Every finding on record at Northern Lakes Nursing and Rehabilitation Center

Based on observation, interview, and record review the facility failed to ensure infection control practices were observed for 7 of 24 residents reviewed (Resident 61, Resident 30, Resident 9, Resident 70, Resident 40, Resident 1, and Resident 86).Findings include:1) During an observation, on 12/01/2025 11:41 AM, Activity Aide (AA)2 served a sandwich, pasta salad, yogurt and peach cobbler to Resident 61 at a table in the dining room. Resident 30 was seated next to Resident 61 and did not have any food or drinks in front of her. On 12/01/25 at 11:43 AM, Resident 30 grabbed a bowl of cobbler from Resident 61, held it in her hands touching the cobbler and the bowl. On 12/1/2025 11:44 AM, AA2 removed the cobbler from Resident 30 and handed it back to Resident 61. Resident 70's lunch tray was served on 12/01/2025 12:05 PM. A few minutes after Resident 70's tray was served, Resident 9, seated next to Resident 70, grabbed Resident 70's silverware, touching handles and mouthpieces of the silverware. After Resident 9 laid the silverware back on the table, Resident 70 picked the silverware up and used it to eat.In an interview, on 12/01/2025 at 11:45 AM, AA2 indicated she should not have handed the cobbler back to Resident 61 after Resident 30 had touched it. She indicated she should have removed the cobbler and obtained a new serving from the kitchen.2. Resident 61's record was reviewed on 12/03/2025 11:25 AM. Diagnoses included Alzheimer's disease, depression, and muscle weakness. Resident 61's current quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 14 (cognitively intact). The MDS indicated Resident 61 needed supervision and touching assistance with dining.Resident 61's current care plan titled I require assistance. indicated Resident 61 had a problem of dementia, with a goal date of 2/10/26. Interventions included supervising Resident 61 while eating.3) Resident 9's record was reviewed on 12/03/2025 12:23 PM. Diagnoses included Pick's disease and dementia, severe with mood disturbance.Resident 9's current quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated his Basic Interview for Mental Status (BIMS) was not conducted because he was rarely able to make himself understood. The MDS indicated Resident 9 was dependent for eating activities.Resident 9's current care plan titled I require assistance.indicated Resident 9 had a problem of functional decline, with a goal date of 2/7/26. Interventions included assisting Resident 9 with meals.4) Resident 70's record was reviewed on 12/3/25 at 11:57 AM. Diagnoses included cerebral infarction and dementia, moderate with agitation.Resident 70's current significant change Minimum Data Set assessment (MDS), dated [DATE], indicated his Basic Interview for Mental Status (BIMS) score was 3 (severely impaired). The MDS indicated Resident 70 needed partial or moderate assistance with eating tasks.A review of Resident 70's current care plan titled I require assistance.indicated Resident 70 had a problem of functional decline, with a goal date of 1/31/26. Interventions included providing close supervision and assistance during all meals.During an interview, on 12/03/2025 10:01 AM, the Director of Nursing indicated staff should serve resident trays and sit next to them providing any needed assistance. She indicated staff should supervise residents and ensure they do not touch one another's food or utensils. Any contaminated items should be immediately removed and replaced.A current policy titled Nursing Responsibilities for Meal Service, undated, provided by the DON on 12/3/25 at 12:40 PM, indicated nursing staff were expected to be available during mealtimes to assist with meal service. 5) During an observation on 12/2/25 at 11:48 AM, Certified Nurse Aide (CNA) 5, touched a pillow, personal items, a cup, and manually positioned Resident 40. CNA 5 touched her hair with her right hand and then obtained an iced tea pitcher, touching it with her right hand. CNA 5 touched a cup at the lip with her left index finger, poured, and gave the cup to Resident 40. CNA 5 then went into Resident 1's room, picked up a napkin from the floor with her right hand. She touched her hair with her right hand, picked up Resident 1's meal tray with both hands, and touched her left eye with her left hand. She went to the kitchen and stood inside the kitchen doorway. She returned to the unit, opened the door to the tray cart, pulled a tray out, and gave it to Resident 30. While serving Resident 30's tray, she touched her silverware, removed lids from bowls and cut Resident 30's food. No hand hygiene occurred during the continuous observation. In an interview, on 12/2/25 at 12:08 PM, CNA 5 indicated she should have used hand sanitizer when contacting anything or touching a resident. She indicated she should have washed her hands if she contacted something soiled. 6 ) Resident 40's record was reviewed on 12/3/25 at 1:41 PM. Diagnoses included heart failure and dementia.A current significant change MDS assessment, dated 11/11/25 indicated Resident 40 had a BIMS score of 14 (cognitively intact). The MDS indicated Resident 40 needed set-up assistance with meals.A current care plan titled I require assistance.indicated Resident 40 had a problem of declining condition, nearing end of life, with a goal date of 2/9/26. Interventions included setting up meals.7) Resident 1's record was reviewed on 12/03/2025 2:13 PM. Diagnoses included cerebrovascular accident with right sided hemiplegia.A current significant change in status MDS assessment, dated 10/14/25, indicated Resident 1 had a BIMS score of 13 (cognitively intact).A current care plan titled I require assistance.indicated Resident 1 had a problem of functional decline, with a goal date of 12/30/25. Interventions included setting up meals.8) Resident 30's record was reviewed on 12/2/25 at 10:42 AM. Diagnoses included neurocognitive disorder with Lewy bodies and major depressive disorder, recurrent.Resident 30's current quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 3 (severely impaired). The MDS indicated Resident 30 needed supervision and touching assistance with dining.Resident 30's current care plan, titled cognitive loss/dementia, indicated Resident 30 had a problem of severe cognitive impairment, with a goal date of 12/31/25. Interventions included setting up meals and assisting Resident 30 if she became tired.In an interview, on 12/2/25 at 2:02 PM, the DON indicated employees should wash their hands after every third tray and use hand sanitizer between each contact. She indicated staff should perform hand hygiene after any contact with their hair or face.A current policy titled Nursing Responsibilities for Meal Service, undated, provided by the DON on 12/3/25 at 12:40 PM, indicated hand sanitizing should occur at least every third tray passed and after every resident contact. A current policy titled Handwashing, dated 1/2025, provided by the Administrator on 12/2/25 at 1:35 PM, indicated hand hygiene should be performed after each direct resident contact, during meal service, and after touching one's face or hair.9) During an observation on 12/02/2025 11:36 AM, Housekeeper 6 was pulling linens off Resident 86's bed. Housekeeper 6 was not wearing gloves and held dirty linens against her body as she stuffed the linens into a plastic bag. In an interview, on 12/02/2025 11:37 AM, Housekeeper 6 indicated she was deep cleaning the room. She indicated she should have been wearing gloves when touching dirty linen and should ensure the contaminated linens did not touch her body. She indicated she got busy and forgot. 10) Resident 86's record was reviewed on 12/03/2025 2:35 PM. Diagnoses included chronic inflammatory demyelinating polyneuritis and acute pyelonephritis.A current significant change in status MDS assessment, dated 10/10/25, indicated Resident 86 had a BIMS score of 15(cognitively intact).A current policy titled Procedure for Handling Linens, dated 1/2025, provided by the DON on 12/3/2025 at 12:40 PM indicated soiled linen should be handled in such a way to prevent the spread of infection.A current policy titled Infection Control: Housekeeping, dated 1/2025, proved by the DON on 12/3/2025 at 12:40 PM indicated gloves should be worn when handling soiled linens and gowns or aprons may be indicated when contact with soiled items may be anticipated. 3.1-18(a)3.1-18(l)

Based on observation, interview, and record review the facility failed to ensure dignity was provided with timely meal service for residents seated together for 2 of 8 residents reviewed (Resident 30 and Resident 70).Findings include:During an observation on 12/01/2025 11:41 AM, Activity Aide (AA) 2 served a sandwich, pasta salad, yogurt and peach cobbler to Resident 61 at a table in the dining room. Resident 30 was seated next to Resident 61 and did not have any food or drinks in front of her. On 12/01/25 at 11:43 AM, Resident 30 grabbed the bowl of cobbler from Resident 61 and held it in her hands touching the cobbler and the bowl. On 12/1/2025 11:44 AM, AA2 removed the cobbler and handed it back to Resident 61. Resident 30 continued to lean toward and reach for Resident 61's food several times over the next few minutes. Resident 30's lunch tray was served on 12/01/25 at 12:05 PM, 24 minutes after the tablemate. In an observation, on 12/01/2025 11:52 AM, Resident 9 was served his lunch. On 12/01/2025 11:58 AM Resident 70, seated next to Resident 9 leaned toward and reached for Resident 9's food. Resident 70's lunch tray was served on 12/01/2025 12:05 PM, 13 minutes after the tablemate. In an observation, on 12/01/2025 12:05 PM, a few minutes after Resident 70's tray was served, Resident 9 grabbed Resident 70's silverware. No staff were in the immediate vicinity of the residents.1) Resident 30's record was reviewed on 12/2/25 at 10:42 AM. Diagnoses included neurocognitive disorder with Lewy bodies and major depressive disorder, recurrent.A review of Resident 30's current quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 3 (severely impaired). The MDS indicated Resident 30 needed supervision and touching assistance with dining.A review of Resident 30's current care plan titled cognitive loss/dementia indicated Resident 30 had a problem of severe cognitive impairment, with a goal date of 12/31/25. Interventions included setting up meals and assisting Resident 30 if she became tired.2) Resident 70's record was reviewed on 12/3/25 at 11:57 AM. Diagnoses included cerebral infarction and dementia, moderate with agitation.A review of Resident 70's current significant change Minimum Data Set assessment (MDS), dated [DATE], indicated his Basic Interview for Mental Status (BIMS) score was 3 (severely impaired). The MDS indicated Resident 70 needed partial or moderate assistance with eating tasks.A review of Resident 70's current care plan titled I require assistance.indicated Resident 70 had a problem of functional decline, with a goal date of 1/31/26. Interventions included providing close supervision and assistance during all meals.During an interview, on 12/03/2025 10:01 AM, the Director of Nursing indicated staff should serve a table at a time in the dining room, ensuring residents would not sit for long periods of time without food when others at their table had food. She indicated a 24-minute wait to be served after a table mate was served was an excessive wait. She indicated this was an undignified practice and should not have occurred.A current policy titled Nursing Responsibilities for Meal Service, undated, provided by the DON on 12/3/25 at 12:40 PM, indicated nursing staff were expected to be available during mealtimes to assist with meal service. The policy indicated meal trays should be distributed in a timely manner and residents should be assisted in eating as needed.3.1-3(a)

