Every finding on record at Oakridge Nursing Center

A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective [DATE], related to the facility's failure to ensure:a. CPR was not stopped for a resident who was a full code, b. staff members could definitively identify a resident's code status, andc. effective cardiopulmonary resuscitation was provided by the use of a backboard and providing rescue breaths. A progress note, dated [DATE] at 4:07 a.m., showed a code had been called for Res #1 and CPR had been started. Staff interviews showed CPR on Res #1 had been halted when they could not determine the resident's code status and the CPR provided did not make use of a backboard or provide rescue breaths via an Ambu bag or use of a face shield thus excluding two valuable tools for providing effective CPR.The past noncompliance IJ was removed effective [DATE] after the facility put measures in place to prevent recurrence:a. On [DATE] all staff were in-serviced on code status, crash carts, code leader, CPR, and mock codes.b. On [DATE] a system to identify staff trained in CPR was put in place.c. On [DATE] staff training on how to identify a resident's code status was completed.d. On [DATE] members of the QAPI team met via TEAMS regarding CPR, mock codes drills, code status accuracy, verification with hospice providers, system review, post code briefings, and investigation completion.On [DATE] facility staff members were interviewed, and facility documentation was reviewed which showed and confirmed steps required for the facility to become compliant had occurred and were place.Based on record review and interview, the facility failed to ensure:a. a backboard was used when chest compressions were used for a resident that was laying on a mattress,b. CPR was not withheld for a resident that wanted CPR because staff could not identify the resident's correct code status; andc. rescue breaths were used during CPR according to the standards of practice and the facility's CPR policy for 1 (#1) of 5 sampled resident reviewed for code status.The administrator identified 56 residents resided in the facility.Findings:A facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation, read in part, Policy Statement. Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. If the first responder is not CPR certified, that person will call 911 and follow the 911 operator's instruction until a CPR certified-staff member arrives. 5. Breathing: after 30 chest compressions provide 2 breaths via Ambu bag or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. All rescuers should also provide ventilations with a compression-ventilation ratio of 30:2.A face sheet located in the Res #1's EMR, dated [DATE], showed the resident's code status was full code (the resident chose to have CPR performed if required).A facility document titled Acknowledgment of Advance Directive, dated [DATE], showed Res #1 had declined to initiate DNR status. (This indicated the resident chose to have CPR performed if required). The document was signed by the resident and witnessed by the resident's legal representative. A physician's order, dated [DATE], showed Res #1's code status was a full code.A CPR certificate of completion, dated [DATE], showed TNA #1 had been trained in CPR for professional rescuers.A care plan for Res #1, revised date [DATE], showed on page one next to the resident's name the resident was a full code.A facility document titled Crash Cart Checklist, dated [DATE] through [DATE], showed the facility crash carts did contain Ambu bag's each date of that month including the date Res #1 had coded, [DATE].A quarterly assessment, dated [DATE], showed in Section C Res #1 had a BIMS score of 15 (this score on the BIMS showed the resident's cognition was intact for decision making).A progress note for Res #1, dated [DATE] at 4:07 a.m., showed the resident had been found unresponsive and a code was called. The note showed an ambulance was called and CPR was started and continued until the ambulance arrived. The note showed the ambulance staff documented the time of death as 4:39 a.m. The note was authored by LPN #2.An initial incident report form (ODH Form 283), incident date [DATE], showed the DON had submitted the form regarding Res #1. The report showed an unidentified CNA had reported information about a code (a staff response to a life-threatening condition) had been performed on Res #1. The form further showed after interviewing staff involved in the code, conflicting accounts had been given, and an investigation was begun.A final incident report form (ODH Form 283), incident date [DATE], showed the DON had submitted the form regarding Res #1. The form showed the facility leadership could not determine if neglect occurred because of conflicting statements and emotions surrounding the event. The report showed facility leadership was unable to determine what staff had provided CPR at any specific time due to staff members entering and exiting the residents' room during the incident. The report showed the nurses on duty adamantly stated CPR was continuous.On [DATE] at 2:30 p.m., CNA #1 was asked to describe the events that occurred on [DATE] when Res #1 was coded. CNA #1 stated they were the person that started chest compressions on Res #1. They stated the resident was lying on their bed while they did chest compressions. CNA #1 stated they were unable to recall how long they did the compressions, but when they became tired, CNA #2 took over and continued chest compressions. CNA #1 was asked if anyone else was with them while they performed CPR. They stated LPN #2 was there watching them. CNA #1 was asked what LPN #2 had done while they did chest compressions. CNA #1 stated they did not see LPN #2 do or say anything during CPR. CNA #1 was asked if a backboard was used when they performed chest compressions. They stated they had not used a backboard and were unaware one was available. CNA #1 was asked what the backboard was for. They stated to make chest compressions more effective. CNA #1 was asked if anything other than chest compressions had been performed. They stated no. CNA #1 was asked if anyone had provided breaths or had used the Ambu bag. They stated they had not seen that done. CNA #1 was asked if the CPR had stopped at any time. They stated LPN #1 had found out from hospice the resident was a DNR and that had confused them, and CNA #2 stopped chest compressions. CNA #1 stated when the EMT's arrived, they figured out the resident was a full code, and they started CPR again. CNA #1 stated they did not recall how long of time had passed between the CPR stopping and when it was restarted.On [DATE] at 3:04 p.m., CNA #2 was asked to describe the events that occurred on [DATE] when Res #1 was coded. CNA #2 stated they had performed chest compressions on Resident #1 when CNA #1 became tired. CNA #2 stated they were unable to state how long they provided chest compressions. CNA #2 was asked where the resident was when they performed chest compressions. They stated the resident was laying on their bed. CNA #2 was asked if there was a mattress on the bed. They stated, yes. CNA #2 was asked if they had used a backboard. They stated they had not. CNA #2 was asked what a backboard was for. They stated to make chest compressions more effective. CNA #2 asked if anyone other than CNA #1 and themselves was present when they were performing chest compressions. They stated no one else was present. CNA #2 was asked who had told them to perform CPR on Res #1. They stated it was LPN #1 who told them to start CPR, and they were also the one who later told them the resident was a DNR and to take our hands off the resident. CNA #2 stated when the EMT's arrived, the EMT's figured out the resident was a full code, and they restarted CPR. CNA #2 was asked, prior to the EMT's arrival, had anyone provided respirations to the Resident #1. They stated no and they did not have an Ambu bag for respirations.On [DATE] at 3:15 p.m., LPN #1 was asked to describe the events that occurred on [DATE] when Res #1 was coded. LPN #1 stated they had gone to Res #1's room to give them some medication and that was when they found the resident non-responsive. LPN #1 stated they stepped out into the hallway and called a code. They stated, CNA #1 then went into the resident's room and began chest compressions. LPN #1 stated they then went to the nurses station to call 911 and the resident's hospice service. LPN #1 stated when they left the resident's room, they saw LPN #2 go in. LPN #1 was asked why CPR was later stopped. They stated when they had contacted the hospice service, their person on the phone told them the Resident #1 was a DNR. LPN #1 stated their records indicated the resident was a full code and as far as they knew the CPR had continued. LPN #1 stated after the EMT's arrival, they went back to the room with them and saw the staff performing CPR. LPN #1 was asked which staff were performing CPR when they returned with the EMT's. They stated they could not recall. LPN #1 was asked if any respirations had been given to the resident. They stated they did not recall.On [DATE] at 3:31 p.m., LPN #2 was asked to describe the events that occurred on [DATE] when Res #1 was coded. LPN #2 stated they had been at the nurse station when LPN #1 had called a code. LPN #2 stated they had seen four nurse aides go down to Res #1's room. LPN #2 stated they also went to the room and stayed with the aides except for a brief moment when they went back to the nurse station to ask about a DNR. LPN #2 stated LPN #1 had told them it was a full code. LPN #2 was asked if CPR had ever stopped being performed on Res #1. They stated as far as they knew CPR never stopped and had not heard anyone tell the nurse aides to stop. LPN #2 was asked if any of the aides had provided breaths to the resident or had the Ambu bag been used. They stated they did not recall respirations having been given.On [DATE] at 9:11 a.m., TNA #2 was asked to describe the events that occurred on [DATE] when Res #1 had coded. TNA #2 stated they had not been a certified nurse aide yet although they had just taken their certification test. They stated they had performed CPR on Res #1 that night. TNA #2 was asked if they had been trained in CPR. They stated they had and had been certified since [DATE]. TNA #2 was asked who else they saw perform CPR to Res #1. They stated they saw CNA #1 provide chest compressions. TNA #2 was asked to continue their description of the event. TNA #2 stated at one point, they asked LPN #2 if they had an Ambu bag and the nurse had said, no. They stated they then performed chest compressions until LPN #1 told them stop as the resident was a DNR and for them to take their hands off the resident. TNA #2 stated about five minutes later, the EMT's arrived, and they stated the resident was full code and started CPR again. TNA #2 stated they asked the EMT's if they could get an Ambu bag from their bag and assist and they told them, yes. TNA #2 stated they assisted the EMT's by providing breaths. They were asked if any form of respirations had been provided before the use of the EMT's Ambu bag. They stated no. TNA #2 was asked if the crash cart was at the scene. They stated the crash cart was in the hallway. TNA #2 stated seeing the crash cart in the hallway was how they had found out about the code. TNA #2 stated they saw the cart and went in to assist. TNA #2 was asked if there was a nurse present during the code. They stated they had observed LPN #2 going in and out of the room but did not recall how often.On [DATE] at 10:13 a.m., TNA #1 was asked to describe the events that had occurred on [DATE] when Res #1 was coded. They stated that it was their first night working at the facility. TNA #1 stated they had checked on Res #1 around 2:50 a.m. during their regular rounds. They stated at that time the resident had asked about getting pain medication. TNA #1 stated after leaving the room they had informed the nurse but could not recall their name. They stated at 3:30 a.m. CNA #1 had checked Res #1's colostomy bag (a bag that collects fecal matter from the intestines) and had burped it (a process where excess gas is allowed to leave the bag through an opening). TNA #1 stated at 4:00 a.m. they heard a nurse say they needed help and there was a full code. TNA #1 stated they told the nurse and other aides they did not know how to perform CPR [a CPR card, listed in the documents section of this citation show this staff member had been trained in CPR]. TNA #1 stated CNA #1 told them to give it a try and they did one round of chest compressions and told them they would not do anymore. TNA #1 stated they then left the room. TNA #1 was asked if they had seen an Ambu bag. They stated they did not know about that and had not seen anyone trying to give breaths. On [DATE] at 3:48 p.m., The DON was asked to give their insight and opinion of the events about the code of Res #1 on [DATE]. The DON stated there had been a mistake on the part of the hospice service when they had told the facility staff Resident #1 was a DNR. The DON stated they felt the facility staff had provided effective CPR by calling the code and called 911 quickly.

