Every finding on record at NHC Healthcare, Dickson

Based on facility policy review, medical record review, observation, and interview, the facility failed to properly store medications when medications were left unattended and unlabeled at bedside for 1 of 175 (Resident #41) residents and when medications were left unsecured and unlabeled in 1 of 10 (2B Medication Cart) medication carts. The findings include: 1. Review of the undated facility policy titled, Storage of Medications, revealed .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.All medications dispensed by the pharmacy are stored in the container with the pharmacy label.Refrigerated medications are kept in closed and labeled containers. Review of the facility policy titled, Self-Administration of Medications, dated 2/25/2025, revealed .In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer.If the resident desires to self-administer medications, a physician order should be obtained then an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility.For those residents who self-administer, a member of the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or if needed, when there is a significant change in condition. 2. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses including Autistic Disorder, Gilbert Syndrome, Delusional Disorders, Hypertension, Edema, Protein-Calorie Malnutrition, and Peripheral Vascular Disease. Review of the Physician's Order dated 3/3/2026, revealed the following medications to be given at 9:00 AM by mouth: a. Amlodipine (used to lower blood pressure) 10 milligram (mg) tablet b. Clomipramine (antidepressant) 50 mg 2 capsules c. Furosemide (diuretic) 40 mg tablet d. Olanzapine (antipsychotic) 2.5 mg half tablet (1.25mg) e. Potassium Chloride extended release 10 milliequivalent (mEq) tablet f. Senna Plus (laxative) 8.6-50mg 2 tablets There was no Physician Orders for Resident to self-administer medications. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. Review of the medical record revealed Resident #41 was not assessed or care planned to self-administer medications. Observation in the resident's room on 4/20/2026 at 11:03 AM, revealed 3 white tablets, 2 orange tablets, 2 light blue and yellow capsules, and 1 white half tablet in a small clear cup on Resident #41's nightstand unattended and unlabeled. During an observation and interview in Resident #41's room on 4/20/2026 at 11:13 AM, Licensed Practical Nurse (LPN) A was asked if medications should be left at Resident #41's bedside unattended. LPN A stated, No. LPN A was asked what medications were in the small clear cup at the Resident #41's bedside. LPN stated, Furosemide 40 mg [white tablet], Amlodipine 10 mg [white tablet], 2 Senna 8.6 mg [2 orange tablets], Potassium 10 mEq [white tablet], Clomipramine 50 mg each pill [2 light blue and yellow capsules], Olanzapine 1/2 tablet 1.25mg [white half tablet]. During an interview on 4/20/2026 at 11:56 AM, the Director of Nursing (DON) was asked should medications be left at a resident's bedside unattended. The DON stated, No. 3. Observation on the 2B medication cart on 4/21/2026 at 2:32 PM, revealed the following medications unsecured and unlabeled: a. in the top drawer 1 medication cup with 1 white tablet b. in the 2nd drawer a medication cup with 5 tablets, and a 2nd medication cup with a pink capsule. During an observation and interview on 4/21/2026 at 2:35 PM, LPN B was asked if medications should be administered after they are prepared. LPN B stated, They [the residents] were either out smoking or in therapy. During an observation and interview at the 2B Medication Cart on 4/21/2026 at 2:40PM, the DON was asked if medications in the 2B medication cart should be stored unsecured and unlabeled. The DON instructed LPN B that meds that were prepared and unable to be administered should be wasted and not stored in the med cart due to safety.

Based on the American Council on Aging Website review, medical record review, and interview, the facility failed in their responsibility in maintaining assets under $2,000 for the 2026 Tennessee Medicaid allowance for 10 of 111 (Resident #11, #16, #38, #86, #92, #101, #110, #119, #128, and #177) sampled residents. The findings include: 1. Review of the American Council on Aging Website, Tennessee Medicaid (TennCare) Income & Asset Limits for Nursing Homes & In-Home Long Term Care, dated 4/23/2026, revealed .In 2026, single Medicaid Nursing Home applicant in Tennessee must meet the following criteria.Assets under $2,000. 2. Review of medical record revealed Resident #11 was admitted to the facility on 11/20/2024, with diagnoses including Atrial Fibrillation, Dementia, Depression, Dysphagia, and Anxiety. Review of the Resident Trust Fund Statement, dated 4/22/2026, revealed Resident #11's balance was $4,945.96, which was $2,945.96 over the $2,000.00 limit. 3. Review of medical record revealed Resident #16 was admitted to the facility on 12/18/2021, with diagnoses including Hemiplegia, Heart Failure, and Diabetes. Review of the Resident Trust Fund Statement, dated 4/22/2026, revealed Resident #16's balance was $7,764.26, which was $5,764.26 over the $2,000.00 limit. 4. Review of medical record revealed Resident #38 was admitted to the facility on 6/21/2022, with diagnoses including Dementia, Malnutrition, and Depression. Review of the Resident Trust Fund Statement, dated 4/22/2026, revealed Resident #38's balance was $3,324.09, which was $1,324.09 over the $2,000.00 limit. 5. Review of medical record revealed Resident #86 was admitted to the facility on 5/5/2023, with diagnoses including Chronic Kidney Disease, Anemia, and Bipolar Disorder. Review of the Resident Trust Fund Statement, dated 4/22/2026, revealed Resident #86's balance was $2,950.01, which was $950.01 over the $2,000.00 limit. 6. Review of medical record revealed Resident #92 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Chronic Respiratory Failure, and Diabetes. Review of the Resident Trust Fund Statement, dated 4/22/2026, revealed Resident #92's balance was $5,350.97, which was $3,350.97 over the $2,000.00 limit. 7. Review of medical record revealed Resident #101 was admitted to the facility on 2/6/2017, with diagnoses including Hypertension, Parkinson's Disease, and Dementia. Review of the Resident Trust Fund Statement, dated 4/22/2026, revealed Resident #101's balance was $3,874.46, which was $1,874.46 over the $2,000.00 limit. 8. Review of medical record revealed Resident #110 was admitted to the facility on 5/6/2022, with diagnoses including Dementia, Hypertension, and Traumatic Subdural Hemorrhage (a brain bleed caused by trauma). Review of the Resident Trust Fund Statement, dated 4/22/2026, revealed Resident #110's balance was $3,931.97, which was $1,931.97 over the $2,000.00 limit. 9. Review of medical record revealed Resident #119 was admitted to the facility on 1/28/2025, with diagnoses including Dementia, Atrial Fibrillation, and Chronic Kidney Disease. Review of the Resident Trust Fund Statement, dated 4/22/2026, revealed Resident #119's balance was $2,769.53, which was $769.53 over the $2,000.00 limit. 10. Review of medical record revealed Resident #128 was admitted to the facility on 2/22/2022, with diagnoses including Dementia, Chronic Kidney Disease, and Malnutrition. Review of the Resident Trust Fund Statement, dated 4/22/2026, revealed Resident #128's balance was $5,911.60, which was $3,911.60 over the $2,000.00 limit. 11. Review of medical record revealed Resident #177 was admitted to the facility on 6/4/2019, with diagnoses including Hemiplegia, Heart Failure, and Dementia. Review of the Resident Trust Fund Statement, dated 4/22/2026, revealed Resident #177's balance was $9,020.33, which was $7,020.33 over the $2,000.00 limit. During an interview on 4/22/2026 at 1:52 PM, the Business Office Manager (BOM) was asked what the limit was for the resident trust accounts. The BOM stated, $2,000.00. During an interview on 4/22/2026 at 3:40 PM, the Administrator was asked the amount for resident trust accounts. The Administrator stated, Under $2,000.00 .