Based on interview and record review, the facility failed to ensure continuous and consistent communication with the dialysis center for 1 of 1 resident reviewed (Resident 6).Findings include:Resident 6's record was reviewed on 12/4/25 at 11:09 AM. Diagnoses included end stage renal disease and diabetes.Resident 6's Quarterly Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 15 (no impairment). The MDS indicated Resident 6 was dependent on dialysis.A physician order, dated 2/1/25, indicated Resident 6's vital signs were to be assessed prior to dialysis and upon return from dialysis.A review of Resident 6's dialysis treatment notes indicated the following:- notes dated 5/7/25 through 8/15/25 were uploaded on 8/18/25-notes dated 9/22/25 through 11/7/25 were uploaded on 11/11/25-notes dated 8/18/25 through 8/29/25 were uploaded on 12/4/25There was no consistent communication documented in the nurses notes, or in a binder to indicate consistent communication with the dialysis center was completed and available to ensure staff could access resident status before, during and after dialysis. In an interview, on 12/4/25 at 10:18 AM, the Director of Nursing (DON) indicated the facility did not communicate with the dialysis center daily on dialysis days. The DON indicated the resident was assessed before and after dialysis. The DON indicated the pre and post assessments were recorded in the resident's medical record. The DON indicated the facility did not utilize a communication binder. The DON indicated the facility communicated with the dialysis center as needed by phone. The DON indicated they were not aware of any requirement to maintain regular ongoing communication with the dialysis center.In an interview, on 12/4/25 at 1:20 PM, Registered Nurse (RN) 10 indicated pre and post dialysis assessments were recorded in the resident progress notes. RN 10 indicated the facility scanned dialysis center treatment notes into the medical record monthly.A current facility policy, dated 11/26/24, provided by the DON on 12/4/25 at 1:55 PM, indicated the facility would send all appropriate medical information with the resident to the dialysis center.3.1-37(a)

Based on observation, interview, and record review the facility failed to ensure a safe and homelike environment for 7 of 7 residents reviewed residing in rooms 17, 19, 20, and 21. Findings include:During a continuous observation on 12/1/25 between 10:50 AM through 11:35 AM, the following was observed:In room [ROOM NUMBER], a large section of marked and scuffed wall, approximately 3 feet by 4 feet, had 2 curls of peeling white substance behind the head of the resident's bed approximately 4 inches long. The wall damage in room [ROOM NUMBER] was visible from the hallway. In room [ROOM NUMBER], a 2 inch by 6 inch section of bathroom floor was missing. In room [ROOM NUMBER], black scuff marks were found on the bathroom door approximately 3 feet high and the full width of the door. Peeling paint with a section of exposed, soft drywall measured approximately 3.5 inch by 3.5 inch was found between the windowsill and room temperature control unit. One of three wooden trim pieces was missing on the left side of the temperature control unit. The wall damage in room [ROOM NUMBER] was visible from the hallway. In room [ROOM NUMBER], peeling paint was found next to the heater unit at the floor trim level. Flooring was missing, approximately 1 foot by 1 foot. The wall damage in rooms [ROOM NUMBERS] was visible from the hallway. In an interview, on 12/1/25 at 11:15 AM, Resident 1, identified as able to answer questions appropriately, indicated the wall damage in room [ROOM NUMBER] had occurred when their roommate had lived there. The former roommate needed mechanical assistance, and the wall had been hit by equipment. The former roommate had been gone from the room for 6 months. In an interview, on 12/3/25 at 1:00 PM, the Director of Maintenance indicated work orders included wheelchair and equipment maintenance, plumbing concerns, and lighting concerns. Any staff could submit a work order. No work orders for room [ROOM NUMBER] had been submitted. Once a month, maintenance was expected to inspect each room. The Director of Maintenance indicated he had forgotten resident's verbal requests for work. A current policy, reviewed in 2025, provided by the Assistant Administrator, indicated work orders were required to be completed to establish priority of maintenance services. Work order forms were to be maintained at nurse's stations. Every employee had a responsibility to fill out work orders.3.1-19(e)

