No documentation could be found to show that the MD or Nurse Practitioner were notified of the elevated blood glucose level. No documentation could be found in regards to resident 149's continued change of condition for the 6 PM to 6 AM shift on [DATE]. On [DATE] at 3:30 PM, CNA 9 and 10 were interviewed. CNA 9 and CNA 10 stated that they had shared care assignments on [DATE] for the 2:00 PM to 10:00 PM shift. CNA 9 and CNA 10 stated that their assignment on [DATE] included the provision of cares to resident 149. CNA 9 and CNA 10 stated that resident 149 was unresponsive for the entire 2:00 PM to 10:00 PM shift on [DATE]. CNA 9 and CNA 10 both stated that they were not provided any instruction to do anything different for resident 149 except to check on him every two hours to make sure he was still breathing. On [DATE] at 8:57 AM, RN 7 documented resident 149's blood glucose level was 352. It should be noted that RN 7 timed the blood glucose for 8:57 AM, yet the blood glucose results were not entered into the electronic medical record until 3:15 PM, after resident 149 was found expired. On [DATE] at 3:20 PM, RN 7 was interviewed. RN 7 stated that she had not contacted resident 149's family to discuss resident 149's condition. RN 7 stated that the nurse on [DATE] had contacted resident 149's family. On [DATE] at 3:15 PM, the facility Nurse Practitioner (NP) was interviewed via telephone. The NP stated that she had been contacted, via text message, about resident 149 on [DATE]. The NP stated that she was told the family did not want any interventions. The NP stated that she was not contacted again regarding resident 149's continued change in condition. The NP stated that she was not notified regarding resident 149's elevated blood glucose levels. The NP stated that if a resident was unresponsive and had an elevated blood glucose level that she would expect to be notified timely. The NP stated that she considered timely to be within an hour. HARM: Resident 88 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 88's medical record was reviewed. Review of the physician's orders [REDACTED]. According to the 2014 Lippincott's Nursing Drug Guide, Lippincott Williams & Wilkins, pg. 333: [MEDICATION NAME] (dabigatran etexilate) is in the drug class of Direct [MEDICATION NAME] inhibitor with the therapeutic actions of Competitive, direct [MEDICATION NAME] inhibitor; [MEDICATION NAME] enables the conversion of [MEDICATION NAME] to [MEDICATION NAME] fibers during the clotting cascade. Inhibiting this process prevents clot development. The Contraindications and cautions include: Contraindicated with history of serious hypersensitivity reactions to dabigatran; active pathologic bleeding. Adverse effects include gastric hemorrhage and bleeding. Additionally, it was documented under the Nursing Considerations section to Be aware that a reversal agent is not available. Review of the nurses' notes revealed the following entries: a. [DATE] 10:32 (10:32 AM) Reported to this nurse by CNA's (sic) on [DATE] that resident has blood in his stool with skin breakdown to buttock r/t frequent episodes of diarrhea/loose bowel movements. Upon assessment it is noted that resident has red, paste consistency stool in his brief. Sample collected, MD notified, order to send lab for [MEDICAL CONDITIONS] and get a CBC (complete blood count). Barrier cream applied generously to buttock, resident has HX (history) of [MEDICAL CONDITION], is on [MEDICATION NAME] ([MEDICATION NAME]) and daily scheduled [MEDICATION NAME] 2mg (milligrams). VSS (vital signs stable), no S/S (signs or symptoms) of dehydration, mucous membranes are moist, encouraging PO (by mouth) Liquids. b. [DATE] 22:08 (10:08 PM) Notified (name of physician) of CBC Lab results, no new orders at this time. [MEDICAL CONDITION] still pending. Will continue to f/u (follow up). Lab placed in medical records to be scanned into (name of computer program). c. [DATE] 09:49 (9:49 AM) Minimal about (sic) of bleeding with his bowel movements, does not have any blood present unless he is having a bm (bowel movement). Has not went to the bathroom yet but when he does we will collect another stool sample. d. [DATE] 13:21 (1:21 PM) No bleeding or diarrhea reported so far this shift by the aids. Resident is alert and oriented and able to make needs known. e. [DATE] 11:08 (11:08 AM) No reports of bloody diarrhea this shift. Continues with redness/rash to buttock, barrier cream applied as ordered. f. [DATE] 10:41 (10:41 AM) Resident is alert and oriented, medicated for generalized discomfort with positive results. Elevated his right leg and he stated that it felt nice that way. Has a brace present to his right hand. Requires extensive assistance of one with adls (activities of daily living), and bed mobility, transfers didn't occur. Incontinent of b/b (bowel and bladder), only has slight amount of blood noted only when he has a bowel movement, no active bleeding without having a BM. Pleasant and cooperative with care, call light in reach and will continue to monitor. g. [DATE] 14:57 (2:57 PM) Seen at request of staff who note bleeding from rectum with clots. Hx (history) of colon CA (cancer). Had [MEDICAL CONDITION] at one point, taken down. Discussed potential seriousness of this with resident, suggesting he see his surgeon again. He is refusing. Resident alert and capable of making personal decisions. (Note: This entry was made by the facility Nurse Practitioner.) h. [DATE] 05:46 (5:46 AM) (resident 88) having increased blood in stool and increased diarrhea. MD notified and order for STAT (immediate) CBC and stool sample for [MEDICAL CONDITION]. Lab req filled out, order put in (computer program), and lab company contacted. Resident informed about the need for CBC and stool sample. i. [DATE] 10:38 (10:38 AM) Stool sample collected and Lab called for stat. The lab tech said they don't pickup stat[DIAGNOSES REDACTED] sample, but they will pick it up today. Resident stool was mostly bright red blood. (Name of physician) notified. j. [DATE] 14:45 (2:45 PM) Call place to resident wife (name of wife) and his sister (name of sister), no one answer, VM (voice message) left to call the facility for update about stat labs and loose stools. k. [DATE] 15:05 (3:05 PM) Resident sister(name of sister) returned call, and writer updated her about stat labs, loose stools, bright red blood in stool. l. [DATE] 16:30 (4:30 PM) (name of Doctor) notified of CBC report, she said to send resident the ER (emergency room ) r/t Hct (Hematocrit) 26. 