Based on Centers for Disease Control and Prevention (CDC) guidelines, policy review, Staff Screening Tool review, Daily Schedule Report review, Timecard Detail review, observation, and interview, the facility failed to ensure practices to prevent the spread of infection were maintained when 2 of 40 staff members (Certified Nursing Assistant (CNA) #15 and #18) failed to don (to put on) Personal Protective Equipment (PPE) when entering a droplet precaution room and failed to properly dispose of a mask, and the facility failed to follow Centers for Disease Control (CDC) Infection Control guidelines to ensure all staff who enter the facility completed the screening process for the prevention and potential spread of COVID 19 when 17 of 269 staff members (Licensed Practical Nurse (LPN) #1, CNA #28, Dietary Staff #1, #2, #3, #4, #5, #6, #7, and #8, Health Information Management (HIM) Staff #1 and #2, Maintenance Staff #1 and #2, Recreation Staff #1 and #2, and the Assistant Director of Nursing (ADON)) failed to complete the screening log prior to working on 3 of 5 days (1/1/2022, 1/2/2022 and 1/5/2022) reviewed. This had the potential to affect the 174 residents residing in the facility. The findings include: Review of the undated Center for Disease Control guidelines titled, HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE), revealed .Mask .remove without touching the front .discard in a waste container . Review of the facility's signage titled DROPLET PRECAUTIONS, revealed .STOP .PPE .Surgical Mask .Eye Protection .Gown .Gloves . Review of the Centers for Disease Control and Prevention (CDC) guidelines titled, Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed .a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2 .symptoms of COVID-19, or .who meets criteria for quarantine or exclusion from work .Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility . Review of the facility's policy manual titled, Infection Control Manuel, dated 1/5/2021, revealed .COVID-19 CORE PRINCIPALS OF COVID-19 INFECTION PREVENTION .Screening of all who enter the center for signs and symptoms of COVID-19 (temperature, checks, questions or observations about signs or symptoms . Observation in the resident's room on 1/18/2022 at 11:38 AM, revealed CNA #18 sanitized her hands, removed a meal tray from the dining cart, knocked and entered Resident #373's room, placed the tray on the over the bed table, exited the room and returned to the meal cart. Resident #373's was in droplet precautions. CNA #18 did not don a gown or gloves prior to entering a Droplet Precaution room. Observation in the resident's room on 1/18/2022 at 11:54 AM, revealed CNA #15 donned gown, gloves, and face covering, removed a meal tray from the dining cart, entered Resident #154's room, exited the room in full PPE, walked over to the dining cart and returned the meal tray to the dining cart. CNA #15 then returned to the room and removed her PPE's inside the room. Resident #154 was in contact isolation precaution. Observation in the resident's room on 1/19/2022 at 5:30 PM, revealed CNA #15 removed her surgical mask and placed the mask on top of the isolation cart outside of Resident #369 and #370's room and put on a N95 (mask used in rooms with confirmed respiratory infections) mask. CNA #15 did not properly store or dispose of the surgical mask. Review of the facility's Staff Screening Tool, Daily Schedule Report, and Timecard Details from 1/1/2022-1/5/2022, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19. a. 1/1/2022- Dietary Staff #1, #3, #4, #5, and #6. b. 1/2/2022 - LPN #1, CNA #28, and Dietary Staff #2, #5, #7 and #8. c. 1/5/2022- Dietary Staff #1, #2, and #3, HIM Staff #1 and #2, Recreation Staff #1 and #2, ADON, Maintenance Staff #1 and #2, and CNA #28. During an interview on 1/21/2022 at 4:22 PM, the Infection Control Preventionist confirmed that all staff should screen upon entering the building before reporting to their work stations. The Infection Control Preventionist confirmed that staff should wear the appropriate listed PPE on the signage outside of the isolation rooms. The Infection Control Preventionist confirmed that all PPE's should be removed before exiting an isolation room. The Infection Control Preventionist confirmed that when staff remove their mask, it should be disposed of in the trash.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 4 of 39 staff members (Certified Nursing Assistant (CNA) #18, #20, #22, and #24) failed to use courtesy titles to address 4 of 166 sampled residents (Resident #109, #159, #372, #373) reviewed during dining observations. The findings include: Review of the facility's policy titled, PATIENT RIGHTS, revealed .The Guarantee of rights that depends on the actions of PARTNERS (employees) are requirements for personnel: right to respect and dignity are requirements of partners . Review of the facility's policy titled, NONDISCRIMINATORY POLICIES, revealed .It is the policy of this center to use courtesy titles ( .Mr., Mrs., Ms.) when addressing patients in all .communications . Observation in the resident's room on 1/18/2022 at 11:24 AM, revealed CNA #20 removed a tray from the meal cart, entered Resident #372's room and stated, Hello Sweetheart. Observation in the resident's room on 1/19/2022 at 5:24 PM, revealed CNA #22 removed a tray from the meal cart, knocked and entered Resident #109's room and stated, Hey Grandma [NAME] are you ready to eat? Observation in the resident's room on 1/19/2022 at 5:45 PM, revealed CNA #18 removed a tray from the meal cart, walked down the hall as she was passing Resident #373's room, and stated to Resident 373, You ok honey. Observation in the resident's room on 1/19/2022 at 6:00 PM, revealed CNA #24 removed a tray from the meal cart, entered Resident #159's room and stated, Hey, sweetie you ready to eat. During an interview on 1/21/2022 at 4:22 PM, the Infection Control Preventionist confirmed that all residents should be addressed by their preferred names and not pet names.