Based on observation, record review, and interview, the facility failed to ensure: a. privacy was provided during care for one (#31) of four sampled residents reviewed for privacy; and b. protected health information was secured for three (#10, 170, and #173) of four sampled residents observed during medication pass. The administrator identified 65 residents resided in the facility. Findings: The Confidentiality of Information and Personal Privacy policy, revised 10/2017, read in part, Our facility will protect and safeguard resident confidentiality and personal privacy. 1. Resident #31 had diagnoses which included dementia and generalized edema. A quarterly assessment, dated 11/09/24, documented the resident had moderately impaired cognition. On 01/23/25 at 8:23 a.m., CNA #3 and CMA #2 were observed to pull Resident #31 up in the bed. The privacy curtain was not pulled. On 01/23/25 at 8:58 a.m., LPN #3 asked Resident #31 when their last Poop was while they were standing at the bedside of Resident #4. On 01/23/25 at 8:59 a.m., LPN #3 asked Resident #31 if they could listen to their tummy and see if there were any bowel sounds. The privacy curtain was not pulled and the door was wide open with the resident's abdomen exposed. On 01/23/25 at 9:03 a.m., LPN #3 told Resident #31 they would fix them a brown cow. The privacy curtain was not pulled and the door was open. Resident #4 was in the room. On 01/23/25 at 2:57 p.m., LPN #3 stated to ensure privacy during resident care or assessments they would knock on the door and pull the curtain between them if there were two in the room to ensure privacy between the patients. They stated the door needed to be shut so other people could not hear what you were talking about or see anything. LPN #3 stated they should have pulled the curtain between the resident. LPN #3 stated they did not pull the curtain when they did the assessment on their belly. They also stated they did not remember if the door was open or shut at the time. On 01/23/25 at 2:59 p.m., LPN #3 was asked if confidential information regarding a resident's assessment be obtained while taking care of another resident. They stated if they were standing by another resident they should have left their bedside, pulled the curtain, and then should have gone to the other resident to be able to see what was going on and do the assessment. On 01/23/25 at 3:01 p.m., CMA #2 stated to ensure privacy during resident care they were to make sure the door was shut and there was not another resident. They stated they pulled the curtain. They stated the curtain should only be pulled when you are discussing private information or giving care like when you are dressing the resident. On 01/23/25 at 3:12 p.m., the DON stated staff needed to shut the door and pull the curtain for privacy during care. They stated the curtain should be pulled between residents when receiving incontinent care, toileting, an if there was a bed side commode. The DON further stated they should pull the curtain if there was a resident assessment being done and they should utilize the curtain if the resident was a two person assist and being pulled up in the bed. The DON was asked should confidential information regarding a resident's assessment be obtained from a resident while taking care of another resident. They stated as long as the curtain was pulled. I am not sure. On 01/24/25 at 8:06 a.m., LPN #1 was observed to prepare medication for Resident #10. On 01/24/25 8:29 a.m., LPN #1 left their computer screen on and entered Resident #10's room to administer their medication. The screen had Resident #10's medication profile visible. There were two staff members observed at the nurse's station. On 01/24/25 at 8:43 a.m., LPN #1 was observed to prepare medication for Resident #173. On 01/24/25 at 8:54 a.m., LPN #1 left their computer screen on and entered Resident #173's room to administer their medication. The screen had Resident #173's medication profile visible. A staff member was observed at the nurse's station and an unknown resident by the nurse's station. On 01/24/25 at 9:02 a.m., LPN #1 was observed to prepare medication for Resident #170. On 01/24/25 at 9:07 a.m., LPN #1 left their computer screen on and entered Resident #170's room to administer their medication. The screen had Resident #170's medication profile visible. On 01/24/25 at 9:14 a.m., LPN #1 stated they did not lock their screen during medication pass observation and should have. 48344 51977