Based on interview and record review, the facility failed to ensure the physician was immediately notified when 1 of 3 residents reviewed had a significant change in physical condition (Resident K). This resulted in Resident K's death. The Immediate Jeopardy began on [DATE] at 8:51 p.m. when Resident K complained of radiating pain to his left arm, shoulder, and chest. The facility failed to notify the physician of the change, and Resident K was observed to be deceased the following morning. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 12:45 PM. Immediate Jeopardy was removed on [DATE] but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy when the facility reeducated all staff on recognizing and communicating change of condition to the physician. Findings include:On [DATE] at 11:04 AM, Resident K's record was reviewed. Diagnoses included chronic obstructive pulmonary disease (COPD), mild dementia, nicotine dependence, intermittent atrial fibrillation , sick sinus syndrome(a rhythm disorder that occurs when the heart's pacemaker, the Sinoatrial node cannot produce a sufficient heart rate), and left shoulder pain due to degenerative joint disease.The most recent comprehensive Minimum Data Set assessment (MDS) indicated Resident K had clear speech, understood and was able to understand others, had a primary debility related cardiorespiratory conditions including atrial fibrillation, low blood sodium, High blood potassium, and COPD. The resident had mild to moderate cognitive impairment, . He had no behaviors or mood indicators. He was independent with his activities of daily living (ADL) but required set up assistance with bathing. During the assessment, he complained of pain in both shoulders but had not received any non-medical interventions. A pain interview indicated Resident K had moderate pain occasionally that did not interfere with activities. The MDS reflected Resident K took medications related to Atrial fibrillation, and a medication to help him sleep at night due to insomnia.Care Plans indicated Resident K was at risk for pain related to multiple old fractures but did not include shoulder pain. The care plan indicated to give medications as ordered, and if the medication was not effective in controlling the pain, or pain worsened, to notify the physician. A care plan regarding intermittent irregular heartbeat indicated to assess for shortness of breath and follow the physician's orders, monitor and assess breath sounds and complaints of shortness of breath, and notify the physician for worsening shortness of breath. The care plan indicated Resident K had insomnia and requested staff not disturb him at night. A Nurse Practitioner (NP) progress note, dated [DATE], indicated Resident K was being seen for follow up after a left shoulder x-ray was completed due to left shoulder pain. The x-ray indicated degenerative joint disease. Referral to Orthopedics vs conservative management was discussed with the resident and he chose to continue current treatment with topical medications and physical therapy. He was planning to be discharged from the facility at the end of the month. His respirations were regular with scattered crackles. Resident K denied chest pain and palpations. A nurse note, dated [DATE] at 8:51 p.m., indicated the nurse had been called to Resident K's room. Resident K complained of left shoulder pain and it was hard to breathe. His oxygen saturation was 92% (normal >90%) on room air. His blood pressure was normal at 108/68, and pulse was 100. The resident was resting and wanted to see if he felt better. The nurse gave as needed (prn) medications at 8:51 pm but did not chart what medications were given or interventions attempted. The note did not indicate the physician had been notified of Resident K's change in shoulder pain.No pain assessment, pain scale, assessment of respiration rate or character was documented. A nurse note, dated [DATE] at 8:14 a.m., indicated Certified Nurse Aide (CNA) 6 came to get the nurse to check on the resident. Resident K was observed to not be breathing and he had no pulse. CPR was not initiated due to irreversible signs of death. The resident family member and NP were notified of the resident's death. There was no documentation the physician was notified of Resident K's change in condition on [DATE] until after Resident K was found breathless and pulseless on [DATE].According to the article titled shoulder pain causes and treatment, dated [DATE], retrieved from my.clevelandclinic.org on [DATE] symptoms of cardiac dysrhythmia included palpitations, shortness of breath and chest discomfort. The website indicated to get immediate help when trouble breathing or left shoulder pain occurred. The article indicated when shoulder pain did not improve, was severe, or worsening, the patient could be experiencing a heart attack and to notify the physician immediately.There was no documentation between [DATE] at 8:51 p.m. and [DATE] at 8:14 a.m. regarding assessing the resident for continued or worsening pain, or any notification of the Registered Nurse on duty or the physician. A review of Resident K's physician's orders indicated to administer Tylenol 500 mg 2 tablets every 4 hours as needed for pain and to apply Voltaren gel to the resident's left shoulder three times per day as needed. There were no orders for routine pain medications. According to the article titled Tylenol, dated [DATE], retrieved for drugs.com on [DATE], pain should be monitored and when pain was new, continued without relief, or worsened, the physician should be notified immediately.Resident K's Medication Administration Record (MAR), dated [DATE], indicated Resident K received Tylenol for generalized pain on [DATE] at 8:50 p.m. and the dose was effective. There was no documentation Tylenol had been given on [DATE].Resident K's Treatment Administration Record (TAR), dated [DATE], did not indicate Resident K had utilized the Voltaren gel. In an interview, on [DATE] at 2:15 PM, Licensed Practical Nurse (LPN) 3 indicated she worked on Resident K's hall on [DATE] into the morning of [DATE]. She indicated the resident had an appointment to see the orthopedic physician pending. Since admission, Resident K would get upset when anyone would come in his room at night, because he could not get back to sleep, so staff limited how often they went into his room. LPN 3 indicated LPN 2 did not indicate in report Resident K had been given any prn medications or she would have assessed the resident at night. LPN 3 did not assess Resident K because she had not been informed the resident had been given any medications or had any pain. She indicated CNA 7 changed Resident K's ice water at 1:00 am, but she did not look at the resident. LPN 3 indicated when changes in condition occur, the physician should be notified immediately.In an interview, on [DATE] at 3:50 PM, Certified Nurse Aide (CNA) 4 indicated Resident K put on his call light about quarter till 9:00 pm on [DATE]. It was unusual for Resident K to use the call light, so CNA 4 went right away because the resident never put the call light on. Resident K told CNA 4 he was having pain in his left shoulder and arm going into his chest. Resident K looked uncomfortable, but CNA 4 could not put his finger on exactly why he felt that way. Resident K was rubbing his left shoulder and looked bad enough CNA 4 went to get the nurse right away. The resident usually did not need help, so CNA 4 did not check on him after reporting to LPN 2. In an interview, on [DATE] at 9:23 AM, LPN 2 indicated QMA 5 had given the resident an inhaler earlier in the day. The nurse indicated CNA 4 did not tell him the pain was radiating to the resident's chest. Resident K was sitting on the side of the bed, complaining his shoulder hurt. He does not remember a change in skin color. He did not assess the shoulder pain, his breath sounds, or his heart sounds. He indicated he asked the resident if he wanted to go to the hospital because he always asked residents if they wanted to go to the hospital. He did not call the physician because Resident K wanted to see if he felt better, but he did not go back and check on the resident. He did not report any issues to the nurse coming on shift.In an interview, on [DATE] at 10:41 AM, Qualified Medication Assistant (QMA) 5 indicated she had administered no prn medications to Resident K on the day shift of [DATE]. QMA 5 indicated Resident K looked to be his normal self, had no complaints of pain and was up and around the facility as usual. QMA 5 indicated when she saw a change in resident condition, she would report it to the nurse who would report it to the doctor.In an interview, on [DATE] at 11:19 AM, CNA 6 indicated she was taking Resident K's breakfast tray to him, and noticed him sitting up in bed, and slumped over. She indicated his color was gray, and when she touched his hand to wake him, his skin was cold and hard.A current undated policy, titled Change of Condition, indicated All staff members shall communicate any information about resident status change to appropriate licensed personnel immediately upon observation. The policy indicated when the nurse was notified of the change of condition, the nurse must immediately assess the resident, including vital signs, lung sounds, and other assessments as indicated by the change, including complaints of new or worsened pain. The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility conducted audits of current resident's condition to ensure no changes and re-educated nursing staff regarding assessments, documentation, and physician notification but will remain at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This Citation relates to Intake 2616068.3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure a resident's complaint of shoulder with radiating chest pain, increased heart rate and shortness of breath (SOB) was re-assessed after initial assessment and treatments given were not monitored for effectiveness for 1 of 3 residents reviewed for quality of care. Resident K was found deceased the following morning. The Immediate Jeopardy began on [DATE] at 8:51 p.m. when Resident K complained of radiating pain to his left arm, shoulder, and chest. The facility failed to assess and monitor his condition, and he was observed to be deceased the following morning. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 12:45 PM. Immediate Jeopardy was removed on [DATE] but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy when the facility re-educated all staff on recognizing and communicating change of condition. Findings include:On [DATE] at 11:04 AM, Resident K's record was reviewed. Diagnoses included chronic obstructive pulmonary disease (COPD), mild dementia, nicotine dependence, intermittent atrial fibrillation, sick sinus syndrome (a heart rhythm disorder that occurs when the heart's sinoatrial node cannot produce a sufficient heart rate, and left shoulder pain due to degenerative joint disease.The most recent comprehensive Minimum Data Set assessment (MDS) indicated Resident K had clear speech, understood and was able to understand others, had a primary debility related cardiorespiratory conditions including atrial fibrillation, low blood sodium, High blood potassium, and COPD. The resident had mild to moderate cognitive impairment, . He had no behaviors or mood indicators. He was independent with his activities of daily living (ADL) but required set up assistance with bathing. During the assessment, he complained of pain in both shoulders but had not received any non-medical interventions. A pain interview indicated Resident K had moderate pain occasionally that did not interfere with activities. The MDS reflected Resident K took medications related to Atrial fibrillation, and a medication to help him sleep at night due to insomnia.A care plans, dated [DATE], indicated Resident K used a hypnotic for sleep, and had insomnia. A care plan, dated [DATE], regarding pain indicated Resident K was at risk for pain related to multiple old fractures, but did not include shoulder pain. The care plan indicated to give medications as ordered, and if the medication was not effective in controlling the pain, or pain worsened, to notify the physician. Certified Nurse Aides (CNA) were to notify the nurse if pain increased or worsened. A care plan, dated [DATE], regarding intermittent irregular heartbeat indicated to assess for shortness of breath and follow the physician's orders; monitor; and assess breath sounds and complaints of shortness of breath. CNAs were to notify the nurse if shortness of breath increased. Physician's orders included to give metoprolol tartrate (for atrial fibrillation), 12.5 milligrams (mg), two times per day and to hold the medication for a heartrate less than 60, or a systolic (the top number on blood pressure) blood pressure of less than 60; midodrine (for low blood pressure) 5 mg, three times daily, and to hold the medication if the residents blood pressure was greater than 110, and to recheck the blood pressure after administration or if the blood pressure was outside of normal range; Tylenol (anti-inflammatory) 500mg 2 tablets as needed every 4 hours for pain, and Voltaren gel (pain reliever) topical to the left shoulder as needed; and Trazadone (an antidepressant) 50 mg at bedtime. According to the article metoprolol tartrate, dated [DATE], retrieved on [DATE] from drugs.com, the medication is used to treat heart failure related to atrial fibrillation. Side effects included slow heartbeats, and the patient should notify the physician for shortness of breath or worsening heart symptoms.According to the article Midodrine, dated [DATE], retrieved on [DATE] from drugs.com, the medication is used to treat low blood pressure. Side effects included slow pulse, and the patient should be closely monitored.According to the article titled Tylenol, dated [DATE], retrieved for drugs.com on [DATE], pain should be monitored and when pain was new, continued without relief, or worsened, the physician should be notified immediately.A Nurse Practitioner (NP) progress note, dated [DATE], indicated Resident K was seen for follow up after a left shoulder x-ray was completed due to arthritis. The x-ray indicated degenerative joint disease. Referral to Orthopedics vs conservative management was discussed with the resident and he chose to continue current treatment with topical medications and physical therapy. He was planning to be discharged from the facility at the end of the month. His respirations were regular with scattered crackles. Resident K denied chest pain and palpations. A nurse note, dated [DATE] at 8:51 p.m., indicated the nurse had been called to the resident's room. Resident K complained of left shoulder pain and indicated it was hard to breathe. His oxygen saturation was 92% (normal >90%) on room air. His blood pressure was normal at 108/68, and pulse was 100. The resident was resting and wanted to see if he felt better. The nurse gave as needed (prn) medications at 8:51 p.m. but did not chart what medications were given or interventions attempted. The documentation did not include a pain assessment, pain scale, respiration rate or character assessment. A nurse note, dated [DATE] at 8:14 a.m., indicated CNA 4 came to get the nurse to check on the resident. Resident K was observed to not be breathing and he had no pulse. CPR was not initiated due to irreversible signs of death. The resident family member and NP were notified of the resident's death. There was no further documentation between [DATE] at 8:51 p.m. and [DATE] at 8:14 a.m. when resident K was found breathless and pulseless. According to the American Heart Association Cardiopulmonary Resuscitation guidelines, dated [DATE], retrieved from cpr.herat.org, indicated left should pain radiating to the chest in a resident with cardiac history could be signs of a heart attack. The article indicated irreversible signs of death included rigor mortis and dependent lividity. A preliminary death certificate, dated [DATE], indicated the cause of Resident K's death was acute cardiac dysrhythmia (abnormal heart rhythm which occurs suddenly and unexpectedly). According to the article cardiac dysrhythmia, dated [DATE], retrieved from my.clevelandclinic.org symptoms of cardiac dysrhythmia included palpitations, shortness of breath and chest discomfort. The website indicated to get immediate help when trouble breathing, or chest pain occurred. Resident K's Medication Administration Record (MAR), dated [DATE], indicated Resident K received Tylenol for generalized pain on [DATE] at 8:50 p.m. and the dose was effective. There was no documentation Tylenol had been given on [DATE].Resident K's Treatment Administration Record (TAR), dated [DATE], did not indicate Resident K had utilized the Voltaren gel. In an interview, on [DATE] at 2:15 PM, Licensed Practical Nurse (LPN) 3 indicated she worked on Resident K's hall on [DATE] into the morning of [DATE]. She indicated the resident had an appointment to see the orthopedic physician pending. Since admission, Resident K would get upset when anyone would come in his room at night, because he could not get back to sleep, so staff limited how often they went in his room. LPN 3 indicated LPN 2 did not indicate in report Resident K had been given any prn medications or she would have assessed the resident at night. LPN 3 did not assess Resident K because she had not been informed the resident had been given any medications or had any pain. She indicated CNA 7 changed Resident K's ice water at 1:00 a.m., but she did not look at the resident. In an interview, on [DATE] at 3:50 PM, CNA 4 indicated Resident K put on his call light about quarter till 9 PM on [DATE]. It was unusual for Resident K to use the call light, so he went right away because the resident never put the call light on. Resident K told CNA 4 he was having pain in his left shoulder and arm going into his chest and asked for his vital signs to be checked because he did not feel well. Resident K looked uncomfortable, but CNA 4 could not put his finger on exactly why he felt that way. Resident K was rubbing his left shoulder and looked bad enough CNA 4 went to get the nurse right away. The resident usually did not need help so CNA 4 did not check on him after reporting to LPN 2.In an interview, on [DATE] at 9:23 AM, LPN 2 indicated Qualified Medication Aide (QMA) 5 had given the resident an inhaler earlier in the day. The nurse indicated CNA 4 did not tell him the pain was radiating to the resident's chest. Resident K was sitting up on the side of the bed when he went in to give him Tylenol as requested. LPN 2 could not remember a change in skin color. He had not assessed the shoulder pain, his breath sounds, or his heart sounds. He indicated he asked the resident if he wanted to go to the hospital because he always asked residents if they wanted to go to the hospital. He did not call the physician because Resident K wanted to see if he felt better, but he did not go back and check on the resident. He did not report any issues to the nurse coming on shift. According to an article titled acute pain, retrieved on [DATE] from simple nursing. com, when a resident complains of pain, the nurse should assess the cause, assess the symptoms, ask the resident their stated level of pain, take vital signs, then monitor the resident's pain level every 2 hours and contact the physician when pain is unrelieved, worsens or radiates into the chest. Pain radiating into the chest could be a sign of heart attack. In an interview, on [DATE] at 10:41 AM, QMA 5 indicated she had administered no prn medications to Resident K on the day shift of [DATE]. QMA 5 indicated Resident K looked to be his normal self, had no complaints of pain and was up and around the facility as usual. In an interview, on [DATE] at 11:19 AM, CNA 6 indicated she was taking Resident K's breakfast tray to him, and noticed him sitting up in bed, and slumped over. She indicated his color was gray, and when she touched his hand to wake him, his skin was cold and hard.A current undated policy, titled Change of Condition, indicated all staff members should communicate any information about resident status change to appropriately licensed personnel immediately upon observation. The policy indicated when the nurse was notified of the change of condition, the nurse must immediately assess the resident, including vital signs, lung sounds, and other assessments as indicated by the change, including complaints of new or worsened pain. The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility conducted audits of current resident's condition to ensure no changes and re-educated nursing staff regarding assessments and documentation but will remain at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This Citation relates to Intake 2616068.3.1-37