Based on the Geriatric Medication Handbook, policy review, medical record review, observation, and interview, the facility failed to ensure residents were free from a significant medication error when 1 of 2 nurses (Licensed Practical Nurse (LPN) #1) failed to provide a substantial snack or meal within 15 minutes of insulin administration for 1 of 5 sampled residents (Resident #137) observed during medication pass. The failure to provide a substantial snack or meal within 15 minutes of insulin administration resulted in a significant medication error. The findings include: Review of the GERIATRIC MEDICATION HANDBOOK, 13TH edition, provided by the American Society of Consultant Pharmacists, page 41 and 43, revealed .DIABETES: INJECTABLE MEDICATIONS .Novolog .Insulin [MEDICATION(S)] .Rapid-Acting Insulin Analog .Onset .15 min [minutes] .ADMINISTRATION/COMMENTS .15 minutes prior to meals .NovoLog .Insulin [MEDICATION(S)] .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION/COMMENTS .5-10 minutes before meals . The findings include: Review of the medical record, revealed Resident #137 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Insulin [MEDICATION(S)] [[MEDICATION(S)]] . Observation in the resident's room on 1/18/2022 at 4:50 PM, revealed Licensed Practical Nurse (LPN) #7 administered [MEDICATION(S)] 8 units into the Resident #137's left arm after acquiring a glucose reading of 396. Resident #137 received his dinner tray at 5:27 PM, 37 minutes after receiving his insulin. During an interview on 1/18/2022 at 5:30 PM, LPN #7 was asked if [MEDICATION(S)] was fast acting or slow acting. LPN #7 stated, .Fast acting. During an interview on 1/18/2022 at 5:45 PM, LPN #8/Unit 1 Coordinator was asked if [MEDICATION(S)] was fast acting or slow acting. LPN #8 stated, I have to google it .same thing as [MEDICATION(S)] .fast acting. During an Interview on 1/20/2022 at 12:20 PM, the Director Of Nursing (DON) was asked when should a resident receive a meal tray or substantial snack after receiving [MEDICATION(S)] insulin. The DON stated, .It should have been given within 30 minutes .

Based on medical record review, observation, and interview, the facility failed to provide timely assessments and treatments for pressure ulcers for 1 of 4 (Resident #87) sampled residents reviewed for pressure ulcers. The findings include: Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/4/19 documented, .has alteration in skin r/t (related to) dark and reddened areas to (R) (right) foot . The Admission assessment dated [DATE] documented, .bilat (bilateral) red heels and outer rt (right) heel dark purple area (possible SDTI) (suspected deep tissue injury) . Review of the wound assessments revealed no assessments were completed for Resident #87's sDTI from admission until 7/9/19. Review of the Treatment Administration Records dated (MONTH) and (MONTH) 2019 revealed there was no documentation of wound care treatment for [REDACTED]. Medical record review revealed the pressure ulcer to the right heel remained an unstageable pressure ulcer and had not worsened. Observations in Resident #87's room on 7/18/18 at 2:05 PM, revealed Resident #87, she had a unstageable pressure injury to the right lateral heel. Interview with the Director of Nursing (DON) on 7/31/19 at 2:38 PM, in the Education Room, the DON was asked if Resident #87 was admitted with any pressure ulcers. The DON stated, .she had a suspected deep tissue injury .outer right heel . The DON was asked if weekly skin assessments and treatments should have been done. The DON stated, Yes. The DON was asked when the wound assessments and treatments began. The DON stated, .we started (MONTH) 2nd . The facility was unable to provide documentation that wound assessments and treatments were provided for Resident #87's pressure ulcer that was identified on 6/4/19, until 7/2/19.

Based on policy review, medical record review, and interview, the facility failed to inform 1 of 2 (Resident #39) sampled residents of a roommate change of the 19 Residents interviewed in stage 1. The findings included: The facility's PATIENT RIGHTS policy documented, .At all times you will be notified of a change in your room or in your roommate . Medical record review revealed Resident #39 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15 indicated she was cognitively intact. Interview with alert and oriented Resident #39 on 7/5/16 at 5:08 PM, in the resident's room, Resident #39 was asked, have you been moved to a different room or had a roommate change in the last 9 months. Resident #39 stated, Yes. Resident #39 was asked, were you given notice before a room change or a change in roommate. Resident #39 stated, .did not tell me about a roommate change . Interview with alert and oriented Resident #39 on 7/7/16 at 3:31 PM, on the 200 hall, Resident #39 stated, I got a new roommate last night. When asked if she was informed of getting a new roommate, Resident #39 stated, No There was no documentation in the medical record that Resident #39 had been notified of a change of roommate. Interview with the Social Services Director (SSD) on 7/7/16 at 5:24 PM, the SSD confirmed there was no documentation that Resident #39 had been informed of a change in her roommate.