Based on observation, record review, and interview, the facility failed to ensure: a. the required PPE was worn when providing care to a resident on transmission based precautions for one (#46) of four sampled residents who were reviewed for transmission based precautions; and b. infection control practices were maintained during medication administration observation. The administrator identified 65 residents resided in the facility. The infection preventionist identified 19 residents were on transmission based precautions. Findings: The Facility COVID-19 Plan, dated 05/16/23. read in part, The objective of this plan is to mobilize the facility's resources to prevent the acquisition, spread, and transmission of COVID-19 (formerly Novel Coronavirus) infection, caused by SARS-CoV-2 virus, within the facility and safely care for residents who may be infection while protecting the safety of other residents and staff. The policy also read, All team members will receive education on identification, prevention, transmission .Direct care providers will receive additional education to include but not limited to identification of residents/staff ill with acute respiratory symptoms and fever, prevention, transmission, and Personal Protective Equipment (PPE). 1. Resident #46 had diagnoses of COVID-19. A physician's order, dated 01/17/25, documented droplet precautions every shift. A progress note, dated 01/17/25 at 1:51 p.m., read in part, Resident tested positive for Covid during routine testing-Dr [name withheld] notified and standing Covid orders implemented. -MARS updated. On 01/24/25 at 9:14 a.m., transport #1 was observed to go into Resident #46's room while stating to another staff member they were working with Resident #46. Transport #1 did not have on any PPE except a mask. The sign on the door read droplet precautions. On 01/24/24 at 9:17 a.m., transport #1 was observed exiting Resident #46's room. They were asked what the precaution was for Resident #46's room. They stated it was for when doing personal care. Transport #1 was asked if droplet precautions were for the COVID residents. They then stated after confirming with the nurse next to them, they stated,Yes. They stated droplet precautions required a mask, goggles, and gown. They stated they did not have on a gown when they went back into the COVID resident's room. On 01/24/25 at 9:45 a.m, the administrator was asked if they were aware of the COVID isolation room breech concern that occurred while they were down the same hall. They stated they were aware. 2. On 01/24/25 at 8:10 a.m. LPN #1 was observed to touch a trash can bag to adjust it. They did not use ABHR (alcohol based hand rub) prior to proceeding with med pass. The only thing in the trash bag were white gloves. LPN #1 did not have gloves on. On 01/24/25 at 9:13 a.m., LPN #1 stated they needed to look up what the policy and procedure was for infection control during med pass. LPN #1 stated infection control was not maintained when they adjusted the trash bag. 48344

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than five percent during the medication pass observation. The medication error rate was 15.38%. The administrator identified 65 residents resided in the facility. Findings: The Medication Administration policy, dated 06/21/17, read in part, Medications will be administered by legally-authorized and trained persons in accordance to applicable State, Local and Federal laws and consistent with accepted standards of practice. 1. Resident #10 had diagnoses which included chronic obstructive pulmonary disease with acute exacerbation. A physician's order, with a start date of 01/22/25, documented prednisone (a corticosteriod) 5 mg one tablet oral daily times three days for chronic obstructive pulmonary disease. It documented an end date of 01/24/25. A physician's order, with a start date of 01/24/25, documented azithromycin (an antibiotic) 500 mg one tablet oral once a day for chronic obstructive pulmonary disease with acute exacerbation. It documented an end date of 01/24/25. On 01/24/25 at 8:06 a.m., LPN #1 was observed to prepare medication for Resident #10. They were observed to prepare and administer azithromycin 250 mg one tablet by mouth to the resident. On 01/24/25 at 8:17 a.m., LPN #1 stated they could not locate the resident's prednisone 5 mg. They stated they would document not available and informed the charge nurse. On 01/24/25 at 8:25 a.m., LPN #2 stated today was the last day for the prednisone. On 01/24/25 at 8:53 a.m., LPN #2 stated they could not locate the prednisone and there was none in the emergency kit. They stated they would have the medication sent to the local pharmacy. On 01/28/25 at 2:31 p.m., the DON provided a progress note by LPN #1. It documented Resident #10's prednisone was administered at 3:00 p.m. on 01/24/25. 2. Resident #173 had diagnoses which included essential hypertension A physician's order, with a start date of 01/23/25, documented aspirin (NSAID) 81 mg one tablet oral delayed released once a day for essential hypertension. On 01/24/25 at 8:43 a.m., LPN #1 was observed to prepare medication for Resident #173. They stated they would find out if they could administer the house stock aspirin 325 mg. They had instructed CMA #1 to find out if they could administer the aspirin 325 mg in place of the 81 mg. The nurse had set the bottle aside. On 01/24/25 at 9:01 a.m., after Resident #173's medications were administered, LPN #1 was asked what they would do about the aspirin. They stated they had already administered the aspirin 325 mg when CMA #1 researched and informed them aspirin 81 mg and aspirin 325 mg were the same. 3. Resident #170 had diagnoses which included long term current use of antithrombotic/antiplatelets. A physician's order, with a start date of 01/22/25, documented aspirin 81 mg chewable one tablet oral once a day. On 01/24/25 at 9:02 a.m., LPN #1 was observed to prepare medication for Resident #170. They were observed to prepare and administer aspirin 325 mg one tablet by mouth. On 01/28/25 at 9:23 a.m., the DON stated they had 81 mg and 325 mg house stock aspirin. They stated if a resident had an order for aspirin 81 mg, they expected the staff to administer the 81 mg. They stated an aspirin dose of 325 mg was different from 81 mg.

Based on record review and interview, the facility failed to ensure restorative therapy was provided to residents with limited ROM for two (#33 and #51) of two sampled residents reviewed for restorative services. The regional survey consultant identified 27 residents who received restorative therapy resided in the facility. Findings: The Restorative Nursing Services policy, revised 07/2017, read in part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 1. Resident #33 had diagnoses which included congestive heart failure, Parkinson's, COPD, and atrial fibrillation. The MDS, dated [DATE], documented Resident #33 needed substantial/maximum assistance from staff. On 01/28/25 at 11:01 a.m., two staff provided resident care. They used a sling and Hoyer lift and transferred the resident from the bed to the shower chair for bathing. On 01/28/25 at 2:15 p.m., the DON stated the resident had three restorative care orders for bed mobility, ROM, and ADLs. The physician order documented a start date of 11/29/24 two days a week on Tuesday and Thursday. On 01/28/25 at 2:20 p.m., the DON stated the CNAs probably did not chart it. There were eleven opportunities for restorative ROM missed from the order date 11/29/24 until 01/28/25 (12/03/24, 12/10/24, 12/12/24, 12/17/24, 12/19/24, 12/24/24, 12/26/24, 12/31/24, 01/02/25, 01/07/25 and 01/09/25). On 01/29/25 at 8:35 a.m., CMA #1 demonstrated using matrix care how staff would know restorative care was ordered and the different restorative care to provide and document. CMA #1 stated documentation was important because it helped residents with their contractures or flaccid limbs because they did not want them to get worse. 2. Resident #51 had diagnoses which included chronic obstructive pulmonary disease and heart failure. Resident #51's quarterly resident assessment, dated 11/15/24, documented Resident #51 had moderate cognitive impairment and was dependent on staff assistance for ADLs. It documented the resident had an impairment on one upper extremity. A physician's order, dated 12/06/23, documented refer to restorative nursing program to address ROM: AAROM exercises to BUEs; AROM/stretching to BLEs with focus on knees (abduction, adduction, flexion and extension) x 15 minutes, once a day on Monday and Wednesday. On 01/22/25 at 10:29 a.m., Resident #51 stated they should be getting restorative therapy. They stated they got it two to three times and the person quit. The November 2024 POC History Report documented Resident #51 received restorative therapy on 11/06/24. There was no documentation for Resident #51's December 2024 restorative therapy. The January 2025 POC History Report documented Resident #51 received restorative therapy on 01/22/25. On 01/28/25 11:35 a.m., the DON provided restorative therapy documentation for Resident #51. They stated that was all they had. On 01/28/25 at 1:31 p.m., LPN #2 stated the nurses were responsible for restorative therapy. They stated it included ROM, grip strength, and getting the residents out of bed. On 01/28/25 at 1:35 p.m., LPN #2 stated if a resident refused restorative therapy, they would document the refusal in a progress note. They stated Resident #51 had refused restorative therapy. On 01/28/25 at 1:43 p.m., LPN #2 reviewed Resident #51's EHR record. They stated they could not locate documentation the resident refused on scheduled days for the months of November 2024, December 2024, and January 2025. On 01/28/25 at 1:59 p.m., the DON stated all refusals were to be documented in the EHR. 48344