Based on observation, interview, and record review the facility failed to ensure privacy of protected health information for 1 of 24 residents reviewed (Resident 44). Findings include: During an observation, on 12/4/24 at 9:34 AM, a worksheet with resident information visible was uncovered on top of a medication cart in the hallway. No staff member was in the area. Unidentified residents were present in the hallway near the cart. Protected health information including nursing assessments, vital signs and behavior notes were visible on the worksheet. During an observation, on 12/4/24 at 11:38 AM, Licensed Practical Nurse (LPN) 30 walked away from the medication cart leaving the computer screen open. Resident information was visible on the screen. During an observation, on 12/4/24 at 1:41 PM, LPN 30 was observed standing at the nurses' station with other staff. The computer screen on the medication cart was open to Resident 44's chart with protected health information visible on the screen. Five additional staff members walked past the cart and took no action to conceal the resident information. During an interview, on 12/4/24 at 1:44 PM, LPN 30 indicated a button on the computer to hide the screen should have been pushed before she walked away from the medication cart. She indicated Resident information should not be visible on the computer screen when the computer is unattended. Resident 44's record was reviewed on 12/9/24 at 9:58 AM. Diagnoses included unspecified subluxation of right hip, subsequent encounter, type 2 diabetes mellitus with hyperglycemia, and essential (primary) hypertension. Resident 44's current admission Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). During an interview, on 12/9/24 at 12:02 PM, the Administrator indicated staff should ensure confidential resident information could not be visible on top of the medication cart or nurses' station. Resident information on the computer screen should be kept confidential by closing the computer or hiding the screen. She indicated she was aware staff had left a computer screen open. The nursing report form with confidential information should have information hidden. A current policy, undated, provided by the Administrator on 12/9/24 at 12:33 PM, indicated confidential information including forms and worksheets should not be left on medication carts unattended. The policy indicated medication cart laptops should not be left open with resident information while unattended. 3-1(p)(5)

Based on interview and record review the facility failed to ensure residents were free from verbal abuse for 3 of 5 residents reviewed (Resident 15, Resident 18, Resident 44). Findings include: During an interview, on 12/5/24 at 11:18 AM, Resident 15 and Resident 18 indicated Resident 15 was assisted onto the commode (toilet) by Certified Nurse Aide (CNA) 2. Resident 18 indicated CNA 2 told Resident 15 to put on her call light when finished on the commode. Resident 15 indicated when CNA 2 was getting ready to exit the room, Resident 15 told CNA 2 she was finished on the commode. Resident 15 indicated CNA 2 responded to turn on her call light. Resident 18 indicated Resident 15 was frustrated so Resident 18 told Licensed Practical Nurse (LPN) 3 of Resident 15's requested assistance. Resident 18 indicated she then observed CNA 2 return to the resident's room and overheard yelling. Resident 18 indicated she also observed CNA 2 exit the resident's room. An investigation file was provided by the Director of Nursing (DON) on 12/6/24 at 11:30 AM. The file included the following: A facility reported incident (FRI), dated 11/23/24, indicated on 11/22/24 CNA 2 and Resident 15 were overheard yelling at each other. The FRI indicated the Administrator suspended CNA 2 and then interviewed 5 residents. CNA 2's file indicated CNA 2 verbally abused a resident by saying if you're going to act like that then someone else can f****** get you. The file indicated other residents also heard CNA 2 in the hallway using foul language. The investigation file included the following interviews: Resident 15's interview with the Administrator indicated the incident occurred on 11/22/24 around 8 PM. Resident 15 indicated she was frustrated with CNA 2. Resident 15 indicated CNA 2 was rude and a B*** towards Resident 15. Resident 18's interview with the Administrator indicated CNA 2 entered the room and assisted her roommate, Resident 15, onto the commode. Prior to leaving the room CNA 2 told Resident 15 she would return. Resident 18 indicated she overheard Resident 15 tell CNA 2 twice she was finished on the commode. Resident 18 indicated CNA 2 left Resident 15 on the commode and left the room. Resident 18 indicated she overheard Resident 15 yell she was finished, and the door was shut. Resident 18 indicated she notified LPN 3 of Resident 15's requested assistance. Resident 18 indicated she then observed CNA 2 return to their room and closed the door. Resident 18 indicated she overheard CNA 2 and Resident 15 yelling at each other. Resident 18 indicated she then observed CNA 2 leave the room and told LPN 3 just because I didn't get back to her room as quickly as she wanted me to, she threw stuff on the floor, and I am not cleaning it up. Resident 44's interview with the Administrator indicated she overheard Resident 15 yelling on 11/22/24 in the evening for assistance. Resident 44 indicated she overheard CNA 2 indicate something about a f**** fool in the hallway. During an interview, on 12/6/24 at 11:15 AM, CNA 4 indicated staff should never yell at any residents. CNA 4 indicated when a resident was frustrated with staff and needs weren't met, the nurse was notified. A record review was completed on 12/6/24 at 11:49 AM. Diagnosis included: major depressive disorder and hemiplegia/hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side. Resident 15's quarterly assessment, dated 10/11/24, indicated Resident 15 had a Brief Interview Mental Status (BIMS) score of 14/15 (cognitively intact). A record review was completed on 12/6/24 at 2:40 PM for Resident 18. Resident 18's admission assessment, dated 9/23/24, indicated Resident 18 had a BIMS score of 15/15 (cognitively intact). intact). A record review was completed on 12/6/24 at 2:41 PM for Resident 44. Resident 44's admission assessment, dated 11/12/24, indicated Resident 44 had a BIMS score of 15/15 (cognitively intact) A policy, last reviewed/updated 1/1/2023, titled Abuse Prohibition, was provided by the Administrator on 12/4/24 at 10 AM. The policy indicated verbal abuse: use of oral or gestured language that willfully includes disparaging and derogatory terms to residents or within hearing distance, regardless of the resident's ability to comprehend. This finding is related to Complaint IN00447844. 3.1-27(a)(b)

Based on observation, interview and record review the facility failed to ensure orders were entered and followed for 1 of 3 residents reviewed (Resident 15). During an interview on 12/5/24 at 11:34 AM, Resident 15 indicated she had a history of a stroke with left side affected. Resident 15 indicated she was discharged from therapy and recommended to use a splint for her left hand. Resident 15 indicated the staff no longer placed the splint on her hand. During an observation on 12/5/24 at 11:34 AM, Resident 15 did not have a splint on her left hand. During an observation on 12/5/24 at 1:30 PM, a palmor hand splint was in a bag by Resident 15's bed. An upside-down paper indicated Resident to wear splint daily/nightly, remove for AM/PM and reapply after care. The paper indicated recommendations provided by Occupational Therapist. During an interview on 12/5/24 at 1:12 PM, Certified Nurse Aide (CNA) 6 indicated Resident 15 wore a hand splint for 4 hours a day, between 6 AM - 10 AM. CNA 6 indicated Resident 15's splint was located in a bag by her bed. During an interview on 12/5/24 at 1:32 PM, Registered Nurse (RN) 5 indicated Resident 15 wore a hand splint per the instructions on the wall by her bed. RN 5 indicated the signage indicated Resident 15 to wear daily/nightly, remove for AM/PM and reapply after care. RN 5 indicated the instructions were signed by occupational therapy. RN 5 indicated Resident 15 did not have an order listed in her chart for the splint, but that staff shared the instructions in the report. RN 5 indicated there should be an order for Resident 15's splint with instructions in her chart. During an interview on 12/5/24 at 1:42 PM, the Director of Nursing (DON) indicated Resident 15 did not have a splint/[NAME] protector order listed. The DON indicated Resident 15 should have a splint order with included instructions/preferences. A record review was completed on 12/6/24 at 11:49 AM. Diagnosis included: hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side, contracture of left hand, and contracture of left wrist. Resident 15's quarterly assessment, dated 10/11/24, indicated Resident 15 had a Brief Interview Mental Status score of 14/15 (cognitively intact). Resident 15's current care plan, dated 8/24, last reviewed 11/11/24 indicated Resident 15 wore a palm protector to my left hand. Resident 15's care plan also indicated Resident 15 was admitted to the facility with a contracture to my left wrist and left-hand r/t cerebral vascular accident (CVA). I am at risk for further contracture to these areas and increased pain. Resident 15's orders were reviewed. There were no orders for a splint or palm protector. Resident 15's Occupational Therapy discharge summary, dated 7/10/24 - 9/3/24 was provided by the DON on 12/6/24 at 11:30 AM. The documentation indicated discharge recommendations: palmor protector for skin breakdown protector. A policy, dated 9/2024, titled Therapy Communication and Recommendations, was provided by the DON on 12/6/24 at 11:30 AM. The policy indicated therapist will complete an order for discharge recommendations including: resident indications, summary of recommendations/interventions, start/end date, therapeutic goals and ongoing precautions. 3.1-37