8, Hgb (hemoglobin) 8.7 it is a big drop from previous lab per (name of Doctor). (Name of ambulance company) ambulance called, resident sister called and notified, and resident notified of hospital transfer r/t lab reports. DON notified. Note: Facility staff identified the increased blood in resident 88's stool at 5:46 AM on [DATE], yet waited approximately 14 hours before contacting resident 88's family regarding the change of condition. Review of resident 88's laboratory reports revealed the following: a. On [DATE] it was documented on the laboratory report that resident 88's Hct was 36.8 L (low). According to the laboratory report the reference range for this lab value was 37.0 - 47.0. Additionally, resident 88's Hgb was documented as being 11.3 L. According to the laboratory report the reference range for this lab value was 12.0 - 16.0 grams per deciliter (gm/dL). b. On [DATE] it was documented on the laboratory report that resident 88's Hct was 26.8 L. According to the laboratory report the reference range for this lab value was 38.7 - 52.5. Additionally, resident 88's Hgb was documented as being 8.7 L. According to the laboratory report the reference range for this lab value was 12.4 - 17.4 gm/dL. Review of the local acute care hospital's Admission History and Physical dated [DATE] revealed Reason for admission: dark bowel movements. Assessment/Plan: (name of resident 88) is a 77 y (year old) M (male) with hx of . who presents with 1 month hx of dark stools . # Concern for GI (gastrointestinal) Bleed: Likely lower GI bleed due to hx of bright red blood per rectum, frank bloody stool at nursing facility. Hb (hemoglobin) dropped from 12 in April to 11 at the end of July, to 9 at time of presentation. Risk factors for bleed include current [MEDICATION NAME] use for [MEDICAL CONDITION] ([MEDICAL CONDITION] ppx ([MEDICATION NAME]), hx of [MEDICAL CONDITION] with concern for new mass. On [DATE], RN 12 was interviewed. RN 12 stated that resident 88 had been experiencing bleeding from his rectum for about a month. RN 12 stated that the facility staff did not report the continual bleeding because it was not getting worse. RN 12 stated that the bleeding was only reported to the MD when it became worse. On [DATE], the facility MD was interviewed via telephone. The MD stated that she was not told on [DATE] that resident 88 was receiving [MEDICATION NAME]. The MD stated that resident 88 should have been taken off the [MEDICATION NAME] with continued rectal bleeding. The MD stated that she would have liked to know that resident 88 was experiencing weeks of rectal bleeding. (Cross refer to F309 and F514)

Based on observation, interview and record review it was determined, for 2 of 45 sample residents, that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident (Residents 88 and 149). The deficient practice identified for resident 149 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for resident 88 was found to have occurred at a Harm level and will not be included in the Immediate Jeopardy. Resident 149 experienced a significant change in condition on the morning of [DATE]. Once the resident was found to have a significant change in condition, facility staff did not notify the resident's family for approximately four and a half hours. Additionally, facility staff did not contact the resident's physician or covering nurse practitioner for more than 10 hours after the significant change in condition. Resident 149's unresponsive status continued, without improvement, until he died , approximately 30 hours following his first noted change in condition. Resident 88 began experiencing rectal bleeding on [DATE]. Facility staff continued to administer a blood thinning medication to resident 88 despite continued rectal bleeding for 24 days. On [DATE], resident 88 was admitted to a local acute care hospital with the [DIAGNOSES REDACTED]. Facility staff assessed the increased rectal bleeding on [DATE] at 5:46 AM yet waited approximately 14 hours before notifying resident 88's family regarding the bleeding and the new physician's orders [REDACTED]. NOTICE: Notice of Immediate Jeopardy was given verbally to the Administrator on [DATE] at 3:30 PM. The Administrator was asked to develop an immediate plan to ensure residents' safety related to monitoring and assessment when residents experience a significant change in condition. PLAN: On [DATE], the Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated [DATE] stated the following: [DATE] State of Utah Department of Public Health 3760 S. Highland Dr., Suite 200 PO Box 3 Salt Lake City, UT ,[DATE] LETTER OF IJ ABATEMENT - F157 & F309 To Whom It May Concern: On [DATE]th at 14:15 p.m. (2:15 PM) Mount Olympus Rehabilitation was put in Immediate Jeopardy status in conjunction with our annual survey and specifically in association to negative outcome findings to F309 and F157. At 17:15 p.m. (5:15 PM) the facility administration team presented a plan of action to correct the Immediate Jeopardy Status. The survey team approved the plan of action. The following presents our facilities good-faith assertion and credible allegation of compliance that we have implemented the aforementioned accepted plan of correction: 1) Facility's Change of Condition policy and procedures have been reviewed for content and accuracy and facility leadership and inter-disciplinary team has affirmed that the Change of Residents Condition or Status policy and Acute Condition Changes protocol achieves and represents the professional standard of nursing care at Mt Olympus. (Attachments 1- 1A) 2) Facility has audited and reviewed all current patients for a potential acute change in mental status within the past 7 days and addressed by the facility. (Attachment 2-audit sheet) 3) Facility has audited the last 72 hours of all patients vital signs. DON (Director of Nursing) has reviewed and confirmed that all 'out of range' vital signs have been assessed for potential change of condition. Any concerns were immediately reported to attending physician by DON for appropriate follow-up. (Attachment-2, audit sheet) 4) Facility has implemented mandatory training for all staff on the new Interact Early Warning Tool Stop and Watch, which the facility will be using as an additional tool to help all staff recognize and report patient changes of condition. (Attachment 4- attendance record) (Attachment 4A- Stop and Watch tool) 5) Facility has in-serviced all current direct care licensed nurses and rehab staff on the new Matrix tool AMDA Know it All - a tool to be used for physician communication and nursing assessment needs. (Attachments 5- in-service attendance record). 