Based on observation, record review, and interview, the facility failed to ensure a call light was within reach of a resident for one (#4) of 24 sampled residents observed for call lights in reach. The administrator identified 65 residents resided in the facility. Findings: Resident #4 had diagnoses which included muscle weakness and history of falling. Resident #4's quarterly resident assessment, dated 11/30/24, documented Resident #4 had severe cognitive impairment and required staff assistance with ADLs. Resident #4's care plan for falls, dated 11/01/24, documented to keep call light within the resident's reach. On 01/23/25 at 8:21 a.m., Resident #4 stated their call light was somewhere as they looked towards the foot of the bed. They stated they sometimes they screamed for help if the call light was not in reach. Resident #4's call light was observed out of reach by the foot of the bed. On 01/23/25 at 8:26 a.m., CNA #1 came in to offer Resident #4 breakfast and assisted with set up. On 01/23/25 at 8:34 a.m., LPN #3 came into the resident's room. They assisted the resident with feeding. CNA #1 left the resident's room. On 01/23/25 at 9:04 a.m., LPN #2 wiped the resident's face, adjusted the resident in bed, and put the bedside table within reach. On 01/23/25 at 9:10 a.m., LPN #2 left the resident's room and turned of the lights. Resident #4's call light was out of the reach. LPN #2 stated they were done with the task in Resident #4's room. On 01/23/25 at 9:11 a.m., LPN #2 stated the process for call light was to keep them within reach of the resident either in bed or chair. They stated Resident #4 could use their call light and liked to hold their call light across their chest. They stated the resident sometimes yelled out for help. On 01/23/25 at 9:12 a.m., LPN #2 retrieved the resident's call light and handed it to the resident. On 01/23/25 at 9:13 a.m., LPN #2 stated Resident #4's call light was not in reach.

Based on observation, record review, and interview, the facilty failed to ensure residents were assisted with eating in a dignified manner for one (#4) of four sampled residents observed during meal service. The administrator identified 65 residents in the facility. Findings: The Accommodation of Needs policy, revised 01/2020, read in part, Our facility's environment and staff behaviors are directed toward assisting the resident in maintain and/or achieving safe independent functioning, dignity and well-being. Resident #4 had diagnoses which included muscle weakness and history of falling. Resident #4's quarterly resident assessment, dated 11/30/24, documented Resident #4 had severe cognitive impairment and required staff assistance with ADLs. On 01/23/25 at 8:26 a.m., CNA #2 offered Resident #4 breakfast. CNA #2 set up the breakfast and elevated the resident's head of the bed. They stated the resident was able to feed themselves. On 01/23/25 at 8:35 a.m., CNA #2 and LPN #3 were standing over Resident #4. LPN #3 told CNA #2 they would assist the resident with feeding. LPN #3 put a bite of scrambled eggs in Resident #4's mouth while standing by the foot of bed. On 01/23/25 at 8:39 a.m., LPN #3 continued to feed Resident #4 while standing by the foot of bed. On 01/23/25 at 8:55 a.m., LPN #3 fed Resident #4 cereal while standing by the foot of bed. On 01/23/25 at 9:04 a.m., LPN #3 asked Resident #4 if they would like to lay down. They wiped the resident's face, adjusted the resident in bed, and put their bedside table within reach. On 01/23/25 at 3:02 p.m., LPN #3 stated there was no chair in the resident's room to sit next to the resident and assist them with feeding. On 01/23/25 at 3:04 p.m., LPN #3 stated they were standing while feeding Resident #4.