Based on observation, interview and record review, the facility failed to ensure a blood sugar meter (glucometer) was properly disinfected between each resident use for 2 of 2 residents reviewed (Resident 59 and Resident 26). Findings include: On 12/5/24 at 11:17 AM, Licensed Practical Nurse (LPN) 20 was observed cleaning a unit glucometer at the medication (med) cart. In an interview, on 12/5/24 at 11:20 AM, LPN 20 indicated the unit glucometer was used to obtain blood sugars for all the diabetic residents on the unit. LPN 20 indicated they cleaned the glucometer between each resident use with an alcohol pad. LPN 20 indicated cleaning the glucometer with alcohol after each use was standard practice. On 12/5/24 at 11:26 AM, items in a unit med cart were observed with LPN 20. The med cart did not contain disposable bleach wipes. On 12/09/24 at11:39 AM, Qualified Medication Aide (QMA) 10 was observed obtaining Resident 59's blood sugar with the unit glucometer. Resident 59's record was reviewed on 12/9/24 at 11:43 AM. Resident 59 had a diagnosis of insulin dependent diabetes. Resident 59's Quarterly Minimum Data Set, (MDS) dated [DATE], indicated Resident 59's Brief Interview for Mental Status (BIMS) score was 4 (severe cognitive impairment). The MDS indicated Resident 59 received insulin injections 7 days a week. A physician order, dated 10/7/24, indicated Resident 59 was to be administered insulin injections according to a sliding scale (doseage calculated from blood sugar results) 4 times a day. On 12/9/24 at 11:57 AM, QMA 10 was observed wiping the glucometer with an alcohol pad. QMA 10 placed the glucometer on top of the med cart. On 12/9/24 at 12:02 PM, QMA 10 was observed obtaining Resident 26's blood sugar with the unit glucometer. On 12/9/24 at 12:05 PM, QMA 10 was observed wiping the unit glucometer with an alcohol pad. After the glucometer was wiped with alcohol, QMA 20 placed the glucometer on the top of the med cart. In an interview, on 12/9/24 at 12:07 PM, QMA 10 indicated all the residents on the unit used the same glucometer. QMA 10 indicated they sanitized the glucometer between each resident use with an alcohol pad and placed the glucometer on top of the med cart to dry for 2 minutes. QMA indicated they had been trained to clean the glucometers with an alcohol pad between each use. On 12/9/24 at 12:12 PM, items in a unit med cart were observed with QMA 10. The med cart did not contain disposable bleach wipes. Resident 26's record was reviewed on 12/9/24 at 12:15 PM. Resident 26 had a diagnosis of insulin dependent diabetes. Resident 26's Annual Minimum Data Set, (MDS) dated [DATE], indicated Resident 26's Brief Interview for Mental Status (BIMS) score was 15 (no cognitive impairment). The MDS indicated Resident 26 received insulin injections 7 days a week. A physician order, dated 9/11/24, indicated Resident 26 was to be administered 5 units of insulin with meals every day. A physician order, dated 10/22/24, indicated Resident 26 was to be administered insulin injections according to a sliding scale 4 times a day. In an interview, on 12/9/24 at 3:26 PM, the Director of Nursing (DON) indicated shared glucometers should be cleaned with an approved bleach sanitizer after each resident use. The DON indicated alcohol pads were not recommended as a disinfectant for shared glucometer use (CDC, 2024). The DON indicated each med cart should be supplied with a container of disposable bleach wipes. A current undated facility policy, provided by the DON on 12/9/24 at 1:50 PM, indicated the glucometers were to be cleaned with disposable bleach wipes after each use. The policy indicated the glucometers were to remain wet for 1 minute. Reference CDC Injection Safety. (2024, August 7). [Centers for Disease Control and Prevention]. https://www.cdc.gov/injection-safety/hcp/infection-control/index.html 3.1-18(a) 3.1-18(b) 3.1-18 (b)(1)

Based on record review and interview the facility failed to ensure non-pharmacologic interventions were implemented and documented for 1 of 3 residents reviewed. (Resident 228). Findings include On 12/07/23 at 4:57 PM, Resident 228's record was reviewed. Diagnoses included chronic pain syndrome, septic arthritis of right knee status post incision and drainage, and severe right knee pain. Resident 228's comprehensive Minimum Data Set (MDS) assessment, dated 12/1/23, indicated the resident's Brief Interview for Mental Status (BIMS) score was 11 (moderately impaired). The MDS indicated she had almost in constant pain at the time of the assessment that frequently limited activity. She rated her pain 10 on a scale of 0 -10 with 0 being no pain and 10 the worst pain one can image. The MDS indicated she received as needed pain medication and was taking opioid pain medication. Resident 228's order, dated 11/25/23, indicated she could receive an oxycodone-acetaminophen 5/325 mg tablet by mouth every 6 hours as needed for pain. Resident 10's Medication Administration Record (MAR) indicated the resident was administered an oxycodone-acetaminophen 5/325 mg tablet on the following dates and times: 11/25/23 9:54 PM 11/26/23 3:37 PM 11/27/23 9:21 AM 7:52 PM 11/28/23 1:36 AM 7:22 AM 1:18 PM 10:17 PM 11/30/23 5:06 AM 12/1/23 5:13 AM 11:39 AM 12/2/23 3:26 AM 11:15 PM 12/3/23 4:51 AM 10:29 AM 5:05 PM 11:14 PM 12/4/23 5:30 AM 11:04 AM 6:53 PM 12/5/23 10:20 AM 7:34 PM 12/6/23 2:09 AM 1:34 PM 9:27 PM No documentation was located in Resident 228's MAR indicating non-pharmacological interventions were implemented prior to the administration of as needed opioid pain medication except on 12/3/23 at 11:14 PM a note indicated the resident refused repositioning and/ or an ice pack. No documentation was located in Resident 228's nursing progress notes, dated 11/25/23 through 11/6/23, indicating non-pharmacological interventions were implemented prior to the administration of as needed opioid pain medication. No non-pharmacological interventions were identified in Resident 228's current care plan, last reviewed 12/5/23, prior to the administration of as needed opioid pain medication. In an interview on 12/11/23 at 12:04 PM, the Director of Nursing (DON) indicated non-pharmacologic interventions should be implemented prior to the administration of as needed opioid pain medication. The DON indicated there was no indicated non-pharmacologic interventions documentation for Resident 228 prior to her being administered an oxycodone-acetaminophen tablet. In an interview on 12/11/23 at 12:06 PM, the Administrator indicated the facility did not have a policy addressing non-pharmacologic interventions prior to the administration of as needed opioid pain medication. A current procedure titled Medication Documentation, revised/updated 2023, provided by the DON on 12/11/23 at 12:32 PM, did not address non-pharmacologic interventions prior to the administration of as needed opioid pain medication. 483.25(k)

Based on interview, and record review the facility failed to ensure dementia care interventions were updated and accurate for 1 of 5 residents reviewed (Resident 4). Findings include: Resident 4's record was reviewed on 12/7/23 at 11:46 AM. Diagnoses included dementia in other diseases classified elsewhere, moderate, with anxiety, congenital cysts, and cerebral infarction, unspecified. A review of Resident 4's current quarterly Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 7 (cognitively impaired). A review of Resident 4's annual MDS dated [DATE] indicated her BIMS score was 12 (mild cognitive impairment). A review of Resident 4's current care plan titled Cognitive Loss/Dementia indicated the resident had a problem of a diagnosis of dementia, with a goal date of 1/9/2024. The care plan indicated Resident 4 had intact memory and her goal was to continue to make daily decisions. In a review of progress notes dated 11/16/23 at 1:33 PM, Nurse Practitioner 2 indicated Resident 4 resided on a memory care unit and had limited cognition and ability to care for herself. In an interview on 12/8/23 at 10:57 AM, Registered Nurse (RN) 3 indicated Resident 4 did not have an intact memory. Upon reviewing the care plan, RN 3 indicated the care plan did not reflect Resident 4's current cognitive status. In an interview on 12/8/23 at 11:37 AM, the MDS Coordinator and Social Services Director indicated they worked together on formulating and updating care plans pertaining to cognitive status. They indicated Resident 4 had a slow cognitive decline over the past year and the care plan should have been updated to reflect her current cognitive status. A current policy last reviewed in 2023 provided by the Director of Nursing on 12/11/23 at 12:35 PM indicated care plans should be updated routinely with the MDS or any other changes, including, but not limited to cognitive/physical functioning. 3.1-37

Based on interview and record review the facility failed to ensure residents were free from physical restraint for 1 of 6 residents reviewed (Resident B). Findings include: An investigation file was provided by the Administrator on 6/15/23 at 2:50 PM. The file included a facility reported incident dated 6/3/23. The report indicated on 6/3/23 Licensed Practical Nurse (LPN) 2 arrived for her shift and noted Resident B had a gait belt around his waist attached to a BRODA (specific wheelchair). LPN 2 received report from Registered Nurse (RN) 3. RN 3 indicated she restrained Resident B due to restlessness and fall prevention. RN 3 also indicated she did not obtain an order from the doctor for the restraint. A resident abuse investigation form indicated RN 3 restrained Resident B. The form also indicated RN 3 quit when the facility requested a statement regarding the incident. The file also included statements as follows: LPN 2's statement, dated 6/3/23, indicated she arrived for her shift at 5:45 AM and observed Resident B at the nurses station. LPN 2 indicated Resident B had a gait belt applied around his waist and a BRODA chair as a restraint. LPN 2 received report from RN 3. The report included Resident B was out of control all evening, fell and the restraint was the only way to keep him from falling again. LPN 2 indicated she immediately removed the restraint, completed a complete body assessment and did not find any [NAME] or redness. Certified Nurse Aide (CNA) 4's statement, dated 6/3/23, indicated Resident B fell on her shift and was restless. CNA 4 indicated they placed a restraint on Resident B, with the use of a gait belt. In an interview on 6/15/23 at 2:40 PM, LPN 2 indicated on 6/3/23 AM she observed Resident B at the nurse's station with his gown mostly off, no blankets and with a gait belt around his chest and his broda chair. LPN 2 indicated she removed the gait belt and performed a skin assessment. She indicated there were no [NAME] or redness. LPN 2 indicated RN 3 did not obtain a doctor's order for the restraint. In an interview on 6/16/23 at 9:40 AM, the Administrator and Director of Nursing (DON) indicated on 6/2/23 Resident B had behaviors and anxiety. The Administrator indicated RN 3 administered as needed medication and spoke with the hospice provider, but no medication was effective. The Administrator indicated RN 3 felt the only option was to secure the resident to the chair with a restraint. LPN 2 arrived for her shift, noticed the gait belt restraint and removed the restraint. LPN 2 then reported to the DON and Administrator. The DON indicated she received a text message from RN 3 around 5:23 AM. The message indicated Resident B was up all night, as needed medications were not effective and RN 3 seat belted him to his chair with a gait belt. The DON indicated RN 3 also messaged her she was aware the belt was a restraint but it was the only way to keep him safe. The DON indicated to RN 3 she should have called the DON. In an interview on 6/15/23 at 2:32 PM, LPN 5 indicated a restraint was anything that restricted the resident from movement. LPN 5 indicated if a resident were anxious or being combative, staff offered snacks, drinks, music, the toilet and as needed medications. Resident B's record was reviewed on 6/16/23 at 8:50 AM. Diagnoses included restlessness, agitation and insomnia. A nursing note, dated 6/3/23 at 12:56 AM, indicated Resident B was agitated, combative and confused. RN 3 administered as needed medication and indicated the medication was somewhat effective. Resident B was brought to the nurse's station for one on one monitoring for fall prevention. A nursing note, dated 6/3/23 at 2:12 AM, indicated Resident B was at the nurse's station aggressive and angry. RN 3 indicated as needed medication was given with mild effectiveness. A nursing note, dated 6/3/23 at 6 AM, indicated LPN 2 observed Resident B at the nurse's station with a gait belt wrapped around his chest and broda chair. LPN 2 also noted Resident B's gown was off and to the side. LPN 2 removed the belt and completed a skin assessment on Resident B. There were no physician orders, communication or other interventions documented prior to the applied restraint. A policy, undated, titled Physical Restraints and Maintaing a Restraint Free Environment, indicated physical restraints are physical or manual devices attached or adjacent to the resident's body which restricted the resident's freedom of normal access or movement. The policy also included using devices in conjunction with a chair, such as trays, tables, bars or belts, that restricts the resident from rising is considered a restraint and should not be utilized. This Federal Finding relates to Complaint IN00410058 and IN00410262. 3.1-3(w) 3.1-26