6) Direct licensed care giver nurses who were unable to attend training will be trained by a trainer prior to starting shift. 7) Facility has completed retention testing with all on-duty scheduled staff to ensure knowledge base of all provided training. (Attachment 7- Retention Quiz) 8) Facility Executive Director and Director of Nursing Services met with facility Medical Director and Nurse Practitioner on [DATE]th to review best facility communication practice for all patient concerns. (Attachment 8- Provider Communication Practice Protocol) I respectfully certify that the elements in our plan of correction have been fully implemented. I allege that as of [DATE], at 3:00 PM that Immediate Jeopardy has been abated and staff trained on facility practice for recognizing and required notification for any patient change of condition. On [DATE], the surveyors confirmed the abatement of the Immediate Jeopardy situation as of [DATE]. Deficient practice with potential for more than minimal harm remained for the risk of injury. Findings include: Immediate Jeopardy: Resident 149 was admitted to the facility on [DATE] for a respite stay. Resident 149 was admitted with [DIAGNOSES REDACTED]. On [DATE] at 1:50 PM, a surveyor entered resident 149's room and observed that resident 149 was not breathing. The surveyor informed Registered Nurse (RN) 7, who assessed the resident and determined that resident 149 had died . On [DATE], resident 149's medical record was reviewed. Review of the medical record revealed the following Progress Notes entries: a. [DATE] 12:54 PM: Resident was difficult to wake up, nurse apply stimuli to try to wake up the resident with nor (sic) result vitals was taken (sic). Vital B/P (blood pressure) ,[DATE] P (pulse) 117 RR (respiratory rate) 24 O2 (oxygen saturation) 88% RA (room air). Family was contact (sic) and requested to let his (sic) sleep for rest of the day. Family stat (sic) My dad does the same think (sic) ones (sic) in a while. Family request to put oxygen. Oxygen in place showing saturation of 94% on 2L (liters). Nurse will continue monitoring. Resident is in (sic)2L nasal cannula SPO2 (oxygen saturation) 94%. Nurse will continue monitoring, By 12:00 resident had all his med (medication) without any problem. b. [DATE] 12:54 PM: Resident was difficult to wake up, nurse apply stimuli to try to wake up the resident with nor (sic) result vitals was taken (sic). Vital B/P ,[DATE] P 117 RR 24 O2 88% RA. Family was contact (sic) and requested to let his (sic) sleep for rest of the day. Family stat (sic) My dad does the same think (sic) ones (sic) in a while. Family request to put oxygen and not sent to the hospital. Oxygen in place showing saturation of 94% on 2L. Nurse will continue monitoring. Resident is in (sic) 2L nasal cannula SPO2 (oxygen saturation) 94%. Nurse will continue monitoring, By 12:00 resident had all his med (medication) without any problem. Note: The above entry was made into the electronic medical record on [DATE] at 2:51 PM. The entry was made into the medical record after resident 149 had been found expired by the state surveyor. The above statement was only changed with the addition of the family not wanting the resident to be sent to the hospital. Additionally, the nurse that made the edited entry on [DATE] was not scheduled nor was observed to be working on [DATE]. c. [DATE] 16:06 (4:06 PM): Recorded as Late Entry on [DATE] 3:02 PM: around 16:00 son called to reported (sic) they will here tomorrow (sic). Nurse reported his condition haven't change (sic) since last time we talk in the phone (sic). Continue with difficult to arouse with not responded (sic). Nurse asked one more time if his condition get worse we can send to the hospital Son state He does the same think (sic) ones (sic) in a while so let him sleep. Nurse did bedside report to the next nurse. Note: The above entry was made into the electronic medical record on [DATE] at 3:02 PM. The entry was made into the medical record after resident 149 had been found expired by the state surveyor. Additionally, the nurse that made the edited entry on [DATE] was not scheduled nor was observed to be working on [DATE]. d. [DATE] 9:02 AM: Resident continues with being non-responsive at this time, CNA (Certified Nursing Assistant) is in providing cares, oral care instruction provided by this nurse to CNA with sponge and water, unable to administer medications d/t (due to) condition, family is aware of resident's status, blood sugars continue to be elevated this AM, resident respiratory rate is regular, even at 16 RR, skin is warm, pale and dry at this time. Will continue to monitor resident, educated CNA r/t (related to) cares and repositioning. Note: The above entry was made into the electronic medical record on [DATE] at 2:04 PM. The entry was made after resident 149 was found to be expired but timed for before resident 149 had expired. e. [DATE] 13:00 (1:00 PM): RD (Registered Dietitian) delivered lunch meal tray at 1300 hours. Resident was asleep and snoring at time of delivery. Tray left at bedside at this time for availably (sic) upon waking. Nursing team informed. Note: The above entry was made into the electronic medical record on [DATE] at 2:49 PM. The entry was made after resident 149 was found to be expired but timed for before resident 149 had expired. f. [DATE] 13:55 (1:55 PM): This nurse was notified at approx (approximately) 1345 (1:45 PM) that the resident appears to not be breathing at this time. Upon assessment the resident is found to not be breathing, no apical pulse auscultated. Resident is pale and warm to the touch at that time. NP (Nurse Practitioner) notified @ (at) 1349 (1:49 PM). DON (Director of Nursing) notified. Attempts to contact the listed family members at 1350 (1:50 PM) . No answer to either numbers, voice message left to please return my call. g. [DATE] 14:41 (2:41 PM): Spoke with resident's son (name of son) at 1438 (2:38 PM), gave him a recapitation of today's cares and events. He states he will be coming in and will contact the mortuary (name of Mortuary). He states he feels guilty because he promised his dad that he could die at home, and he wanted to come and check him out this AM but didn't get in until late last night. This nurse provided comfort and reassurance to the resident's son. On [DATE] at 2:05 PM, CNA 6 was interviewed. CNA 6 stated that his work