Based on observation, interview, and record review, the facility failed to obtain behavioral health services and develop a care plan related to the resident's behavioral health for one (#46) of two sampled residents reviewed for behavioral health service needs. The DON identified 48 residents who resided at the facility. Findings: Res #46 had diagnoses which included dementia with mood disturbance, affective mood disorder, psychotic disorder with delusions, and anxiety. A nurse note, dated 01/08/23 at 7:58 p.m., documented the resident was noted to be confused and anxious seeing her two late husbands and believed her son-in-law was her brother and he found him a wife who was seven and a half foot tall. The note documented the resident believed there was a man living in their window. The note documented the resident was found rocking and rubbing the tops of their legs and crying and telling the nurse about things from their past they thought they had buried and forgotten. An annual assessment, dated 01/12/23, documented the resident was severely cognitively impaired, required limited assistance with most activities of daily living, and the resident had a psychotic disorder. The annual assessment also documented the resident received antipsychotic medications on a regular basis. A nurse note, dated 02/25/23 at 8:44 p.m., documented the resident was noted to be sitting in the dark in her room angry and crying. The resident stated everyone was talking about her. The resident stated someone runs by her window at night scratching at her screen. A nurse note, dated 02/26/23 at 8:37 p.m., documented the resident continued to state the other residents were telling her she was not welcome in the dining room and there were people in the bathroom planning to get back at her. The note documented the resident packed her entire room up stating she was going home because she couldn't take it anymore. The note documented redirecting the resident was unsuccessful and became very upset, crying, and refusing to answer questions. A nurse note, dated 06/22/23 at 10:12 a.m., documented the resident went to the DON'S office visibly upset and tearful. The note documented the resident stated her daughter sent her a message that her cat ate her face off. The note documented the resident stated now they can't get a hold of their daughter and doesn't know her address to call the police. A quarterly assessment, dated 07/15/23, documented the resident was severely cognitively impaired, required limited assistance with most activities of daily living, and the resident had a anxiety disorder. The annual assessment also documented the resident received no antipsychotic medications. The EHR did not contain a care plan to address Res #46's behavioral health. A nurse note, dated 09/05/23 at 8:30 a.m., documented the resident reported she had several items missing and they were tired of people stealing from them. The note documented the resident tended to pack their things and send them home with family or hid them in their room. The note documented the resident believed someone was standing outside at night pecking at the window. The note documented the resident also reported they believed other people were talking about them and saying they were not welcome here and they needed to go back where they came from. The note documented staff had attempted to redirect the resident without success. The note documented the resident became agitated and tearful. On 10/25/23 at 1:27 p.m., Res #46 was observed sitting in their room on the left side of their bed. The resident was asked how they were doing. They stated they were concerned about the vivid visual hallucination like nightmares they were experiencing. The resident stated the nightmares frightened her and made her cry. On 10/25/23 at 1:39 p.m., the DON was asked if Res #46 received behavioral health services. They stated, No. The DON was asked if the resident had behaviors. They stated, Yes. They were asked what type of behaviors. They stated delusions, paranoia, and nightmares. They were asked if the resident had hallucinations. They stated, yes, once the resident had come into their office visibly upset and tearful. They stated the resident thought a cat had eaten their daughter's face off. The DON were asked if Res #46 received any services for her mental illness diagnoses. They stated, No. They were asked if there were behavioral health services available for the resident. They stated, Yes. The DON was asked if the resident would benefit from behavioral health services. They stated, Yes. On 10/26/23 at 9:10 a.m., CNA #1 was asked to describe the resident's behaviors/mood. The CNA stated resident #46 has experienced increased confusion, delusions, nightmares, visual hallucinations and anxiety lately. The CNA stated the resident was not easily redirected after having a nightmare. On 10/26/23 at 9:17 a.m., LPN #1 was asked to describe the resident's behaviors/mood. The LPN stated Res #46 was panicky, paranoid, and believed her stuffed bear sweet pea was real and could talk. The LPN stated the resident had communicated to them that sweet pea woke up frequently crying because she had a nightmare. The LPN stated once they took the resident outside and Res #46 believed the cat roaming in the smoking area had the same face as the LPN. The LPN stated the resident was very argumentative, became extremely upset, and they were unable to redirect them. The LPN was asked if the resident would benefit from behavioral services. They stated yes. On 10/26/23 at 10:45 a.m., LPN #2 was asked to describe the resident's behaviors/mood. The LPN stated the resident had been repeatedly molested as a child by their father. They also reported Res# 46 has recurring nightmares of the molestation and will often wake up crying. The LPN stated Res #46 was paranoid, delusional, and experienced auditory and visual hallucinations. They stated the resident believed they were having real conversations with their stuffed bear. The LPN stated the resident frequently complains about the resident they shared a restroom with. They believed their neighbor was deliberately throwing urine and feces in the restroom floor. The LPN stated Res #46 saw things that were not there. They stated every time the resident had complained about the urine and feces, the staff had gone to check and there had not been any feces or urine on the floor. The LPN was asked if the resident would benefit from behavioral services. They stated, Yes. On 10/27/23 at 8:20 a.m., CNA #2 was asked to describe the resident's behaviors/mood. The CNA stated the resident was paranoid, delusional, and had frequent nightmares causing them distress and agitation and could be difficult to redirect. On 10/27/23 at 8:39 a.m., the SSD was asked to describe the resident's behaviors/mood. The SSD stated Res #46 is very anxious and at times is difficult to redirect. The SSD was asked if the resident would benefit from behavioral services. They stated, Yes. On 10/27/23 at 9:54 a.m., Res #46 was observed sitting in the dark on the edge of their bed. The resident was asked how they were feeling. The resident stated, I don't know but sweet pea had a big party in here last night. This room was filled with people.

Based on observation, record review, and interview, the facility failed to ensure residents with limited range of motion received received restorative services to prevent further decrease in range of motion for one (#14) of two sampled residents reviewed for mobility. The DON identified 19 residents with impaired range of motion. Findings: Res #14 was admitted to the facility on [DATE] and had diagnoses which included sequelae of cerebral infarction, hemiplegia, affecting right dominant side, muscle weakness, unsteadiness on feet, unspecified tremor, and lack of coordination. An admission assessment, dated 12/16/22, documented the resident was cognitively intact; was independent except for needing set up help with eating and bathing; and had impaired range of motion on one side of the upper and lower extremities. The assessment documented the resident was not steady, but could stablize without assistance, and had not received therapy restorative services. An ''Occupational Therapy Discharge Summary, dated 06/19/23, documented the resident was to be referred to the restorative nursing program. A quarterly assessment, dated 09/18/23, documented the resident was moderately cognitively impaired; was independent except for needing set up help with eating and bathing; and had impaired range of motion on one side of the upper and lower extremities. The assessment documented the resident was not steady, but could stablize without assistance, and had not received therapy restorative services since the last assessment. On 10/26/23 at 8:53 a.m., Res #14 demonstrated they could not lift their right arm over approximately five to six inches from his elbow to his side. Res #14 stated they would like it if someone would work with their right arm to keep what movement they had. Res #14 stated in therapy their right arm could move with more range if the therapist moved it for him. Res #14 stated they had a stroke last year and had went through therapy, but no one was working with him now. Res #14 stated he worked with his right hand to keep his fingers from getting stiff and curling under. Res #14 stated they walked with a cane. On 10/26/23 at 9:22 a.m., the MDS coordinator stated the Res #14 had Part B therapy in February 2023 and again on 05/29/23 through 06/19/23. The MDS coordinator reviewed the June 2023 therapy discharge note and stated the resident was to be referred to restorative nursing program, but could not see where they had been. On 10/27/23 at 12:00, the DON stated they were not aware therapy had referred the resident to restorative services.

Based on record review and interview, the facility failed to ensure accurate code status was documented for a resident with DNR status for one (#13) of 16 sampled residents whose code status was reviewed. The administrator identified 48 residents resided in the facility. Findings: Res #13's face sheet documented the resident's code status as DNR. A physician order, dated 12/28/2021, documented Res #13 as a full code. A quarterly assessment, dated 10/04/23, documented the Res #13 was cognitively intact. The resident's care plan, updated 10/12/2023, documented Res #13 was a DNR. During record review a resident signed DNR, dated 10/12/23, was found in the EHR. On 10/27/23 at 7:55 a.m., the MDS coordinator was asked what their process was with updating the physician orders when a resident had a change in code status. The MDS coordinator stated it was the responsibility of the nurse who had taken the order. MDS was asked to review Res #13's code status on the physician orders. They stated it read full code. The MDS coordinator stated Res #13's code status had change on 10/12/23. The MDS coordinator stated the order should have been updated at that time. On 10/27/23 at 8:17 a.m., the DON was asked what their process was with updating the physician orders when a resident had a change in code status. The DON stated it was the responsibility of the nurse who had taken the order. The DON was asked if Res #13's code status order should have been updated when the resident signed the DNR paperwork. They stated it should have been.

Based on observation, record review, and interview, the facility failed to change oxygen tubing according to physician orders for one (#13) of one resident sampled for respiratory care. The DON identified 11 residents received oxygen therapy. Findings: Res #13 had diagnoses which included COPD and heart failure. A physician order, dated 02/28/23, documented to change oxygen tubing on concentrator and portable oxygen tank weekly on the Sunday day shift. A quarterly MDS assessment, dated 10/04/23, documented Res #13 was cognitively intact. On 10/25/23 at 10:25 a.m., Res #13 was observed in their room. An oxygen concentrator was observed at the end of the resident's bed. The tubing was observed with a piece of tape wrapped around it labeled with the date of 10/15/23. The resident stated they were unaware of when the tubing was last changed. On 10/26/23 at 8:02 a.m., the label on the oxygen concentrator had not been changed. The tubing label was dated 10/15/23. On 10/26/23 at 8:34 a.m., LPN #2 was asked when the oxygen tubing was supposed to be changed. The LPN stated the tubing was to be changed weekly on Sunday. On 10/26/23 at 9:02 a.m., the DON was asked what the process was for changing oxygen tubing/and labeling. They stated weekly on Sunday day shift.