Based on policy review, medical record review, observations, and interview, the facility failed to monitor behaviors for 1 of 2 (Resident #146) sampled residents of the 2 residents reviewed with behaviors; failed to ensure communication between the facility staff and Hospice for 1 of 1 (Resident #60) sampled residents reviewed for hospice services, and failed to provide treatment to 1 of 1 (Resident #60) sampled residents with skin tears observed during a random observation. The findings included: 1. The facility's Behavior Documentation policy documented, .Behaviors are documented numerically on an every shift basis . Medical record review revealed Resident #146 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] documented Resident #146 had severe cognitive deficits, hallucinates and had delusions, and exhibited physical and verbal behaviors towards others. The physician's orders [REDACTED].[MEDICATION NAME] 125 mg (milligram) .Give two (2) capsules twice daily . The Physician's Progress Note dated 6/7/16 documented, .Patient is on [MEDICATION NAME] for behavior modification . The Medication, Treatment and Task Administration Record Report dated June 2016 did not document behavior monitoring after June 6, 2016, 7am-7pm shift. Interview with Registered Nurse (RN) #1 on 7/7/16 at 10:03 AM, at the Unit 1 nursing station, RN #1 was asked why Resident #146 was on [MEDICATION NAME]. RN #1 stated, .in the physician's progress note, it states the [MEDICATION NAME] is prescribed for behavior modification . RN #1 was asked if Resident #146 behaviors should then be monitored every shift. RN #1 stated, I would think so, yes, yes .I can see in the nurses notes they are monitoring behaviors but it is not shift to shift . Observations in Resident #146's room on 7/5/16 at 3:54 PM, revealed Resident #146 in her rock and go wheelchair and attempted multiple times to get out of her chair. Resident #146's sitter was encouraging her to stay seated. Observations at the Unit 1 nursing station on 7/7/16 at 8:27 AM, revealed Resident #146 sitting in her rock and go wheelchair opposite the nursing station. Resident #146 attempted to get out of her chair and disconnected her chair alarm. Resident #146 stated loudly, That stupid thing is going off once again! Interview with the Director of Nursing (DON) on 7/7/16 at 11:45 AM, in the DON's office, the DON was asked if Resident #146's behavior's should have been monitored. The DON stated, .her behavior monitoring every shift should not have been discontinued . 2. The facility's contract with Named Hospice services documented, .Coordination of care .Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day . Medical record review revealed Resident #60 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse (LPN ) #1 on 7/7/16 at 8:00 AM, at the 300 Hall nurses' desk, the LPN was asked where Resident #81's hospice notes were. The LPN stated, .don't have access to the hospice notes . Interview with LPN #2 on 7/7/16 at 8:02 AM, at the 300 Hall nurses' desk, the LPN stated, .they document on their tablet .have a lot of their paperwork in (Team Coordinator) office .Usually here 2-3 times a week . Interview with the 300 Hall Team Coordinator on 7/7/16 at 8:05 AM, the 300 Hall Team Coordinator went to her office and brought to this Surveyor a small stack of Hospice notes. The 300 Hall Team Coordinator was asked how nurses would know what hospice did if they do not have access to the hospice notes. The 300 Hall Team Coordinator stated, I see what you mean. Interview with the 300 Hall Team Coordinator on 7/7/16 at 8:30 AM, in the Team Coordinator's office, the 300 Hall Team Coordinator was asked if the small stack of papers from hospice was all the documentation that they had. The 300 Hall Team Coordinator gave surveyor a large stack of papers from hospice stating, This is what they gave me .my fault. They just come in and hand me a stack . Interview with Hospice RN on 7/7/16 at 10:31 AM, in the education room, the Hospice RN was asked if notes are documented in a tablet, how would the staff nurses get the report. The Hospice RN stated, .I don't know. Interview with the Director of Nursing (DON) on 7/7/16 at 6:15 PM, in the DON office, the DON stated, .there needs to be better communication with hospice . 3. The facility's Accidents and Untoward Occurrences policy documented, .Charting Guidelines .Skin Tears .Description of what happened, if witnessed. If the patient states that a specific object caused the skin tear, document what the patient said .Description of the skin tear .First aid treatment rendered .Notification of physician .Notification of family .Patient's reaction to injury .Initiate Alert Charting . Medical record review revealed no documentation of a skin tear for Resident #60. Observations on 7/5/16 at 12:00 PM and on 7/6/16 at 8:32 AM, revealed 2 dressings on Resident #60's right elbow area dated 6/26 . Interview on 7/7/16 at 8:17 AM, the 300 Hall Team Coordinator confirmed there was no documentation of skin tears to Resident #60's arm. The 300 Hall Team Coordinator was asked if it was acceptable not to provide treatment for [REDACTED]. The 300 Hall Team Coordinator stated, No . Interview with the Director of Nursing (DON) on 7/7/16 at 6:15 PM, in the DON office, the DON stated, .someone should have caught that the dressing had not been changed .

Based on medical record review, observation, and interview, the facility failed to ensure care plan interventions were followed for falls for 1 of 21 (Resident #144) sampled residents reviewed of the 37 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #144 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment, and that Resident #144 required extensive staff assistance for activities of daily living. The MDS documented Resident #144 was not steady and required human assistance to stabilize when moving from a seated to a standing position, and with surface-to-surface transfers. The MDS documented no falls since the prior assessment. The care plan dated 6/5/15 documented, .PROBLEM. Safety risk. at high risk for falls. does not often recognize her limitations. APPROACHES. Keep Wheelchair out of patients (patient's) sight when she is in bed. Observations in Resident #144's room on 6/22/15 at 4:43 PM and 6/23/15 at 7:23 AM and 3:35 PM, revealed Resident #144 lying in the bed with the wheelchair at the bedside within her sight. Interview with Licensed Practical Nurse (LPN) #2 on 6/23/15 at 3:27 PM, at the unit 4 nurses' station, LPN #2 was asked to explain the care plan intervention related to keeping the wheelchair out of Resident #144's sight while she was in bed. LPN #2 stated, That is because when she sees it (wheelchair), she thinks she can get up and go by herself. But, she is not safe to go by herself. Interview with LPN #2 on 6/23/15 at 3:35 PM, in Resident #144's room, LPN #2 was asked if the wheelchair was in the resident's sight at this time while she is in bed. LPN #2 stated, Yes. Right now it is.