assignment for [DATE] and [DATE], during the 6 AM to 2 PM shift, included the provision of cares to resident 149. CNA 6 stated that at breakfast time on [DATE], he went to take resident 149 to breakfast but noted that resident 149 was unresponsive and was breathing fast. CNA 6 stated that he had reported resident 149's condition to the nurse. CNA 6 stated that resident 149 remained unresponsive throughout the day shift on [DATE] and was in the same unresponsive state on [DATE]. Additionally, CNA 6 stated that he had not been in resident 149's room on [DATE] since around 11:30 AM. On [DATE] at 2:05 PM, CNA 4 was interviewed. CNA 4 stated that her work assignment on [DATE] consisted of providing cares to resident 149 for the 6 AM to 2 PM shift. CNA 4 stated that resident 149 had been unresponsive for the entire 6 AM to 2 PM shift. CNA 4 stated that at or around 11:30 AM on [DATE], RN 7 had shown her how to provide oral care to resident 149. CNA 4 stated that she had tried to provide milk to resident 149 around 11:30 AM, but the milk just drooled out of resident 149's mouth. CNA 4 stated that resident 149 would not respond to anything. CNA 4 stated that she had not been in resident 149's room on [DATE] since 11:30 AM. Review of the medical record revealed the following entries: On [DATE] at 8:13 AM, a facility nurse documented resident 149's blood glucose level was 428. According to a physician order [REDACTED]. No documentation could be found to show that the physician was notified regarding resident 149's elevated blood glucose level that had been obtained on [DATE] at 8:13 AM. Review of the facility's [DIAGNOSES REDACTED]/[MEDICAL CONDITION] Protocol revealed that for blood sugars over 400, facility staff were to notify the MD (Medical Doctor). On [DATE] at 9:23 AM, nurse aide computer charting for resident 149 included documentation that no breakfast was taken. On [DATE] at 3:15 PM, a telephone interview was conducted with the facility nurse (Licensed Practical Nurse ((LPN)) 1) that made the [DATE] at 12:54 PM entry. The nurse was asked what information he had provided to resident 149's son on [DATE]. The nurse stated he informed the son that resident 149 was sleepy and difficult to arouse and that the resident had low oxygen levels. According to LPN 1, on [DATE] at 5:39 PM, LPN 1 sent a text message to the facility Nurse Practitioner, who was on-call for resident 149's attending physician. Review of the text message revealed the following: (Resident 149) being very sleepy and being so difficult to wake up him (sic). Nurse scrape his chest with not (sic) respond vital ,[DATE] P 102 RR 22 O2 97 2 L. Family state hi (sic) does that ones (sic) in a while. Any action at this time? The nurse practitioner responded via text by asking for resident 149's code status. The nurse replied via text that the resident's code status was Do Not Resuscitate/Do Not Intubate. The nurse practitioner responded via text to monitor. Note: No information was provided regarding the resident's morning blood glucose level that was greater than 400. Additionally, it should be noted that the text message was sent to the Nurse Practitioner nine and a half hours after the high blood glucose level was obtained and the resident was noted to be unresponsive. On [DATE] at 7:47 PM, a facility nurse documented that resident 149's blood glucose level was 469. No documentation could be found to show that the MD or Nurse Practitioner were notified of the elevated blood glucose level. No documentation could be found in regards to resident 149's continued change of condition for the 6 PM to 6 AM shift on [DATE]. On [DATE] at 3:30 PM, CNA 9 and 10 were interviewed. CNA 9 and CNA 10 stated that they had shared care assignments on [DATE] for the 2:00 PM to 10:00 PM shift. CNA 9 and CNA 10 stated that their assignment on [DATE] included the provision of cares to resident 149. CNA 9 and CNA 10 stated that resident 149 was unresponsive for the entire 2:00 PM to 10:00 PM shift on [DATE]. CNA 9 and CNA 10 both stated that they were not provided any instruction to do anything different for resident 149 except to check on him every two hours to make sure he was still breathing. On [DATE] at 8:57 AM, RN 7 documented resident 149's blood glucose level was 352. It should be noted that RN 7 timed the blood glucose for 8:57 AM, yet the blood glucose results were not entered into the electronic medical record until 3:15 PM, after resident 149 was found expired. On [DATE] at 3:20 PM, RN 7 was interviewed. RN 7 stated that she had not contacted resident 149's family to discuss resident 149's condition. RN 7 stated that the nurse on [DATE] had contacted resident 149's family. On [DATE] at 3:15 PM, the facility Nurse Practitioner (NP) was interviewed via telephone. The NP stated that she had been contacted, via text message, about resident 149 on [DATE]. The NP stated that she was told the family did not want any interventions. The NP stated that she was not contacted again regarding resident 149's continued change in condition. The NP stated that she was not notified regarding resident 149's elevated blood glucose levels. The NP stated that if a resident was unresponsive and had an elevated blood glucose level that she would expect to be notified timely. The NP stated that she considered timely to be within an hour. HARM: Resident 88 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 88's medical record was reviewed. Review of the physician's orders [REDACTED]. According to the 2014 Lippincott's Nursing Drug Guide, Lippincott Williams & Wilkins, pg. 333: [MEDICATION NAME] (dabigatran etexilate) is in the drug class of Direct [MEDICATION NAME] inhibitor with the therapeutic actions of Competitive, direct [MEDICATION NAME] inhibitor; [MEDICATION NAME] enables the conversion of [MEDICATION NAME] to [MEDICATION NAME] fibers during the clotting cascade. Inhibiting this process prevents clot development. The Contraindications and cautions include: Contraindicated with history of serious hypersensitivity reactions to dabigatran; active pathologic bleeding. Adverse effects include gastric hemorrhage and bleeding. Additionally, it was documented under the Nursing Considerations section to Be aware that a reversal agent is not available. Review of the nurses' notes revealed the following entries: a. [DATE] 10:32 (10:32 AM) Reported to this nurse by CNA's (sic) on [DATE] that resident has blood in his stool with skin breakdown to buttock r/t frequent episodes of diarrhea/loose bowel movements. Upon