Based on observation, record review, and interview, the facility failed to notify the physician of significant weight loss and implement interventions for one (#43) of two sampled residents reviewed for nutrition. The administrator identified 48 residents resided in the facility. Findings: Res #43 admitted to the facility on [DATE] with diagnoses which included history of vertebral fracture, pain, heart failure, HTN, and COPD. A vital signs record, dated 08/09/23, documented the resident weighed 182.0 lbs. A physician order, dated 08/09/23, documented the resident was to receive a regular diet. An admission MDS assessment, dated 08/15/23, documented the resident was cognitively intact and was independent with setup/supervision for eating. The MDS documented the admission weight was 182 lbs. A vital signs record, dated 08/17/23, documented the resident weighed 171.5 lbs. A physician order, dated 08/17/23, documented the resident was to receive a regular diet with fortified foods with breakfast. A vital signs record, dated 08/23/23, documented the resident weighed 181.0 lbs. A vital signs record, dated 08/30/23, documented the resident weighed 170.0 lbs. A vital signs record, dated 09/06/23, documented the resident weighed 170.5 lbs. A vital signs record, dated 09/15/23, documented the resident weighed 166.0 lbs. A vital signs record, dated 10/05/23, documented the resident weighed 163.5 lbs, a greater than 10% weight loss since admission. On 10/26/23 at 12:23 p.m., the resident was observed resting in bed with eyes closed. A Styrofoam food container was observed on the overbed table. The box was observed to contain a sandwich with condiment packets. The resident stated to leave the box where it was and they would eat it when they felt like it. On 10/26/23 at 12:44 p.m., Cook #1 stated the kitchen sent the resident a regular tray but it was sent back and the resident asked for a turkey sandwich for lunch. They stated supplements are not offered to the resident from the kitchen. On 10/26/23 at 1:10 p.m., the DON stated residents get weighed weekly for four weeks then monthly upon admission to identify weight loss. They stated they ran a report weekly to identify residents who triggered for weight loss. The DON stated the last report was ran on 10/20/23 and Res #43 was not identified for significant weight loss. On 10/26/23 at 2:32 p.m., the DON stated the physician was not notified of significant weight loss after 08/17/23. They stated no additional interventions had been placed after the diet order was changed.

Based on record review and interview, the facility failed to ensure baseline care plans were developed within 48 hours of admission for one (#32) of 17 sampled residents reviewed for care plans. The administrator identified 48 residents resided in the facility. Findings: Res #32 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, diabetes mellitus with diabetic nephropathy, epilepsy, GERD, anxiety disorder, depression, and chronic pain. There was no documentation a baseline care plan was developed. On 10/30/23 at 12:55 p.m., the DON was asked if a baseline care plan was developed for the resident. On 10/30/23 at 1:05 p.m., the DON stated a baseline care plan had not been completed. They stated the care plan should have been completed within 48 hours of admission.

Based on record review and interview, the facility failed to notify the state authority of a new mental health diagnoses for two (#4 and #46) of three sampled residents reviewed for PASRRs. The administrator identified 48 residents resided in the facility. Findings: 1. A level I PASRR screen, dated 02/18/21, documented Res #4 was screened and a level I was completed. It was documented there were no indicators for a level II PASRR. On 09/09/21, Res #4 received a new diagnosis of schizoaffective disorder. There was no documentation the state authority had been notified of the resident's new diagnoses to see if a level II PASRR was required. On 10/26/23 at 11:15 a.m., the MDS coordinator stated Res #4's level I PASRR documented no serious mental illness. They stated Res #4's new diagnosis of schizoaffective disorder was not included on the screening form and there was no indication the state was notified. 2. A level I PASRR screen, dated 01/05/23, documented Res #46 was screened and a level I was completed. It was documented there were no indicators for a level II PASRR. On 01/08/23, Res #46 had a new diagnosis of affective psychosis. There was no documentation the state authority had been notified of the resident's new diagnoses to see if a level II PASRR was required. On 10/26/23 at 11:22 a.m., the MDS coordinator stated Res #46's level one PASRR documented no serious mental illness. They stated Res #46's new diagnosis of affective psychosis was not included on the screening form and there was no indication the state was notified.

Based on observation and interview, the facility failed to provide a safe, homelike environment for one (#1) of three residents whose environment was reviewed. The Resident Census and Conditions of Residents, dated 03/14/23, documented a census of 53. Findings: Res #1 had diagnoses which included dementia and cerebral infarction. An assessment, dated 12/22/22, documented Res #1 was severely impaired in cognition and required moderate assistance with activities of daily living. On 03/14/23 at 7:40 a.m., the headboard on Res #1's bed was tilted forward and not secure. On 03/14/23 at 8:05 a.m., Res #1 reported the headboard on the bed had been tilted forward and not secure for quiet a while. On 03/14/23 at 11:00 a.m., the Administrator observed the headboard on Res #1's bed and reported the headboard was tilted forward and not secure. The administrator reported the headboard should have been secured.

Based on record review, observation, and interview, the facility failed to obtain physicians orders for urinary catheter care for two (#33 and #51) of two residents reviewed for urinary catheters. The Resident Census and Conditions of Residents documented four residents had indwelling or external catheters. Findings: Res #33 was admitted to facility with diagnoses which included pressure-induced deep tissue damage of sacral region, and neuropathy. A significant change assessment, dated 04/21/22, documented the resident was severly cognitively impaired and required assistance with activities of daily living. A progress note, dated 05/20/22 at 12:00 p.m., documented in parts .Foley catheter placed using aseptic technique d/t stage 4 decub to sacral area . A care plan, dated 05/24/22, documented in part . provide catheter care every shift and PRN. On 06/20/22 at 10:45 a.m., Res #33 was observed in their room with a urinary catheter. On 06/22/22 at 3:06 p.m., CNA #3 reported they thought Res #33's urinary catheter had been discontinued. CNA #3 reported the aides should have performed urinary catheter care every shift and as needed. CNA #3 reported urinary catheter care should have been documented on the TAR. CNA #3 reviewed Res #33's TAR and reported urinary catheter care was not on the TAR. On 06/22/22 at 3:28 p.m the DON reported Res #33 did not have orders for urinary catheter care. The DON stated an order should have been obtained for urinary catheter care. Res #51 was admitted to facility with diagnoses which included a UTI and long term use of antibiotics. An admission assessment, dated 06/08/22, documented the resident was mildly cognitively impaired and required moderate assistance with activities of daily living. A care plan, dated 06/01/22, documented in part . provide catheter care every shift and prn. On 06/20/22 at 10:00 a.m., Res #51 was observed sitting on their bed with a urinary catheter leg bag. On 06/22/22 at 1:40 p.m., RN #1 reported the resident did not have any orders for urinary catheter care. On 06/22/22 at 1:46 p.m., the DON reported Res #51 did not have orders for urinary catheter care and the TAR did not contain documentation of urinary catheter care. On 06/22/22 at 1:56 p.m., the administrator reported Res #51 did not have orders for urinary catheter care and the TAR did not contain documentation of urinary catheter care. The administrator reported urinary catheter care should have been ordered and documented.