Based on closed medical record review and interview, the facility failed to follow physician's orders for the administration of intravenous (IV) antibiotics for 1 of 37 (Resident #329) sampled residents included in the stage 2 review. The findings included: Closed medical record review revealed Resident #329 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #329 had a cognitive score of 12 indicating the resident was moderately impaired. The Medication Discharge Report documented, 3/26/15. [MEDICATION NAME] 2 gm, (gram) Intravenous (IV), Every 24 hours, stop date 4/27. The Medication, Treatment and Task Administration Record Report for March 2015 documented the IV antibiotic [MEDICATION NAME] was administered one time on 3/27/15. The facility HISTORY & (and) PHYSICAL documented, DOS (date of services) 3/28/15. presented (named the hospital). with fever and chills and back pain. Evaluation accomplished in the hospital revealed that she has a bacterial endocarditis. has been transferred here for continued IV antibiotic therapy, which she will need for a total of six weeks. The Telephone Orders documented, .4/15/15. pt (patient) went out to Cardiologist apt (appointment) and was admitted to Hospital from that apt. The hospital Discharge Summary documented, .admitted : 4/14/15. Dischg (discharge) 4/21/15. History and Physical. recent admission for group B [DIAGNOSES REDACTED] bacteremia was suspected endocarditis, bioprosthetic aortic valve, severe back pain secondary to a [MEDICATION NAME] 12 compression fracture. was recently discharged to (named nursing home facility) after being admitted here. diagnosed with [REDACTED]. On presentation to the. clinic, it was determined that her antibiotic course was shortened by 1 month and given her symptoms of nausea, vomiting, and worsening back pain. will be admitted to the hospitalist service. and re-initiation of her antibiotics as there is a concern for recurrent bacteremia. Interview with Registered Nurse (RN) #1 on 6/23/15 at 5:46 PM, in the team coordinator's office, Registered Nurse (RN) #1 was asked if she had admitted Resident #329. RN #1 stated, I did not admit her myself. was admitted with endocarditis. had order with IV antibiotics. for recovery of endocarditis. that was her main admitting. RN #1 was asked why Resident #329 had been admitted to the hospital after her doctor's appointment. RN #1 stated, What happen was on the initial orders [MEDICATION NAME] and [MEDICATION NAME] was to run for 10 days. (named the Assistance Director of Nursing (ADON)) put in the order. She hit the zero. was dc'd (discontinue) out the following day had gotten only one day of the [MEDICATION NAME] until the follow up appt. I was concerned about the mistake. Interview with the Director of Nursing (DON) on 6/24/15 at 6:15 AM, in the care plan office, the DON was asked why Resident #329 was hospitalized on ,[DATE]. The DON stated, Went to doctor's appointment. We sent copy of medication list. Doctor called back. she (Resident #329) was supposed to be on 2 antibiotics for 20 something days. (one medication) was put in on admission wrong. Only got 1 of the antibiotics ([MEDICATION NAME]) for 1 day. The stop date was 4/27 and she (named ADON) put in 3/27. The doctor was concerned because she only got 1 day of 1 of the antibiotics was going to put her in. Interview with Licensed Practical Nurse (LPN) #1 on 6/24/15 at 8:04 AM, in the team coordinator office on unit 1, LPN #1 was asked if she had taken care of Resident #329. LPN #1 stated, One or two times. came in with endocarditis. that was her primary diagnoses. she had good and bad days. went to the cardiologist appointment and was straight admitted to the hospital from there. The day I was here the doctor's office called and was looking at medication list. Wanted to know why she wasn't getting the other antibiotic ([MEDICATION NAME]). It was dc'd or something, wasn't given the way it should have been. Interview with the ADON on 6/24/15 at 9:50 AM, in the DON's office, the ADON was asked about Resident #329 antibiotics. The ADON stated, I put her meds in the computer. I don't know how I did it. I put in wrong date (on one medication). The hospital called and said she was being readmitted that they had discovered she wasn't getting her antibiotics as ordered. I talked to the husband and son. Told them both what happened.

Based on medical record review, observation, and interview, the facility failed to ensure a resident, who were unable to carry out activities of daily living (ADLs), received the necessary assistance with dining for 1 of 4 (Resident #252) sampled residents reviewed for ADL care of the 37 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #252 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] documented Resident #252 was severely cognitively impaired, required extensive staff assistance for eating. The care plan dated 4/13/15 documented, .requires max (maximum) assist (assistance) with ADLs. PROBLEM. Altered Food and/or Intake as evidenced by. Hospice services. Encourage greater than 75% intake of diet, supplements, fluid. A hospice case conference summary dated 6/18/15 documented, .Re-Evaluation of patient's overall condition during the past benefit period reveals: FUNCTIONAL DECLINE NOTED IN THAT PT (patient) IS NO LONGER ABLE TO FEED HERSELF AND HAS BECOME A DEPENDENT DINER. TOTAL ASSIST ADL'S. The physician's orders [REDACTED]. The nurses' note dated 3/24/15 documented Resident #252 was a dependent diner. Nurses' notes dated 4/15/15 and 4/29/15 documented Resident #252 required total staff assistance for ADLs. A nutritional assessment dated [DATE] documented, .Describe the patient's ability to feed themselves: Limited or Extensive Assistance. Deteriorated/Dependent ADL status. Observations on 6/22/15 at 12:35 PM, in the unit 4 dining room revealed Resident #252 sitting at a table alone in a wheelchair. There was a glass of tea with a plastic cover on the table in front of her. Resident #252 was using a spoon to scoop at the cover on the top of the tea glass. Certified Nursing Assistant (CNA) #1 placed a lipped plate containing pureed foods (chicken, potatoes, cabbage) on the table in front of the resident, and placed a straw in the tea glass. CNA #1 left the resident to eat independently. Resident #252 poured the tea out over the pureed food in her plate. CNA #2 observed the Resident pouring the tea over the food and stated, Oh, (named Resident #252). CNA #2 did not get the resident a new plate. At 12:50 PM, CNA #2 gave Resident #252 a bite of potatoes from the same plate, and left the resident to try and finish eating from the same plate independently. At 12:55 PM, CNA #1 removed the plate of approximately 50% of the remaining food from the table. Interview with the Director of Nursing (DON) on 6/24/15 at 5:30 PM, in the education room, the DON was asked what she expected the nursing staff to do for hospice residents related to feeding assistance. The DON stated, They are to provide all of that (assistance). The DON was asked if Resident #252 should always receive feeding assistance. The DON stated, Off the top of my head, I can't remember. The DON confirmed a new plate of food should have been provided when the cognitively impaired resident poured tea onto her pureed food.