Based on interview and record review, the facility failed to assess, monitor, and notify the physician of an acute change in condition that led to a delay in treatment, and decline in condition for 1 of 3 residents reviewed (Resident D). Findings include: On 1/31/23 at 10:29 A.M., Resident D's record was reviewed. Diagnoses included paraplegia and right sided inguinal hernia (a bulging of the contents of the abdomen through a weak area in the lower abdominal wall which most often contain fat or part of the small intestine). Physician notes indicated the resident was being monitored by a general surgeon and his primary care physician (PCP) for a right sided inguinal hernia, bothersome to the resident. He was last seen by the surgeon on 11/3/22 and it was agreed that the hernia would be monitored for enlargement, pain, tenderness and incarceration (part of the bowel becomes trapped in the abdominal muscles creating a blockage with symptoms of nausea, vomiting, abdominal pain, fever). He was visited by the PCP on 1/11/23 and continued to complain of the hernia. On exam, the PCP indicated the resident's abdomen was soft and the hernia visible but not emergent. A quarterly MDS (Minimum Data Set) assessment, dated 11/2/22, indicated the resident had no cognitive impairment and no mood indicators or behaviors. He required extensive assistance from 2 staff members for bed mobility, transfers, toileting, dressing, and personal hygiene. A care plan, dated 5/16/17, indicated the resident had a diagnosis of GERD (acid reflux) with history of nausea and vomiting. Interventions were to assess frequency, color, character, consistency, odor, and amount of emesis and/or stool; check abdomen for rebound tenderness; and monitor for evidence of gastrointestinal bleed such as coffee ground emesis and or black tarry stools and report immediately. The care plan didn't indicate the resident had a right inguinal hernia, how to assess and monitor the hernia or signs and symptoms of complications. A Medication Administration Record (MAR), dated January 2023, and nurse progress notes indicated the following: -1/12/23 at 11:33 p.m., Resident D was given Imodium anti-diarrheal medication for 2 loose stools. -1/13/23 at 4:20 a.m., the resident was given Imodium anti-diarrheal medication for 2 loose stools. The physicinan was notified. Zofran (an anti-emetic medication) was ordered and given for nausea and vomiting. The physician indicated to notify him if there was further change in condition. -1/13/23 at 3:03 p.m., he was given Ibuprofen for complaints of headache. -1/14/23 at 3:13 a.m., the resident had a large emesis which required him to be showered and complete bed change done. He denied nausea after vomiting. -1/14/23 at 7:13 a.m., the resident complained of nausea and was given Zofran as ordered. -1/14/23 at 12:57 p.m., the resident complained of a headache and was given Ibuprofen as ordered. -1/14/23 at 2:08 p.m., the resident had requested to speak with the nurse, indicated he had an upset stomach and was nauseated. He was given PRN (as needed) Zofran. He refused his afternoon pills but requested PRN Ibuprofen for a headache which he was given. The nurse was called to his room. There he was audible congestion in his throat and chest on examination. He was encouraged to try and cough to bring up the congestion. He was repositioned and then began vomiting dark brown/black emesis. The nurse went to call EMS to transfer to the hospital and when returned to the room, observed the resident to be very pale, unresponsive, and with no pulse. On 1/31/23 at 1:59 P.M., QMA 2 (Qualified Medication Aide) was interviewed. She indicated she had administered Ibuprofen to Resident D on 1/13/23 at 3:03 p.m. for complaints of a headache. She hadn't heard him yelling out for help and wasn't told during report from the day shift, that he had been yelling out or that he'd had diarrhea, nausea, and vomiting during the night. QMA 2 indicated she had told the nurse about his headache prior to giving him the medication but hadn't known if the nurse had assessed him. She couldn't remember who the nurse was that she'd reported to. On 1/31/23 at 2:09 P.M., LPN 4 (Licensed Practical Nurse) was interviewed. She indicated she cared for Resident D on 1/14/23, but had not been made aware the resident had loose stools and nausea and vomiting on 1/13/23. She hadn't heard the resident yelling out for help. On 1/14/23, she was given report from night shift and had been told the resident had a large emesis during the night. LPN 4 was told by an aide the resident wanted to go to the hospital. She checked on him and he indicated he wanted to go to the hospital due to vomiting. She gave him Zofran for complaints of nausea. She checked on him again after breakfast and noted he'd only eaten a couple bites. He said his nausea was better and he was given his morning medications. When questioned, she indicated she had checked his abdomen and his inguinal hernia and nothing looked out of the ordinary but she hadn't documented it. She checked on him after lunch and observed he'd only eaten a few bites of lunch. He refused his afternoon medications and requested Ibuprofen for a headache which she gave him. He then indicated that whatever she had just given him had made it worse and wanted to go to the hospital. She left the room and went to the nurses station to call the EMS. She returned to his room and observed him seated upright in bed with dark emesis on him and he was unresponsive with no pulse. She had not contacted the doctor to report the resident's request to go to the hospital due to vomiting. When questioned about the resident's inguinal hernia and complications to watch for, she indicated she didn't know but would expect to find it on his care plan or the facility would have a policy for monitoring of his hernia. According to Lippincott's Manual of Nursing Practice, a strangulated hernia presents with pain, nausea, vomiting, and swelling. On 1/31/23 at 3:14 P.M., the Director of Nursing provided a current copy of the facility policy, titled Change of Condition which stated the following: All staff members shall communicate any information about resident status change to appropriate licensed personnel immediately upon observation. 1. The resident's primary physician or assigned alternate will be notified immediately of any change in resident's physical or mental condition .Notification of physicians and/or responsible parties shall be documented in the clinical record .Procedure: 1. When the nurse is notified of a change of condition, she/he must immediately assess the resident, this would include vital signs, lung sounds, and other assessments indicated by the change .The following is a list of some significant changes of condition .nausea and vomiting, diarrhea, loss of appetite This Federal tag relates to Complaint IN00400155. 3.1-37(a)

Based on interview and record review, the facility failed to notify the physician of a resident's significant change in condition for 1 of 3 residents reviewed (Resident D). Findings include: On 1/31/23 at 10:29 A.M., Resident D's record was reviewed. Diagnoses included paraplegia and right sided inguinal hernia. A quarterly MDS (Minimum Data Set) assessment, dated 11/2/22, indicated the resident had no cognitive impairment and no mood indicators or behaviors. He required extensive assistance from 2 staff members for bed mobility, transfers, toileting, dressing, and personal hygiene. A care plan, dated 5/16/17, indicated the resident had a diagnosis of GERD (acid reflux) with history of nausea and vomiting. Interventions were to assess frequency, color, character, consistency, odor, and amount of emesis and/or stool; check abdomen for rebound tenderness; and monitor for evidence of gastrointestinal bleed such as coffee ground emesis and or black tarry stools and report immediately. A Medication Administration Record (MAR), dated January 2023, and nurse progress notes indicated the following: -1/12/23 at 11:33 p.m., Resident D was given Imodium anti-diarrheal medication for 2 loose stools. -1/13/23 at 4:20 a.m., the resident was given Imodium anti-diarrheal medication for 2 loose stools and Zofran anti-emetic medication for nausea and vomiting. -1/13/23 at 3:03 p.m., he was given Ibuprofen for complaints of headache. -1/14/23 at 3:13 a.m., the resident had a large emesis which required him to be showered and complete bed change done. He denied nausea after vomiting. -1/14/23 at 7:13 a.m., the resident complained of nausea and was given Zofran as ordered. -1/14/23 at 12:57 p.m., the resident complained of a headache and was given Ibuprofen as ordered. -1/14/23 at 2:08 p.m., the resident had requested to speak with the nurse, indicated he had an upset stomach and was nauseated. He was given PRN (as needed) Zofran which he said helped. He refused his afternoon pills but requested PRN Ibuprofen for a headache which he was given. The nurse was called to his room, he was heard with audible congestion in his throat and chest. He was encouraged to try and cough to bring up the congestion. He was repositioned and then began vomiting dark brown/black emesis. The nurse went to call EMS to transfer to the hospital and when returned to the room, observed the resident to be very pale, unresponsive, and with no pulse. On 1/31/23 at 1:59 P.M., QMA 2 (Qualified Medication Aide) was interviewed. She indicated she had administered Ibuprofen to Resident D on 1/13/23 at 3:03 p.m. for complaints of a headache. QMA 2 indicated she had told the nurse about his headache prior to giving him the medication but hadn't known if the nurse had assessed him. She couldn't remember who the nurse was that she'd reported to. On 1/31/23 at 2:09 P.M., LPN 4 (Licensed Practical Nurse) was interviewed. She indicated she cared for the resident on 1/14/23 and had not been made aware the resident had loose stools, nausea and vomiting on 1/13/23. On 1/14/23, she was given report from night shift and had been told the resident had a large emesis during the night. LPN 4 was told by an aide the resident wanted to go to the hospital. She checked on him and he indicated he wanted to go to the hospital due to vomiting. She gave him Zofran for complaints of nausea. She checked on him after lunch and observed he'd only eaten a few bites of lunch. He refused his afternoon medications and requested Ibuprofen for a headache which she gave him. He then indicated that whatever she had just given him had made it worse and wanted to go to the hospital. She left the room and went to the nurse's station to call the EMS. She returned to his room and observed him seated upright in bed with dark emesis on him and he was unresponsive with no pulse. She had not contacted the doctor to report the resident's request to go to the hospital due to vomiting. There was no documentation completed to indicate the physician had been notified of the resident's loose stools, nausea and vomiting, or the resident had requested to go to the hospital on 1/13 or 1/14/23. On 1/31/23 at 3:14 P.M., the Director of Nursing provided a current copy of the facility policy, titled Change of Condition which stated the following: All staff members shall communicate any information about resident status change to appropriate licensed personnel immediately upon observation. 1. The resident's primary physician or assigned alternate will be notified immediately of any change in resident's physical or mental condition .Notification of physicians and/or responsible parties shall be documented in the clinical record .Procedure: 1. When the nurse is notified of a change of condition, she/he must immediately assess the resident, this would include vital signs, lung sounds, and other assessments indicated by the change .The following is a list of some significant changes of condition .nausea and vomiting, diarrhea, loss of appetite This Federal tag relates to Complaint IN00400155. 3.1-5(a)(2)