Based on record review and interview, the facility failed to follow physician's orders related to diabetic care for three (#43, 52 and #14) of three residents reviewed for diabetic care. The DON identified 18 residents with a diagnosis of diabetes. Findings: Resident #43 was admitted with diagnoses which included diabetes with diabetic peripheral angiopathy. A physician's order, dated 04/06/22, read in parts, .If Blood Sugar is less than 60, call MD If Blood Sugar is greater than 349, call MD . An Insulin Administration History, dated 06/01/22 - 06/23/22, documented the following out of parameter FSBS: a. On 06/03/22 at 06:00 a.m. res #43's FSBS was 354 b. On 06/10/22 at 08:00 p.m. res #43's FSBS was 378. c. On 06/17/22 at 06:00 a.m. res #43's FSBS was 409. d. On 06/20/22 at 08:00 p.m. res #43's FSBS was 404. There was no documentation in the progress notes of Res #43's physician being notified of abnormal FSBS. On 06/22/22 at 2:00 p.m., the DON stated physician notification of abnormal FSBS would have been documented in the progress notes. The DON reported the physician's order for blood sugar should have been followed. Res #14 was admitted with diagnoses which included diabetes with peripheral neuropathy. A physician's order, dated 07/22/19, read in parts, .If Blood Sugar is less than 60, notify MD .Special Instructions: if (BS) <60 or >400 Notify PCP . An Insulin Administration History, dated 06/01/22 - 06/23/22, documented on 06/10/22 at 06:30 a.m. Res #14's blood sugar was 58. A progress note, dated 06/10/22 at 7:16 a.m., read in part, FSBS 58. Apple juice given. All insulin held at this time. Will report to oncoming nurse for follow up. There was no documentation to show the physician was notified of the abnormal FSBS. On 06/22/22 at 10:06 a.m., LPN #3 reported there was no particular diabetic protocol for staff to follow when a resident had a low blood sugar. On 06/22/22 at 10:28 a.m., RN #1 reported they were unaware of a particular diabetic protocol. RN #1 reported staff would use their nursing judgement, give orange juice if a resident had a low FSBS, and if it didn't raise the blood sugar, they would call 911. On 06/22/22 at 2:00 p.m., the DON stated for a low FSBS, we give juice and recheck the blood sugar to see what it is before we call the physician. The DON also stated the physician's orders should probably be rewritten to reflect that. The DON stated the physician's order should have been followed as written. Resident #52 was admitted with diagnoses which included diabetes. A progress note dated, 05/17/22 at 11:24 p.m., read in parts, .(name removed) (NP) stated to give pt 20 reg [sic] Q4hrs until under 200, check FSBS Q2hrs. I passed all info on to .night shift nurse. The DON was unable to provide documentation of insulin administration every four hours or every two hour FSBS monitoring for Res #52. A physician's order, dated 11/25/21, read in parts, Glucose-15 (dextrose) gel 40% .once a day - PRN, daily. A progress note, dated 06/05/22 at 12:50 a.m., read in parts, Called to res room by CNA, res sweaty and clammy, FSBS 32, gave oral glucose x 3. On 06/23/22 at 10:03 a.m., the DON stated the physician's orders for every four hour insulin administration, and every two hours FSBS should have been followed and documented. The DON also reported the physician's order for glucose gel should have been followed or rewritten to give more often than daily.

Based on record review and interview, the facility failed to provide residents with an advance directive acknowledgement for five (#14, 19, 43, 52, and #258) of five residents reviewed. The Census and Conditions of Residents form documented 50 residents resided in the facility. Findings: Resident records reviewed for residents #14, 19, 43, 52, and #258, did not contain advance directive acknowledgements. On 06/21/22 at 2:02 p.m., the administrator reported the facility had initiated a new form asking if residents were designated as DNR or full code status. The administrator said they thought a DNR was the same as an advance directive. The administrator stated the facility had not offered residents an advance directive acknowledgement.

Based on observation and interview, the facility failed to ensure medications were stored in a secure manner and under the direct observation of staff during medication administration. The administrator reported the facility utilized two medication carts. Findings: On 06/22/22 at 5:30 a.m., a medication cart in the hallway outside room [ROOM NUMBER] was unattended by staff and the top drawer of the cart was open with medications visible. At 5:35 a.m. LPN #4 stepped out of room [ROOM NUMBER], looked at the surveyor, and closed the drawer on the medication cart. On 06/22/22 at 5:45 a.m., LPN #2 was in the hallway outside room [ROOM NUMBER] standing at the medication cart. Two open clear plastic containers were on the top of the medication cart. One container was labeled with Res #14's last name and contained one tablet. One container was labeled with Res #6's last name and contained three tablets. On 06/22/22 at 5:55 a.m., LPN #2 reported medications should not have been placed on the top of the medication cart. LPN #2 reported the medications should have been in a locked drawer on the medication cart. LPN #2 reported the medications were to have been administered to Res #14 and Res #6. On 06/22/22 at 6:00 a.m., LPN #4 reported the medication cart drawer should have been locked while not in use and in staff's direct sight. On 06/22/22 at 8:00 a.m., the administrator reported the medication cart drawers were to be locked unless they were in direct sight of staff. The administrator reported medications were not to be kept on top of the medication carts.