assessment it is noted that resident has red, paste consistency stool in his brief. Sample collected, MD notified, order to send lab for [MEDICAL CONDITIONS] and get a CBC (complete blood count). Barrier cream applied generously to buttock, resident has HX (history) of [MEDICAL CONDITION], is on [MEDICATION NAME] ([MEDICATION NAME]) and daily scheduled [MEDICATION NAME] 2mg (milligrams). VSS (vital signs stable), no S/S (signs or symptoms) of dehydration, mucous membranes are moist, encouraging PO (by mouth) Liquids. b. [DATE] 22:08 (10:08 PM) Notified (name of physician) of CBC Lab results, no new orders at this time. [MEDICAL CONDITION] still pending. Will continue to f/u (follow up). Lab placed in medical records to be scanned into (name of computer program). c. [DATE] 09:49 (9:49 AM) Minimal about (sic) of bleeding with his bowel movements, does not have any blood present unless he is having a bm (bowel movement). Has not went to the bathroom yet but when he does we will collect another stool sample. d. [DATE] 13:21 (1:21 PM) No bleeding or diarrhea reported so far this shift by the aids. Resident is alert and oriented and able to make needs known. e. [DATE] 11:08 (11:08 AM) No reports of bloody diarrhea this shift. Continues with redness/rash to buttock, barrier cream applied as ordered. f. [DATE] 10:41 (10:41 AM) Resident is alert and oriented, medicated for generalized discomfort with positive results. Elevated his right leg and he stated that it felt nice that way. Has a brace present to his right hand. Requires extensive assistance of one with adls (activities of daily living), and bed mobility, transfers didn't occur. Incontinent of b/b (bowel and bladder), only has slight amount of blood noted only when he has a bowel movement, no active bleeding without having a BM. Pleasant and cooperative with care, call light in reach and will continue to monitor. g. [DATE] 14:57 (2:57 PM) Seen at request of staff who note bleeding from rectum with clots. Hx (history) of colon CA (cancer). Had [MEDICAL CONDITION] at one point, taken down. Discussed potential seriousness of this with resident, suggesting he see his surgeon again. He is refusing. Resident alert and capable of making personal decisions. (Note: This entry was made by the facility Nurse Practitioner.) h. [DATE] 05:46 (5:46 AM) (resident 88) having increased blood in stool and increased diarrhea. MD notified and order for STAT (immediate) CBC and stool sample for [MEDICAL CONDITION]. Lab req filled out, order put in (computer program), and lab company contacted. Resident informed about the need for CBC and stool sample. i. [DATE] 10:38 (10:38 AM) Stool sample collected and Lab called for stat. The lab tech said they don't pickup stat[DIAGNOSES REDACTED] sample, but they will pick it up today. Resident stool was mostly bright red blood. (Name of physician) notified. j. [DATE] 14:45 (2:45 PM) Call place to resident wife (name of wife) and his sister (name of sister), no one answer, VM (voice message) left to call the facility for update about stat labs and loose stools. k. [DATE] 15:05 (3:05 PM) Resident sister(name of sister) returned call, and writer updated her about stat labs, loose stools, bright red blood in stool. l. [DATE] 16:30 (4:30 PM) (name of Doctor) notified of CBC report, she said to send resident the ER (emergency room ) r/t Hct (Hematocrit) 26. 8, Hgb (hemoglobin) 8.7 it is a big drop from previous lab per (name of Doctor). (Name of ambulance company) ambulance called, resident sister called and notified, and resident notified of hospital transfer r/t lab reports. DON notified. Note: Facility staff identified the increased blood in resident 88's stool at 5:46 AM on [DATE], yet waited approximately 14 hours before contacting resident 88's family regarding the change of condition. Review of resident 88's laboratory reports revealed the following: a. On [DATE] it was documented on the laboratory report that resident 88's Hct was 36.8 L (low). According to the laboratory report the reference range for this lab value was 37.0 - 47.0. Additionally, resident 88's Hgb was documented as being 11.3 L. According to the laboratory report the reference range for this lab value was 12.0 - 16.0 grams per deciliter (gm/dL). b. On [DATE] it was documented on the laboratory report that resident 88's Hct was 26.8 L. According to the laboratory report the reference range for this lab value was 38.7 - 52.5. Additionally, resident 88's Hgb was documented as being 8.7 L. According to the laboratory report the reference range for this lab value was 12.4 - 17.4 gm/dL. Review of the local acute care hospital's Admission History and Physical dated [DATE] revealed Reason for admission: dark bowel movements. Assessment/Plan: (name of resident 88) is a 77 y (year old) M (male) with hx of . who presents with 1 month hx of dark stools . # Concern for GI (gastrointestinal) Bleed: Likely lower GI bleed due to hx of bright red blood per rectum, frank bloody stool at nursing facility. Hb (hemoglobin) dropped from 12 in April to 11 at the end of July, to 9 at time of presentation. Risk factors for bleed include current [MEDICATION NAME] use for [MEDICAL CONDITION] ([MEDICAL CONDITION] ppx ([MEDICATION NAME]), hx of [MEDICAL CONDITION] with concern for new mass. On [DATE], RN 12 was interviewed. RN 12 stated that resident 88 had been experiencing bleeding from his rectum for about a month. RN 12 stated that the facility staff did not report the continual bleeding because it was not getting worse. RN 12 stated that the bleeding was only reported to the MD when it became worse. On [DATE], the facility MD was interviewed via telephone. The MD stated that she was not told on [DATE] that resident 88 was receiving [MEDICATION NAME]. The MD stated that resident 88 should have been taken off the [MEDICATION NAME] with continued rectal bleeding. The MD stated that she would have liked to know that resident 88 was experiencing weeks of rectal bleeding. (Cross refer to F157 and F514)