Based on policy review, medical record review, observation, and interview, the facility failed to implement falls interventions for 1 of 3 (Resident #144) sampled residents of 5 residents reviewed with falls. The findings included: The facility's FALLS policy documented, .PURPOSE. To reduce patient risk of falling. Post falls nursing assessment to be completed when patient incident occurs. Intervention to prevent further falls to be put in place at the time of the incident. Interventions will be added to the multidisciplinary (multidisciplinary) note and Care Plan Coordinator notified of intervention. Staff will be notified of intervention. Medical record review revealed Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #144 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment, and that Resident #144 required extensive staff assistance for activities of daily living. The MDS documented the resident was not steady and required human assistance to stabilize when moving from a seated to a standing position, and with surface-to-surface transfers. The MDS documented no falls since the prior assessment. The care plan dated 6/5/15 documented, .PROBLEM. Safety risk. at high risk for falls. does not often recognize her limitations. APPROACHES. Keep Wheelchair out of patients (patient's) sight when she is in bed. A Post Falls Nursing Assessment dated 6/20/15 documented, .6/19/2015 9:20 PM. PT (patient) WAS FOUND SITTING IN THE FLOOR NEXT TO HER BED. PT STATED THAT SHE WAS GETTING UP TO USE THE BATHROOM AND SLIPPED. PT WAS PLACED BACK INTO HER WC (wheelchair). fell from bed to go bathroom. Observations on 6/22/15 at 4:43 PM, and 6/23/15 at 7:23 AM and 3:35 PM, in Resident #144's room revealed Resident #144 lying in the bed with the wheelchair at bedside within her sight. Interview with Licensed Practical Nurse (LPN) #2 on 6/23/15 at 3:27 PM, at the unit 4 nurses' station, LPN #2 was asked to explain the care plan intervention related to keeping the wheelchair out of Resident #144's sight while she is was in bed. LPN #2 stated, That is because when she sees it, she thinks she can get up and go by herself. But, she is not safe to go by herself. Interview with LPN #2 on 6/23/15 at 3:35 PM, in Resident #144's room, LPN #2 was asked if the wheelchair was in the resident's sight at this time while she is in bed. LPN #2 stated, Yes. Right now it is. Interview with the Director of Nursing (DON) on 6/24/15 at 5:30 PM, in the education room, the DON was asked whether she expected the staff to follow fall interventions. The DON confirmed that she did.

Based on observation and interview, the facility failed to ensure all call systems were functioning properly in 1 of 4 (100 hall shower room) common shower areas. The findings included: Observations during the initial tour of the 100 hall on 6/22/15 at 9:35 AM, revealed the emergency call light in the 100 hall shower room would not sound an alarm and there was no light above the door. Interview with Registered Nurse (RN) #1 on 6/23/15 at 7:53 AM, in the 100 Hall, RN #1 was asked if the shower room was used by residents. RN #1 stated Yes. RN #1 was asked if the call light was functioning. RN #1 stated, No, it is not.

Based on policy review, medical record review, observation and interview, it was determined the facility failed to follow the care plan intervention of a bed alarm for 1 of 20 (Resident #233) sampled residents reviewed of the 37 residents included in the stage 2 review. The findings included: Review of the facility's "Post Falls Intervention" policy documented, "...Bed Alarm..." Medical record review for Resident #233 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a "High-Risk Patient Selection Form" dated 12/1/13 documented the resident was at risk for falls. Review of the care plan dated 12/6/13 and updated 1/10/14 documented, "...PROBLEM PRIORITY... Falls, at risk for as evidenced by... is assisted with ambulation... APPROACHES... Bed alarms placed..." Observations in Resident #233's room on 2/4/14 at 2:33 PM and 3:00 PM and on 2/5/14 at 7:25 AM and 8:50 AM, revealed Resident #233 lying in bed, with no bed alarm in place as care planned. During an interview in Resident #233's room on 2/5/14 at 8:50 AM, Nurse #2 was asked to locate Resident #233's bed alarm. After checking the bed, Nurse #2 stated, "I will, embarrassingly, tell you it's not there..."

Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure a bed alarm intervention to prevent accidents/falls was implemented for 1 of 3 (Resident #233) sampled residents reviewed of 7 residents with falls of the 37 residents included in the stage 2 review. The findings included: Review of the facility's "Post Falls Intervention" policy documented, "...Bed Alarm..." Medical record review for Resident #233 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "High-Risk Patient Selection Form" dated 12/1/13 documented the resident was at risk for falls. Review of the care plan dated 12/6/13 and updated 1/10/14 documented, "...PROBLEM PRIORITY... Falls, at risk for as evidenced by... is assisted with ambulation... APPROACHES... Bed alarms placed..." Observations in Resident #233's room on 2/4/14 at 2:33 PM and 3:00 PM, and on 2/5/14 at 7:25 AM and 8:50 AM, revealed Resident #233 lying in bed, with no bed alarm in place. During an interview in Resident #233's room on 2/5/14 at 8:50 AM, Nurse #2 was asked to locate Resident #233's bed alarm. After checking the bed, Nurse #2 stated, "I will, embarrassingly, tell you it's not there..."