Based on observation, interview and record review, the facility failed to ensure proper food temperatures were maintained at the time of meal service. 78 of 78 residents residing in the facility ate food prepared in the kitchen. Findings include: During an interview on 11/13/22 at 10:50 AM, Cook 2 indicated food temperatures were normally checked when food was finished cooking prior to placing on the steam table. He indicated lunch items are placed on the steam table between 10 and 11 AM. He indicated temperatures are not checked again prior to meal service. In an observation on 11/13/22 at 10:55 AM, just prior to meal service food temperatures taken included pureed chicken, 122 degrees, tomato soup 110 degrees, and hamburgers 104 degrees. During an interview on 11/13/22 at 11:09 AM, the Dietary Manager indicated temperatures should be checked just prior to the meal service to ensure proper temperatures and items should be reheated if not at or above 135 degrees. During an interview on 11/14/22 at 10:24 AM, Resident 69, identified by the facility as interviewable, he indicated his breakfast was cold that morning. He indicated food is frequently served cold when he eats in his room. A policy titled Monitoring Food Temperatures for meal service dated 1998 indicated food temperatures should be taken and recorded for all hot foods prior to placement on the service line and recorded on a temperature log. Temperature logs dated 11/6/22-11/14/22 indicated temperatures were being checked, but times of the temperature checks did not specify the exact time of the check. 3.1-21(a)(2)

Based on interview, observation and record review, the facility failed to ensure a resident received showers or bed baths as scheduled for 1 of 1 resident reviewed. (Resident 26). Findings include: In an interview on 11/14/22 at 12:33 PM, Resident 26 indicated he was not getting showers consistently twice a week as expected. During an observation on 11/14/22 at 12:33 PM, Resident 26 was clean, hair and nails groomed and without odor, but had a little facial hair growth. On 11/14/22 at 3:39 PM, Resident's 26 record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 26's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 15, he was alert, oriented and interviewable. The MDS assessment indicated he was totally dependent for bathing and required a two-person physical assist for personal hygiene support. A review of the resident's order, dated 7/19/21, indicated he was to have a shower every Tuesday and Saturday on second shift (2:00 PM - 10 PM). During the showering process, staff were to report any refusals, complete skin checks and document any areas of concern. A review of Resident 26's care plan, last revised 10/5/22, indicated he preferred to take 2 shower a week and require 1 staff for bathing assistance and 2 staff for transfer assistance. A review of Resident 26's Nurse Aide Skin Communication forms, to be completed with every shower, dated between 10/1/22 to 11/13/22, indicated the following: 10/4 7:00 PM Red under belly, nails cleaned clipped and filed. 10/8 No documentation 10/11 5:30 PM Redness on right upper thigh and spot on buttock, nails cleaned, clipped and filed 10/15 No documentation 10/18 Refused 10/22 No documentation 10/25 6:15 PM Scratches on back of left leg, nails cleaned, clipped and filed 10/29 (Time not indicated) Bottom is red/sore, no new skin issue 11/1 First resident refused then said it was too late 11/5 Refused 11/8 9:30 PM Bandage on buttock, nails cleaned, clipped and filed 11/12 7:00 PM Buttock red, nails cleaned, clipped and filed Resident 26 received 7 of the 10 showers/bed baths he should have received from 10/1/22 through 11/13/22. In an interview on 11/17/22 at 11:09 AM, the DON indicated all showers should had been documented or marked refused on the Nurse Aid Skin Communication form and provided to the nurse at the end of each shift. On 11/17/22 at 11:05 AM, a current policy titled Bathing, Complete and Bathing, Shower', undated, provided by the Director of Nursing (DON), indicated to document all appropriate information in the medical record. 3.1-38(a)(3)

Based on observation, interview and record review, the facility failed to ensure medications were administered as ordered by the physician for 1 of 1 resident reviewed (Resident 42). Findings include: During an observation on 11/13/22 at 3:18 PM, Resident 42 was observed sitting in a recliner in his room. A bottle of Tums (antacid tablets) and an unlabeled bottle was observed on a bedside table. During an interview at the same time, Resident 42 indicated the unlabeled bottle was nasal spray and he ordered the medications by mail and administers them himself. He indicated he did not notify staff or keep any records of when he used them. During a record review conducted on 11/14/22 at 2:05 PM, a Minimum Data Set, dated dated dated [DATE] indicated Resident 42 was alert and oriented with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan last reviewed 10/20/22 indicated Resident 42 used medications to control his symptoms of rhinitis (postnasal drainage). The care plan indicated staff should administer his medications as ordered. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Director of Nursing (DON) on 11/14/22 at 2:26PM, she indicated medication self-administration assessments should be completed quarterly for residents who self-administer medications. She also indicated all self-administered medications should have a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the DON on 11/15/22 at 1:11 PM, she indicated Resident 42 ordered medications online frequently and staff is not always aware of deliveries. A policy regarding medication self-administration was not available for review by the time of the survey exit. 3.1-37

Based on observation, interview, and record review, the facility failed to monitor medication side effects for 1 of 5 residents reviewed. (Resident 19). Findings include: On 11/14/22 at 9:43 PM, Resident 19's record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 19's Minimum Data Set (MDS) assessment, dated 8/12/22, indicated her Brief Interview for Mental Status (BIMS) score was 15, she was alert and oriented. The resident's orders indicated she should have 2.5mg [MEDICATION(S)] tablet orally twice a day beginning 8/14/22 and 5-325mg [MEDICATION(S)]-acetaminophen tablet orally for pain as needed every 6 hours beginning 8/5/22 . The resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 19's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's current care plan, last reviewed 10/31/22, failed to address monitoring the resident's side effects of [MEDICATION(S)] (anticoagulant) and [MEDICATION(S)]-acetaminophen (opioid). In an interview on 11/17/22 at 11:16 AM, the DON indicated the facility should had monitored for anticoagulant and opioid side effect per federal guidelines. On 11/17/22 at 11:15 AM, a current policy titled Preventing & Detecting Adverse Consequences related to administration of Opioids, dated 11/16/22, provided by the DON, indicated the facility staff will monitor the resident for possible medication-related adverse consequences related to opioid medication including: constipation, drowsiness, confusion, nausea, respiratory depression, changes in bowel status including abdominal distention, changes in sleep patterns, loss of appetite and dizziness. A policy titled Preventing & Detecting Adverse Consequences related to administration of Anticoagulants, dated 11/16/22, provided by the DON, indicated residents receiving [MEDICATION(S)] would be monitored for possible medication-related adverse effects related to anticoagulant medication including: bruising, bleeding, skin changes, and observe nose, urine, and stool for any sign of bleeding. 3.1-48(a)(1)-(6)

Based on observation and interviews, the facility failed to ensure residents environment was clean, well kept, and free from odors for 2 of 4 halls in the facility affecting 4 residents. ( Resident A, Resident D, Resident E and Resident J) Findings include: On 12/28/21 at 10:39 A.M., a resident's family member was interviewed by phone. During the interview, the family member alleged that the facility was unclean and had urine like odors throughout the facility, that were noticed during several visits to the facility to see their loved one On 12/28/21 at 9:14 A.M., during an initial tour of the facility, and again at 11:00 A.M., there were strong [MEDICATION(S)] odors noted in Hallway 1 and Hallway 3. Hallway 1 had paper debris scattered around, there were several food and drink stains on the floor of various colors and thickness and there was black debris in the crevices and cracks in the base boards of the hall. -The floors of resident rooms 1, 2, 6, 7, 8, 9, 10, 11, and 12 were observed with brown/black debris on the floors, unidentified dried food items, various paper debris, and overflowing trash cans. -A very strong [MEDICATION(S)] odor was smelled between rooms 3 and 11 which were located across from each other in the hall. Room 3's floor was discolored with various shades of dried debris across the floor. -Room 4 was cluttered with resident personal items scattered around. There were 3 missing laminate floorboards missing from the floor near the head of the bed for the resident that resided in bed B and a missing laminate floorboard between Resident J's bed and Resident A's bed. The exposed areas were black and sticky with bits of hair and debris on them. -Room 5's floor was dirty with several brown/black stains on the floor. The floor was sticky when walked on. There were crushed food items on the floor next to Resident D's bed. Resident E and Resident D , both had overbed tables that had dried, sticky appearing, shiny debris over them. The bathroom had black debris around the bottom of the toilet stand and the sink had rusted faucets and fixtures. -The entrance to Room 13 had streaks of grey/black dried debris across the floor and there were various colored dried stains across the floor of the room. There were no housekeeping personnel or carts observed in the hallway. Hallway 3 had hard laminate flooring that was soft when walked on. There was black debris along the base boards and various paper product debris scattered across the floor of the hall. There were slight odors of [MEDICATION(S)] throughout the hallway where there were 7 resident rooms occupied. On 12/28/21, during confidential interviews, interviewable residents indicated the following: -Resident E indicated there were issues with cleanliness in the rooms and that spilled food items were just left and not cleaned up and floors not mopped, or rooms cleaned daily. -Resident J indicated the room was very cluttered and there were papers everywhere. They indicated staff didn't put things away and just scattered them around making the room look cluttered and unorganized. The room was not cleaned often nor were the floors mopped. On 12/28/21 at 11:01 A.M., the Housekeeping Director was interviewed. She indicated the housekeeping department was very staff challenged at this time. The facility had 3 housekeepers-2 of which were just hired-plus herself for a total of 4 staff. She indicated she needed 3 housekeepers per day to keep the facility clean but didn't have the staff. Housekeepers were to clean and mop each room daily and had a checklist they were supposed to document on however, this had not been done due to staffing issues. This Federal tag relates to Complaints IN 665 and IN 695. 3.1-19(e)