Based on interview and record review, it was determined for 5 of 45 sample residents, the facility did not ensure that residents were free of significant medication errors. Specifically, residents received incorrect doses of blood thinning medication, and one resident did not receive his antibiotic therapy. Resident identifiers: 10, 40, 43, 47 and 58. Findings include: 1. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 40's medical record was reviewed on 8/17/15. Nurses notes dated 5/7/15 revealed that resident 40's PT/INR was drawn and the INR for resident 40 was 2.6. No change to current dose. Recheck INR in 1 week (5/14/15). Nurses notes dated 5/14/15 revealed that resident 40's PT/INR was drawn and the INR for resident 40 was 3.4. New order to hold one dose of [MEDICATION NAME] then restart 5 mg on 5/16/15. Recheck INR on Tuesday 5/19/15. (It should be noted that review of resident 40's May 2015 MARs, revealed that resident 40 received a 6 mg dose of [MEDICATION NAME] on 5/15/15 despite the physician's orders [REDACTED].) Laboratory results revealed that resident 40's PT/INR was drawn on 5/19/15 at 7:29 AM, and the results were received by the facility at 9:51 AM. The INR for resident 40 was 4.6, which was higher than the reference range listed on the laboratory results sheet. Facility staff obtained an order to discontinue the [MEDICATION NAME] and recheck the PT/INR on 5/21/15. (It should be noted that per the May 2015 MAR, resident 40 received a 5 mg dose of [MEDICATION NAME] on 5/19/15, despite the physician order [REDACTED]. Laboratory results revealed that resident 40's PT/INR was drawn on 5/21/15 at 6:50 AM, and the results were received by the facility at 9:50 AM. The INR for resident 40 was 5.9. Facility staff obtained a physician order [REDACTED]. Nurses notes dated 5/22/15 revealed that resident 40's PT/INR was drawn and the INR for resident 40 was 3.0. Facility staff obtained an order on 5/22/15 to start resident 40 on 3 mg of [MEDICATION NAME] and recheck PT/INR on 5/26/15. (It should be noted that per the May 2015 MARs, resident 10 did not receive the [MEDICATION NAME] dose on 5/22/15, despite the physician order [REDACTED]. 2. Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 10's medical record was reviewed on 8/17/15. Laboratory results revealed that resident 10's PT/INR was drawn on 7/5/15 at 3:30 PM, however the results were not received by the facility until 7/6/15 at 10:07 AM. The INR for resident 10 was 0.99. Facility staff obtained a physician order [REDACTED]. (It should be noted that per the July 2015 Medication Administration Record [REDACTED].) Laboratory results revealed that resident 10's PT/INR was drawn on 8/2/15 at 3:30 PM, however results were not received by the facility until 8/3/15 at 11:13 AM. The INR for resident 10 was 1.65. Facility staff received an order to increase [MEDICATION NAME] to 12 mg and recheck PT/INR on 8/5/15. (It should be noted that per the August 2015 MAR, resident 10 received an 11 mg dose of [MEDICATION NAME] on 8/3/15, despite the physician order [REDACTED].) Laboratory results revealed that resident 10's PT/INR was drawn on 8/5/15 at 3:20 AM and results were received at 10:43 AM. The INR for resident 10 was 1.66. Facility staff received an order to increase [MEDICATION NAME] to 12.5 mg and recheck in one week. (It should be noted that per the August 2015 MAR, resident 10 received a 12 mg dose of [MEDICATION NAME] on 8/5/15, despite the physician order [REDACTED].) 3. Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 8/24/15, resident 47's medical record was reviewed. Review of the MAR for May 2015 revealed that resident 47 was receiving 2.5 mg of [MEDICATION NAME] from 5/1/15 - 5/10/15 with the dose being administered at 5:00 PM. On 5/10/15 a facility nurse documented the following in a progress note: Informed by resident to DC (discontinue) [MEDICATION NAME], she is having her right leg amputated on Wednesday 5/13/15. It should be noted that resident 47 received 2.5 mg of [MEDICATION NAME] on 5/10/15 despite the order to discontinue the medication. Resident 47 was readmitted to the facility on [DATE], after her amputation, with a physician's orders [REDACTED]. Laboratory results revealed that resident 47 had a PT/INR completed on 5/18/15 at 8:15 AM. The results of the PT/INR were received by the facility on 5/18/15 at 12:51 PM. According to the laboratory report, resident 47's PT/INR was 3.5. Facility staff received an order on 5/18/15 to hold the [MEDICATION NAME] X 1 day then restart 2 mg of [MEDICATION NAME] and check resident 47's INR on 5/21/15. It should be noted that resident 47 received 2.5 mg of [MEDICATION NAME] on 5/18/15 despite the order to hold the [MEDICATION NAME] for 1 day. Laboratory results revealed that resident 47 had a PT/INR drawn on 7/1/15 at 3:28 AM. Facility staff received the results of the PT/INR on 7/1/15 at 10:03 AM. Facility staff obtained an order to change the [MEDICATION NAME] to 2 mg every day and recheck the PT/INR in one week on 7/8/15. Review of the July 2015 MAR indicated [REDACTED]. Laboratory results revealed that resident 47 had a PT/INR drawn on 7/8/15 at 3:40 AM. Facility staff received the results of the PT/INR on 7/8/15 at 9:39 AM. Facility staff obtained on order to increase the [MEDICATION NAME] to 3 mg every day and recheck the PT/INR in one week on 7/15/15. Review of the July 2015 MAR indicated [REDACTED]. 4. Resident 58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/19/15 resident 58's medical record was reviewed. Review of the Progress Notes revealed the following entry: Returned from Clinic 28 Dermatology, Orders: start [MEDICATION NAME] Modified 100 mg PO (by mouth) BID (twice daily). Progress Note: Non healing ulcers on the (B) (bilateral) lower extremities (thighs and legs) with surrounding [DIAGNOSES REDACTED]. History exam concerning for pyoderma gangreusom. Plan to initiate treatment with [MEDICATION NAME]. Review of the medical record revealed the following physician's orders [REDACTED]. Review of the August 2015 MAR indicated [REDACTED]. Additionally, according to documentation, resident 58 did not receive the 200 mg of [MEDICATION NAME] on 8/14/15, 8/15/15 and 8/16/15. The following entries were noted on the MAR: 8/16/15 9:30 AM: Not Administered: Other. Comment: med on order. 8/17/15 9:30 AM: Not Administered: Drug/Item unavailable. Comment: delivery will be today. 8/14/15 20:00 (8:00 PM): Not Administered: Drug/Item unavailable. Comment: Called the pharmacy. 8/15/15 20:00: Not Administered: Drug/Item unavailable. Comment: Still not here. 8/16/15 20:00: Not Administered: Refused. Note: The [MEDICATION NAME] was not available for administration on the morning of 8/16/15 or 8/17/15 yet the evening dose on 8/16/15 was charted as being refused. Review of the nurse's notes revealed the following entries: 8/14/15 9:24 AM: Faxed the two orders for [MEDICATION NAME] to pharmacy for refill, per pharmacy request. 