Based on medical record review and interviews, it was determined the facility failed to ensure appropriate treatment and services were provided to correct the assessed behaviors of crying, agitation and restlessness for 1 of 3 (Resident #203) sampled residents with behavioral problems of the 37 residents included in the stage 2 Review. The findings included: Medical record review for Resident #203 documented an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of a behavior assessment dated [DATE] documented, "...Antipsychotic Drug Use... [MEDICATION NAME] 25mg (milligram)... Reason for Use Dementia... behavioral disturbance Hx (history) of hallucinations... Notify the drug review committee or consulting pharmacist that the resident is in the Fall Prevention Program and their use of antipsychotic medication should be reevaluated..." Review of the care plan dated 12/13/13 revealed the care plan had not been updated to address the behavioral problems of crying, agitation and restlessness. Review of the Minimum Data Set ((MDS) dated [DATE], documented that Resident #203 exhibited hallucinations, [MEDICAL CONDITION], other behavioral symptoms not directed toward others and rejection of care on 1 to 3 days during the 30 days after admission. Review of physician orders [REDACTED]. Review of a physician's progress notes documented the following: a. 12/24/14 - "...Patient is being seen this day for agitation and restlessness. She has had some delusional thought as well as thinking that her family has abandoned her here. She has been very disruptive to her peers as well... IMPRESSION... Dementia with [MEDICAL CONDITION] and behavioral problems..." b. 12/26/13 - "...The patient is being seen today per family request reported that she has had increased sedation. Apparently the patient had a bad day on Monday with excessive crying and tearfulness. She was placed on a milligram of [MEDICATION NAME] q4 as needed and [MEDICATION NAME] was increased from 25 mg q.h.s. (every hour of sleep) to 25 mg b.i.d. She was also given a loading dose of 25 mg. Prior to going to her daughter's house, she received a milligram of [MEDICATION NAME] and 2 doses of [MEDICATION NAME]. Today, family reports that she has been more alert though she is not participating as well in therapy. She is acting like she is having more difficulty moving her legs and leaning somewhat to the right... Impression... Lethargy most likely medication related..." c. 12/28/13 - "...dementia occasionally with behavior disturbances..." During an interview at the 200 hall nurse's station on 1/4/14 at 5:00 PM, Nurse #4 was asked what type of behaviors were displayed by Resident #203. Nurse #4 stated, "She's crying out a lot and fights staff." Nurse #4 was asked what type of behavioral management the staff uses. Nurse #4 stated, "Diversional activities and calls daughter." Nurse #4 was asked if Resident #203's behavior warranted an increase in her [MEDICATION NAME]. Nurse #4 stated, "No, not really." Nurse #4 was asked if she thought Resident #203 would benefit from social services. Nurse #4 stated, "Probably." During an interview in the Director of Nursing's (DON) office on 1/4/14 at 6:10 PM, the DON was asked what were her expectations of the staff after a resident falls. The DON stated, "They should assess the resident, identify the cause if possible, identify immediate interventions and apply to care plan, notify the physician and family." The DON was asked what type of behavioral management does your staff use beyond drugs. The DON stated, "We have diversional activities, and we call the families to get involved. We have a psychologist and social service involvement." The DON was asked why this resident's [MEDICATION NAME] was increased on 12/24/13. The DON stated, "...increased confusion and agitation..." The DON was asked if she thought this resident would benefit from social services. The DON stated, "Yes." The DON was asked if the resident had a psychology (psych) consult. The DON stated, "I don't think so... to be honest with you. I think we should have had psych services review resident..."

Based on policy review, medical record review, observation and interview, it was determined the facility failed to provide appropriate care and treatment for [REDACTED]. The findings included: Review of the facility's "PRESSURE ULCER PREVENTION" policy documented, "...PATIENT CARE PLAN; STRATEGIES FOR INTERVENTION... Orders are implemented promptly and the physician is kept informed of wound progress and/or the lack there of..." Review of the facility's "SKIN INTEGRITY PREVENTION AND MANAGEMENT" policy documented, "ASSESSMENT GUIDELINES... Current treatment and a patient's response to treatment and progress toward healing..." Medical record review for Resident #330 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the interim care plan dated 1/13/14 and updated 1/28/14 documented, "...Alteration in skin integrity... potential (marked)... Stage: Coccyx... Wound/skin/surgical wound care as ordered (marked)... 1/28 ordered wound care..." Review of the "Admission Nursing Assessment" dated 1/13/14 documented Resident #330 with redness to the coccyx. Review of the weekly wound assessment dated [DATE] documented Resident #330 with a stage 1 pressure ulcer to the coccyx. Review of the weekly wound assessment progress note dated 1/14/14 documented, "...Wound assessment complete. Stage I to coccyx... Red, non- blanchable area... Cleansed buttocks, pat dry, apply [MEDICATION NAME] BID (twice a day) et (and) PRN (as needed). Keep pt (patient) turned side to side... Will cont (continue) to monitor et tx (treatment) as indicated..." Review of the "Discontinued Medication Order" documented, "...CLEAN BUTTOCKS, PAT DRY. APPLY [MEDICATION NAME] TO BUTTOCKS QID... Stage I to coccyx effective 1/13/14..." Review of the Treatment Administration Record (TAR) for January 2014 documented, "...CLEAN BUTTOCKS, PAT DRY, APPLY [MEDICATION NAME] TO BUTTOCKS QID (four times a day)... Diagnosis... stage 1 to coccyx... effective 1/13/14..." Signed out 1/20/14. There were no orders for wound care until 1/20/14 and no documentation wound care was performed other than on 1/14/14 and 1/20/14. Resident #330 was hospitalized from [DATE] through 1/28/14 due to decreased oxygen saturations. Review of the 1/28/14 "Admission Nursing Assessment" (readmission from hospital) documented Resident #330 with redness to the coccyx. Review of the weekly wound assessment dated [DATE] documented Resident #330 with a unstageable pressure ulcer to the coccyx and the left upper thigh. Review of the "Ancillary Orders" documented, "...CLEAN COCCYX AND LEFT UPPER THIGH (BACK), PAT DRY. APPLY SKIN PREP TO PERIWOUND AREA, THEN APPLY [MEDICATION NAME] TO WOUND BED AND COVER WITH ALLEVYN DRESSING... Every 3 days... Start: 02/01/2014... Diagnosis... stage II effective 1/28/14..." Review of the "Medication Order" documented, "...CLEAN COCCYX AND LEFT UPPER THIGH (BACK), PAT DRY. APPLY SKIN PREP TO PERIWOUND AREA, THEN APPLY [MEDICATION NAME] TO WOUND BED AND COVER WITH ALLEVYN DRESSING Q (every) 3 DAYS AND PRN (as needed) unstageables to coccyx and left thigh effective 1/28/14..." Review of the February 2014 TAR documented the following: a. "...CLEAN COCCYX, PAT DRY. APPLY SKIN PREP TO PERIWOUND AREA, THEN APPLY [MEDICATION NAME] TO WOUND BED AND COVER WITH ALLEVYN DRESSING. CHANGE Q (every) 3 DAYS AND PRN (as needed)... Start: 02/01/2014 DC (discontinue) Date: 02/04/2014... Diagnosis... stage II effective 1/28/14..." and signed out as done 2/1/14. b. "...CLEAN COCCYX AND LEFT UPPER THIGH (BACK), PAT DRY. APPLY SKIN PREP TO PERIWOUND AREA, THEN APPLY [MEDICATION NAME] TO WOUND BED AND COVER WITH ALLEVYN DRESSING. CHANGE Q 3 DAYS AND PRN... Start: 02/01/2014... Diagnosis... unstageables to coccyx and left thigh effective 1/28/14..." and signed out as done 2/4/14. Resident #330 returned from the hospital on [DATE], but there was no order for wound care until 2/1/14 and no documentation wound care was performed from 1/28/14 until to 2/1/14. Observations in Resident #330's room on 2/5/14 at 9:35 AM, the Treatment Nurse changed the dressings for the wounds to the left upper thigh (back) and the left coccyx of Resident #330. The wound to the left upper thigh (back) was pink to the edges, with a yellow wound bed. The wound to the left coccyx was pink to the edges, with the wound bed yellow and approximately 40 percent necrosis noted. No redness or [MEDICAL CONDITION] was noted to either wound. During an Interview at the 100 Hall nurses' station on 2/4/14 at 3:30 PM, Nurse #3 was asked about the wound to the coccyx area documented as redness/stage 2 on 1/28/14 return from hospital and as unstageable 1/29/14 on the wound care assessment. Nurse #3 stated, "...I was not here when the resident returned from the hospital... assessed the wound the next day after he came back from hospital.... it was necrotic... the nurses are not supposed to assess/stage the wounds... because they are not always correct... I am supposed to do that... the first order was incorrect that stated stage 2, that is why I had to modify it..." Nurse #3 confirmed there was no documentation of the wound care being performed to the coccyx until 2/1/14 and to left thigh until 2/4/14. During an Interview in the education room on 2/4/14 at 4:20 PM, Nurse #3 was asked about the stage 1 wound to coccyx effective 1/13/14 and no orders for wound care until 1/20/14. Nurse #3 confirmed there should have been orders for a stage 1 wound, and stated, "should have called doctor and written wound care orders, cannot find until this date..."