Based on observation, interview and record review, the facility failed to ensure the safety of a cognitively impaired resident (Resident B) who exited the facility, unattended, on 2 seperate occasions. The deficient practice had the potential to affect 21 of 26 residents with impaired cognition that resided in unsecured areas of the facility. The deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 1:45 P.M. when Resident B exited the facility unattended. A second elopement occurred on [DATE] at 9:40 P.M. with the same resident. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 3:46 P.M. Findings include: On [DATE] at 9:44 A.M., Resident B's record was reviewed. [DIAGNOSES REDACTED]. Resident B had been admitted to the facility on to the secured memory care unit, in [DATE] where she resided until her family took her home in [DATE]. Resident B was readmitted to the facility on a unsecured area of the facility on [DATE]. A Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident B had a BIMS (Brief Interview Mental Status) score of 6 which signified severely impaired cognition. The assessment indicated the resident was feeling down and depressed and had behaviors of physical and verbal abuse towards staff. The MDS indicated Resident B required no physical assistance with transfers or ambulation. A Plan of Care with a start date of [DATE] and updated on [DATE], indicated Resident B had cognitive loss/dementia which worsened, prior to admission, due to loss of her daughter. A Plan of Care with a start date of [DATE] and updated on [DATE], indicated Resident B had significant end stage dementia which worsened following loss of her daughter. The resident had a history of [REDACTED]. The goal target date was ,[DATE] and was that Resident B would not have an increase in depression. Interventions included, but were not limited to, encourage family to visit as she enjoys visits with her son and monitor for signs and symptoms of depression. A Plan of Care with a start date of [DATE] and updated on [DATE], indicated Resident B had behavioral symptoms. The resident had angry agitated behaviors and would kick, scream and swing at staff. The resident indicated she wants to go home. A Plan of Care, dated [DATE], indicated Resident B's son passed away; son came to visit the resident daily; and if son was every late, she would request that staff contact him. A Nurse Note, dated [DATE] at 2:30 P.M., indicated the resident's grandaughter voiced to writer at 11 am that today during visit, resident voiced several times she 'was leaving today and gonna get out of here'. Also stated she would wait until midnight when everyone was sleeping so nobody would cathc her. A Wander Data Collection Tool, last dated [DATE], indicated Resident B was not at risk for elopement despite a BIMS score of 6, independent mobility, and frequently asking to see her son. A Nurse Note, dated [DATE] at 2:30 P.M., indicated the resident was screaming and crying nonstop for her son whom she wanted to come to the facility and wanted to see. Family visited and intervened to calm the resident. A Nurse Note, dated [DATE] at 6:00 P.M., indicated a note had been given to Social Services about the resident's distress. A Nurse Note, dated [DATE] at 1:45 P.M., indicated staff were alerted by a visitor, that Resident B was walking with her rolling walker down the sidewalk approximately one block away from the nursing home. Resident B indicated she was looking for her son (who is deceased ). Resident B was assisted back into the facility. A Nurse Note, dated [DATE] at 2:00 P.M., indicated the resident attempted to exit the facility two times and was trying to find her son. A Nurse Note, dated [DATE] at 12:00 P.M., indicated Resident B's family reported that Resident B stated that she was going to leave the facility. SS (Social Services) informed. A Plan of Care, dated [DATE], indicated Resident B was an elopement risk and had eloped from the facility on [DATE] to look for her son; the resident is at risk for depression and anxiety due to death of son. The goal was that Resident B would not attempt elopement from the facility and would be supported thru the grief process. Interventions included, but were not limited to, alert staff to the risk, monitor for signs of elopement; alert staff and other staff and place on 15 minute checks; administer anti-anxiet medication if the resident is having a difficult time dealing with the death of her son or if she is searching for him. A Nurse Note, dated [DATE] at 9:40 P.M., indicated Resident B went out of the facility on shift-walked to end of driveway-was re-directed and brought back into building. A Continued Stay Review form, dated [DATE], indicated Resident B is at extremely high risk of eloping and would benefit from a secure unit. On [DATE] at 2:34 P.M., the DON (Director of Nursing) was interviewed. During the interview, she indicated that Resident B had been on 15 minute checks from [DATE] until [DATE] when the resident was relocated to the secured memory care unit. The DON indicated she was unable to find documentation that staff had completed and initialed the 15 minute check worksheet. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility reassessed all independantly mobile residents with a BIMS score of less than 12, and reeducated staffon elopement risk, but the noncompliance remained at the lower scope and severity of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy because quality moniotoring had not been completed. This Federal tag is related to Complaint IN 844. 3XXX,[DATE](a)(2)

Based on observation, interview and record review, the facility failed to ensure medically related social services were provided to address the grief process for 1 of 5 residents receiving medically related social services (Resident B). This resulted in increased psychosocial distress for Resident B. Findings include: On [DATE] at 9:44 A.M., Resident B's record was reviewed. [DIAGNOSES REDACTED]. Resident B had been admitted to the facility on to the secured memory care unit in [DATE], where she resided until her family took her home in [DATE]. Resident B was readmitted to the facility in an unsecured area of the facility on [DATE]. A Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident B had a BIMS (Brief Interview Mental Status) score of 6. This signified severely impaired cognition. The assessment indicated the resident was feeling down and depressed for more than 4 of 7 days, and had behaviors of physical and verbal abuse towards staff. The MDS indicated Resident B required no physical assistance with transfers or ambulation. A Plan of Care with a start date of [DATE] and updated on [DATE], indicated Resident B had cognitive loss/dementia which worsened, prior to admission, due to loss of her daughter. A Plan of Care with a start date of [DATE] and updated on [DATE], indicated Resident B had significant end stage dementia which worsened following loss of her daughter. The resident had a history of [REDACTED]. The goal target date was ,[DATE] and was that Resident B would not have an increase in depression. Interventions included, but were not limited to, encourage family to visit as she enjoys visits with her son and monitor for signs and symptoms of depression. A Plan of Care with a start date of [DATE] and updated on [DATE], indicated Resident B had behavioral symptoms. The resident had angry, agitated behaviors and would kick, scream and swing at staff. The resident indicated she wanted to go home. The current Plan of Care did not address Resident B's grief related to the loss of her son in August of 2016. On [DATE] at 12:49 P.M., Resident B was observed sitting in the dining room of the secured memory care unit. She had a rolling walker beside her with a basket that contained various items. She appeared distressed with a frown on her face and was not heard to speak to anyone at the table. An Activities Progress Note, dated [DATE] (no time), indicated that Resident B was informed on this day of son's death. Resident B's Nurse Notes were reviewed and indicated the following: [DATE] at 3:30 A.M., Resident has yelled out for the past four nights. [DATE] at 4:10 A.M., Resident was yelling out from 10:00 P.M. to 1:20 A.M. Resident B stated there was a bum in my room and it scared me and I must have been dreaming. Resident B yelled out at night and indicated she could not sleep on the following dates: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]. [DATE] at 1:30 P.M., Resident B had a animated motion sensored stuffed cat. The resident laid paper out on the floor for the cat to use and tried to give the cat milk. [DATE] (no time), Resident B was tearful this am and had her cat wrapped in a blanket. The resident indicated her cat died at 12:30 and my daughter is coming to pick up so she can bury her. Staff replaced batteries in cat and returned to the resident. [DATE] at 3:30 P.M., Resident yelling out frequently this day with 'no reason' as to why. Resident anxious getting upset with staff. [DATE] at 1:15 A.M., Resident has been yelling since 10 P.M. States she can't sleep. [DATE] at 1:00 P.M., Resident crying/tearful, wanting to go home. Resident B asked staff to call her son or expressed wanting to see him on the following dates: [DATE], [DATE], [DATE], and [DATE]. [DATE] at 8:00 P.M., Resident was screaming extremely loud tonight. Was upset about not being able to see son. [DATE] at 9:50 P.M., Alert resident with confusion, continues to ask for deceased son to be called although she attended showing/funeral. [DATE] at 9:30 A.M., Resident B asks staff several times a day to call her son and have him come in. Son is deceased . [DATE] at 11:25 P.M., Resident B asks staff to call her deceased son. [DATE] at 10:30 P.M., Resident frequently asks for staff to call deceased son to come to visit. [DATE] at 10:35 P.M., Resident B doesn't remember that her son, (name) passed away and often comes to nurses station-asking staff to call (name). [DATE] at 10:00 A.M., Resident B continues to ask for deceased son to come visit. States 'I haven't seen him in couple of weeks'. Requests staff phone him and 'tell him to get in here'. [DATE] at 9:00 P.M., Resident B asks staff to call her deceased son at times, she's forgotten his death. [DATE] at 1:00 P.M., Resident B continues to forget son has passed away. [DATE] at 3:00 P.M., Resident B continues with no memory of son being deceased . Asks staff to call him and tell him to 'get in here' to see her. [DATE] at 11:15 A.M., Resident B came to desk to ask for sleeping pill; nurse replied that the resident had her medications. Resident replied that was at 7 p.m., that was a long time ago and it wore off. The resident was upset and yelling and while ambulating back to her room, sustained a fall. [DATE] at 10:23 P.M. and [DATE] at 10:25 P.M., Resident B continues to ask for her deceased son to be called-she wants to see him. [DATE] at 3:15 P.M., Resident B has no memory of son (name) passing away. Asks staff to call him and tell him to 'get in here and see her'. [DATE] at 2:30 P.M., indicated the resident was screaming and crying nonstop for her son whom she wanted to come to the facility and wanted to see. Resident B screamed (name), I want (name)! Why doesn't he come here to see me? The resident screamed over and over. Family visited and intervened to calm the resident. [DATE] at 6:00 P.M., indicated a note had been given to Social Services about the resident's distress. A review of Social Services notes indicated there were no Social Service Progress Notes written to address the residents distress regarding the loss of her loved ones. Social Service Progress Notes dated [DATE], [DATE], and [DATE] did not indicate Resident B's son had passed away nor did they address the resident's distress at not seeing her son. A Social Service Progress Note, dated [DATE], indicated Resident B reported feeling down for several days. A Social Service Progress Note, dated [DATE], indicated Resident B had been moved to a secured unit for her safety and that the resident has been attempting to leave the facility to find her son who is deceased for the past year. On [DATE] at 5:10 P.M., the thinned medical record for Resident B was reviewed. A Plan of Care, dated [DATE], indicated Resident B's son passed away; son came to visit the resident daily; and if son was every late, she would request that staff contact him. On [DATE] at 11:26 A.M., the Social Services Director was interviewed. During the interview, she indicated being new to the facility last year and it had been her understanding that family had decided not to tell Resident B that her son was deceased . The Social Services Director indicated she had not been aware that Resident B had been told her son was deceased and had focused on medication interventions for the resident's difficulty with sleeping. She indicated that Resident B was not offered counseling services for grief and there was no Plan of Care to address the resident's grief or distress. This Federal tag relates to Complaint IN 844 3XXX,[DATE](a)