8/17/15 19:25 (7:25 PM): Called pharmacy about pts (patient's) [MEDICATION NAME]. They had order of the am dose but not the PM dose, Should be delivered tonight. On 8/19/15, Registered Nurse (RN) 7 was interviewed. RN 7 stated that the facility was having problems with getting medications from the pharmacy. RN 7 stated that medications were not being delivered. 5. Resident 43 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 43's medical record was reviewed on 8/24/15. A review of resident 43's physician's orders [REDACTED]. Start date: 7/11/15. Review of resident 43's progress notes revealed the following entries: a. 7/11/15 2:30 PM; Created by Registered Nurse: Resident returned from (name of hospital), order for [MEDICATION NAME] nasal [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant staphylococcus aureus), order on hold pending nasal swab culture which the swabs were ordered from lab and will be here Wednesday, will culture nares and start order if indicated. b. 7/14/15 4:43 PM; Created by Advanced Practice Registered Nurse (APRN): Seen at request of staff and resident. Resident complaining of discomfort to bridge of his nose, such that wearing O2 (oxygen) cannula and mask painful. treated for [REDACTED].[MEDICAL CONDITION] nasal swab ordered 7/2/15, not done for unclear reasons. Discussed with ADON (Assistant Director of Nursing) and consult. Denies earache, sore throat, respiratory congestion. Sent to ER (emergency room ) over weekend secondary to his complaint of a lump about his pacemaker, with prior history of [MEDICAL CONDITION] ([MEDICAL CONDITION] in his area per report. [MEDICAL CONDITION] to ER physician who did decline to culture nose but sent him back with [MEDICATION NAME] order. Sinusitis: history [MEDICAL CONDITION], culturettes available, will swab now; start Bactrim empirically pending culture. A second review of resident 43's physician's orders [REDACTED]. Start date: 7/17/15. (Note: The APRN progress noted indicated that resident 43 was to start Bactrim on 7/14/15.) (Note: No documentation could be located to indicate resident 43 received [MEDICATION NAME] nasal ointment from 7/11/15 through 7/14/15 as indicated on the physician's orders [REDACTED].) Review of the July 2015 MAR indicated [REDACTED]. The following entries were noted on the July 2015 MAR: 07/18/2015 02:22: Not Administered: Drug/Item unavailable 07/18/2015 08:09: Not Administered: Drug/Item unavailable 07/20/2015 22:57: Not Administered: Drug/Item unavailable On 8/24/15 at 1:15 PM, an interview was conducted with RN 11. RN 11 stated that when a resident was out of a medication they would call the pharmacy. RN 11 stated that the nursing staff sometimes had to call the pharmacy back to remind them to deliver a medication. RN 11 stated that this had been a problem for about two months since they started using a new pharmacy. (Cross refer to F329, F425, and F502)

Based on interview and medical record review it was determined that for 1 of 6 sample residents the facility did not provide the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically, the facility did not monitor and intervene when a resident had a significant change in level of consciousness following a fall. The resident was determined to have experienced a subdural hematoma. Resident identifier: 5 Findings include: Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's electronic medical record (EMR) was reviewed on [DATE]. Review of the facility's EMR for resident 5 revealed an admission nursing assessment dated [DATE] at 7:19 PM. A facility nurse documented in the EMR that, "(Resident 5) has right parietal subdermal extrusion r/t (related to) shunt and recent craniotomy, which is wnl (within normal limits). Otherwise Heent (head, ears, eyes, nose, and throat) wnl, and Perrla (pupils, equal, round, reactive to light and accomodation), able to verbalize but has cognitive deficit w/ (with) varying STM (short-term memory) changes. No s/s (signs or symptoms) of ICP (intracranial pressure), or acute alteration in LOC (Level of Consciousness), ... Pt. (patient) at risk for falls d/t (due to) poor decision skills and intermittent disorientation. ... " It was documented on [DATE] at 8:06 PM, by the physical therapist that, "Pt is a high fall risk - bed alarm, low bed w/ mat recommended. Pt also requires assisted feeding d/t visual deficits and poor motor planning. ..." On [DATE] at 7:53 PM, the attending physician for resident 5 completed an admission history and physical for resident 5. It was documented by the attending physician that resident 5 had decreased vision. No documentation could be found to indicate that resident 5 was blind. It was documented on [DATE] at 8:43 PM, by the physical therapist that, "... (pt. displaying some response to balloon in his visual field prior to contact but usually not until balloon was very close). ..." Review of the EMR revealed an entry dated [DATE] at 4:05 PM. Licensed Practical Nurse (LPN) 1 documented that, "pt is taking off seat belt and trying to stand causing pt to fall. pressure alarm in place. new order for lap buddy. pts (patients) family informed and to sign informed consent." On [DATE] at 1:13 PM, Licensed Practical Nurse (LPN) 1 documented in the EMR (a late entry for [DATE] at 10:30 AM) that, "pts family informed staff that pt has taken off his seat belt and fallen to the floor a min (minute) ago. pts family picked pt off the floor and informed staff a few hrs. (hours) later. VS (vital signs) stable when taken. pupils no PEARL (pupils equal and reactive to light); pt has had neuro (neurological) issues and is 90% (percent) blind. pt is able to take off seat belt and tries to stand." The entry was made approximately 26.5 hours after the incident occurred and resident 5 had been transferred to the local hospital for a decrease in level of consciousness. On [DATE] at 3:21 PM, LPN 1 amended her entry from 1:13 PM. The amended entry read, "pts family informed staff that pt has taken off his seat belt and fallen to the floor a min ago. pts family picked pt off the floor and informed staff a few min. later. VS stable when taken. pupils not PEARL; pt has had neuro issues and is 90% blind. pt is able to take off seat belt and tries to stand. pts head shows no signs of visual trauma, pt cont (continues) to be confused; this is common for pt." The amended entry was made approximately 28.5 hours after the incident occurred. On [DATE] at 12:00 PM, LPN 1 documented that, "pt has been unresponsive since about 0600 (6:00 AM). pts VS were stable. MD (medical doctor) notified with a new order to send him to (local hospital) ER (emergency room ) for eval (evaluation). (Ambulance) notified and pt sent to hospital. pts brother (name) with pt." On [DATE] at 12:19 PM, LPN 1 amended her entry from 12:00 PM. The amended entry read, "pt was seen awake at about 0630 (6:30 AM) and verbalized when asked that he was fine. pt was making slight movements. HOB (head of bed) elevated. pts VS were stable. ,[DATE] (blood pressure), 100 (pulse), 90% RA (room air oxygen saturation), 14 (respirations), 97.0 (body temperature). pt VS have been checked consistently with all VS normal. pt breathing was equal and unlabored. MD notified with a new order to send him to (local hospital) ER for eval. (Ambulance) notified and pt sent to hospital. pts brother (name) with pt." On [DATE] at 1:27 PM, LPN 1 amended her amended entry from 12:19 PM. The amended entry read, "pt was seen awake at about 0630 and verbalized when asked that he was fine. pt was making slight movements. HOB elevated. at appx (approximately) 1100 (11:00 AM) pts brother asked LN (Licensed Nurse) if pt had eaten breakfast and i informed him that CNA (Certified Nursing Assistant) was unable to get pt up. pts brother then stated he could go to pts dr (doctor) appt (appointment) tomorrow if he could get work off tomorrow. LN went in to check on pt after convo (conversation) with pts brother. pts VS were stable. ,[DATE], 100, 90% RA, 14, 97.0. pt VS have been checked consistently with all VS normal. pt breathing was equal and unlabored. MD notified with a new order to send him to (local hospital) ER for eval. (Ambulance) notified and pt sent to hospital. pts brother (name) with pt. attempted to call (patient's wife) to notify with no answer. message left." Review of facility incident reports revealed an incident report dated [DATE] at 1:04 PM which was completed by LPN 1. LPN 1 documented in the "Description of events" that, "painters (construction workers) heard pressure alarm going off, noticed pt on floor. painters placed pt back into bed and notified FSN (facility staff nurse) a few hours later, pt had taken seatbelt off byself." LPN 1 documented the following vital signs for resident 5: Temperature 97.5, Pulse 67, Respirations 20, and Blood Pressure ,[DATE]. No oxygen saturation could be found in the documentation. LPN 1 did not document on the incident report if resident 5's pupils were equal and reactive to light, if resident 5's hand grasps were equal or any other assessment measures. LPN 1 documented that first aid was not rendered. On [DATE] facility EMR vital signs report was reviewed for resident 5. Review of the report revealed that the vital signs documented on the incident report dated [DATE] at 1:04 PM were vital signs recorded in the EMR on [DATE] at 10:45 AM, approximately 12 hours after the incident occurred. On [DATE] at 1:50 PM, the Regional Nurse Consultant (RNC) was interviewed regarding the fall resident 5 experienced on [DATE]. The RNC stated that resident 5 did not get up the day after the fall and the nurse felt that he was sleeping in. She further stated that resident 5's brother had to come and get the nurse to check on resident 5 because resident 5 was not right. The RNC stated that if a resident experienced a fall, the facility protocol would include an assessment of the resident by the nurse. The assessment would include vital signs and neurological checks if the resident had hit their head. The RNC stated that if the fall was unwitnessed by staff the staff should have automatically initiated neurological checks. The RNC further stated that if a resident experienced a fall, alert charting should be completed on the resident for 72 hours after the fall, vital signs should be done every shift for 72 hours and the Interdisciplinary Team should complete a review to document the events and determine/implement other interventions. The RNC stated that she was not sure why the nurse did not follow protocol when she had previously. She further stated the nurse did not make an entry into resident 5's medical record until after she found out there was a problem with resident 5. On [DATE] at 9:34 AM, LPN 1 was interviewed, via telephone, regarding the fall resident 5 experienced on [DATE]. LPN 1 stated that resident 5 experienced a fall on [DATE] between 12:00 PM and 2:00 PM. LPN 1 stated that the construction workers heard resident 5's tab alarm and found resident 5 on his knees. She stated that the construction workers did not tell anybody for a few hours. LPN 1 stated that resident 5's eyes were not reactive to light due to the aneurysm he had behind his optic nerve. She further stated that it was pointless to do neurological checks because resident 5 was blind and the neurological checks were a waste of time. On [DATE] at 8:43 AM, CNA 1 was interviewed regarding the condition of resident 5 on [DATE]. CNA 1 stated that she went into resident 5's room around 6:00 AM and resident 5 appeared to be in a "deep sleep." CNA 1 stated that she moved resident 5 and touched resident 5's arm and he did not respond but he was "breathing." CNA 1 further stated that at about 7:00 AM she went back into resident 5's room and got him dressed for the day and he still did not respond, he was still in a "deep sleep." CNA 1 stated that she remembers the Restorative Nursing Assistant coming to get resident 5 for breakfast and they decided to let him sleep instead of taking him to breakfast. CNA 1 stated that she went back in after breakfast, around 9:00 AM, and resident 5 still did not wake up. CNA 1 stated that she told the nurse about resident 5 not waking up at about 7:00 AM and the nurse told the CNA to just let resident 5 sleep. On [DATE] at 12:00 PM, the attending physician was interviewed regarding resident 5. The attending physician stated that she was not notified of resident 5's fall on [DATE]. The attending physician stated that had she been notified of the fall she would have had the facility staff due neurological checks on resident 5 and notify her of any changes in his neurological status. On [DATE] resident 5's hospital admission records were obtained and reviewed. It was documented in the hospital History and Physical report dated [DATE] that resident 5 was a "[AGE] year-old male who sustained acute on chronic significant life threatening subdural hematoma." Review of the Hospital Discharge Summary dated [DATE] revealed that resident 5 expired on [DATE] after, "... found down unresponsive and pupils nonreactive and Subdural hematoma, acute on chronic...." Cross Reference F-157.