Based on medical record review and interviews, it was determined the facility failed to revise the comprehensive care plan to address behaviors for 1 of 20 (Resident # 203) sampled residents of the 37 residents included in the stage 2 Review. The findings included: Medical record review for Resident #203 documented an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], documented that Resident #203 exhibited hallucinations, [MEDICAL CONDITION], other behavioral symptoms not directed toward others and rejection of care on 1 to 3 days during the 30 days after admission. Review of physician orders [REDACTED]. Review of a physician's progress notes documented the following: a. 12/24/14 - "...Patient is being seen this day for agitation and restlessness. She has had some delusional thought as well as thinking that her family has abandoned her here. She has been very disruptive to her peers as well... IMPRESSION... Dementia with [MEDICAL CONDITION] and behavioral problems..." b. 12/26/13 - "...The patient is being seen today per family request reported that she has had increased sedation. Apparently the patient had a bad day on Monday with excessive crying and tearfulness... " The care plan dated 12/13/13 had not been updated to address the behavioral problems of crying, agitation and restlessness. During an interview at the nurse's station on 1/4/14 at 5:00 PM, Nurse #4 was asked what type of behaviors were displayed by Resident #203. Nurse #4 stated, "She's crying out a lot and fights staff." Nurse #4 was asked what type of behavioral management the staff uses. Nurse #4 stated, "Diversional activities and calls daughter."

Based on medical record review and interview, it was determined the facility failed to accurately assess hospice care for 1 of 18 (Resident #201) sampled residents of the 37 residents included in the stage 2 review. The findings included: Medical record review for Resident #201 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Resident #201's Minimum Data Set (MDS) documented the following: a. Annual MDS dated [DATE] - receiving hospice care. b. Quarterly MDS dated [DATE] - not receiving hospice care. c. Quarterly MDS dated [DATE] - receiving hospice care. Review of the January recertification orders dated 1/18/14 documented, "...06/08/2012 Hospice Services..." Review of the care plan dated 11/12/13 documented, "...receiving Hospice services for End stage late effects of [MEDICAL CONDITION]" During an interview in the education room on 2/5/14 at 3:05 PM, Nurse #1 was asked about the 8/3/13 quarterly MDS which documented Resident #201 was not receiving hospice. Nurse #1 stated, "...was an error... I did check the life expectancy of less than 6 months on it (MDS)..."

Intakes: TN 209 Based on policy review, medical record review and interview, it was determined the facility failed to notify the responsible party of a change in medication for 1 of 5 (Resident #1) sampled residents. The findings included: Review of the facility's "POLICIES AND PROCEDURES REGARDING CHANGE IN PATIENT STATUS" documented, "...The patient or decision maker is encouraged to be involved in all decision-making regarding changes in the plan of care..." Medical record review for Resident #1 documented an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Review of the "Nutritional Assessment Report" dated 6/28/13 documented, "...CBW (current body weight) 181 # (pounds); some variation since admit 16# (pound) (8.1% (percent)) compared to the stated UBW (usual body weight) 197#..." Review of the physician's progress notes dated 7/1/13 documented, "...This patient was referred by the dietician due to having trigger for malnourishment on a recent assessment. He has a significant weight loss due to poor intake and has chronic [DIAGNOSES REDACTED].o. (by mouth) q.h.s. (every hour of sleep)..." Review of the physician's orders [REDACTED].O. (new order) rec'd (received) r/t (related to) wt (weight) loss..." There was no documentation the family was notified of this change. During an interview in the Director of Nursing's (DON) office on 8/13/13 at 3:00 PM, the DON was asked what is the responsibility of staff in relation to family when a resident has a change in condition or medication. The DON stated, "Family should be notified." The DON confirmed the responsible party was not notified of the new medication on 7/1/13 and stated, "I did become aware of this... that nurse was educated..."