Based on record review, observation, and interview, the facility failed to provide pressure relieving techniques on one (#6) of two residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents documented four residents with pressure ulcers. Findings: Res #6 was admitted to the facility with diagnoses which included a pressure ulcer on the left heel, and hemiplegia. A physician's order, dated 05/11/22, documented in part, float heels while in bed and in geri chair. A care plan, dated 05/11/22, documented in part, float heels in bed, and while in geri chair. An annual assessment, dated 06/11/22, documented the resident was severely cognitively impaired and required assistance of two staff members with activities of daily living. On 06/20/22 from 10:35 a.m. to 12:35 p.m., Res #6 was observed in bed without their heels floated. On 06/21/22 at 7:32 a.m., Res #6 was observed in bed without their heels floated. On 06/22/22 at 9:33 a.m., CNA #2 reported floating the resident's heels would mean placing a pillow under their calves to make sure their heels were not touching the bed. CNA #2 observed Res #6 in bed and stated their heels were not floated. On 06/22/22 at 9:45 a.m., Corporate Nurse #2 reported the residents heels should have been floated when in bed or up in a reclining chair. Corporate Nurse #2 observed Res #6 and reported their heels were not floated as ordered.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents without impaired range of motion (ROM) and/or with impaired ROM received services to maintain, increase, and/or prevent further decline for two (#3 and #15) of three residents sampled for impaired mobility. Resident #3 was observed to have contractures in two fingers on his left hand, three fingers on his right hand, both knees, and both ankles. Resident #3 had not received services to maintain and/or prevent decline since (MONTH) (YEAR). Resident #15 had not received restorative services to maintain or increase his ROM for his hands/fingers. The director of nursing (DON) identified six residents who required range of motion services. Findings: 1. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A physical therapy/occupational therapy (PT/OT) evaluation, dated 03/09/16, documented the resident's upper extremities and lower extremities were within functional limits. The PT/OT evaluation documented the resident's muscle tone was normal. The evaluation did not document any impaired ROM or contractures. A physician order, dated 04/15/16, documented to implement restorative nursing program (RNP) and include bilateral upper and lower extremity exercises with 10 to 15 repetitions of active range of motion and sit to stand with total dependence per patient tolerance three to five times a week. A physician order, dated 08/12/16, documented clarification for restorative therapy to include bilateral upper and lower extremity exercises with 10 to 15 repetitions of active range of motion. A physician order, dated 08/31/16, documented to discontinue from restorative due to resident having to use a lift. The order documented for the certified nurse aide (CNA) to continue ROM. The resident's medical record did not contain any documentation the resident received ROM services after (MONTH) (YEAR). A nursing evaluation (eval) titled, 'Limited ROM', dated 06/20/17, documented the resident had limited range of motion in his hand, leg, and foot. The eval did not document specifically if it was the left or right extremity, or what the specific limitations were on the resident's hand, leg, or foot. An annual assessment, dated 09/30/17, documented the resident was moderately cognitively impaired and had no rejection of care behaviors. The assessment documented the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, eating, personal hygiene, and did not walk. The assessment documented the resident had impairment of both lower extremities, no impairment of his upper extremities, and had not received restorative services. The care plan, with a review date of 12/30/17, documented the resident had decreased mobility and to reposition the resident as needed. The care plan documented the resident required extensive to total assistance with most activities of daily living (ADLs). The care plan documented the resident had impaired mobility related to a history of a [MEDICAL CONDITION]. The care plan did not document any contractures or limited and/or impaired ROM. A nursing eval titled, 'Limited ROM', dated 02/01/18, documented the resident had limited range of motion in his arm, leg, and foot. The eval did not document specifically if it was the left or right extremity, or what the specific limitations were on the resident's arm, leg, or foot. The eval did not documented any impairment to the resident's hands or fingers. A quarterly assessment, dated 03/30/18, documented the resident was moderately cognitively impaired and did not have rejection of care behaviors. The assessment documented the resident required extensive assistance with bed mobility, transfers, dressing, eating and toilet, use, personal hygiene, and did not walk. The assessment documented the resident did not have any impairment of his upper or lower extremities and had not received restorative services. The care plan, with a review date of 03/30/18, documented the resident had decreased mobility and to reposition the resident as needed. The care plan documented the resident required extensive to total assistance with most activities of daily living (ADLs). The care plan documented the resident had impaired mobility related to a history of [MEDICAL CONDITION]. The care plan did not document any contractures or limited and/or impaired ROM. On 07/09/18 at 12:00 p.m., an observation was made of the resident lying in his bed. The resident appeared to have contractures to both hands. The resident's fourth and fifth digits had limited ROM. The resident's right hand was observed to have limited ROM to the third, fourth, and fifth digits. The resident was asked if he was receiving ROM services. The resident reported no one was helping him with ROM. On 07/12/18 at 8:20 a.m., the resident was observed in his bed with the head of the bed elevated. A staff was observed to feed the resident breakfast. On 07/16/18 at 2:12 p.m., certified medication aide (CMA) #1 was interviewed related to the resident's ROM impairment. The CMA stated she had worked at the facility since (MONTH) 2014. She said she used to take care of the resident when she was a CNA on the skilled unit. She reported the resident's legs were now contracted at the knees and his feet are pointed downward. She reported his hands have not always been contracted because she said she remembered when he came into the facility, he would feed himself. She reported he did have some limitation to his left knee because of a surgery to his knee when he was first admitted . On 07/16/18 at 2:27 p.m., CMA #1 and a surveyor observed the resident's legs and ankles. The resident's knees were observed to be bent at at approximately a 60 degree angle. The CMA could move his legs to approximately a 90 degree angle before meeting resistance. His left ankle would slightly move with help from the CN[NAME] His right ankle would move a little more that his left ankle and his right foot pointed out to the right. On 07/16/18 at 4:10 p.m., the minimum date set (MDS) coordinator was interviewed. The MDS coordinator was asked if the resident had any contractures. She said the resident did not have any contractures which she was aware. The MDS coordinator was asked where she received her information for coding the MDS assessment regarding impairment in ROM for the resident. She reported the system was pulling the information forward. She was asked if she had observed the resident lately. She reported she had not looked at the resident recently. She was asked if the resident was receiving ROM services. She reported she did not think so. She said ROM impairment or contractures were not care planned for the resident. On 07/17/18 at 2:55 p.m., the restorative aide was asked if she had the resident on the restorative program. She reported she had started doing restorative a month ago and there had not been anyone doing restorative since (MONTH) (YEAR). She reported the resident was on hospice and she did not work with hospice residents. On 07/18/18 at 10:11 a.m., the resident was asked about the ROM in his hands, knees, and ankles. He reported his knees and ankles have been this way for a while. He reported his hands have been getting worse in the last few months. He reported he had not been getting ROM exercises. He reported he would like to get ROM services to maintain what movement he had left in his hands. On 07/18/18 at 10:19 a.m., CNA/CMA #2 was asked if she took care of the resident. She said she had taken care of the resident for a while and is now his medication aide. She reported he had full ROM a year ago when she was a CN[NAME] She said his right hand is more contracted now. She was asked if she had seen restorative work with him. She reported they used to but had not seen anyone work with the resident in a while. He was still getting out of bed and brushing his dentures last summer. On 07/18/18 at 11:01 a.m., licensed practical nurse (LPN) #1 was asked about the resident's limitations in ROM. She said his fingers straighten out fully. She said when the resident discharged from OT and physical therapy (PT) the restorative aide worked with him on his upper body for a while. She said when he was not able to get up anymore he started to decline. She said his knees are bent. She said the aides turned him on his side and put a pillow between his legs and so he always had his legs bent. On 07/18/18 at 2:28 p.m., CNA #3 was interviewed about the resident's ROM limitations. The CNA stated she used to be the restorative aide and worked with the resident up until the time he was discharged from the RNP around (MONTH) (YEAR). She said when she first started working with the resident he was standing up. She said he would stand on the outside of his right ankle. She said that kept him from doing the sit to stand exercise. She said it got to the point she would have to do passive ROM and not active anymore. The CNA said his ankles and knees had some ROM limitations but not a lot and he had one pinky finger which was contracted on one hand. She said he had full ROM in all of his other fingers at that time. A nursing eval titled, 'Limited ROM', dated 07/18/18, documented the resident had limited ROM in his arm, hand, leg, and foot. The eval documented to see an additional nurse note on page nine. The eval documented the resident's left hand's pinky was contracted and the ring finger was 50 percent contracted at the knuckle. The eval documented all of the fingers on the resident's right hand except for the thumb were contracted. The eval documented the resident's elbows had full adduction ROM and slight contraction related to the abduction of the elbows. The eval documented the resident's knees were contracted slightly. The eval document left knee replacement history. The eval documented the resident stated after surgery he was not able to fully straighten the left knee. The eval documented the resident was unable to bend his toes on the left foot fully but was able to flex toes to right foot except for the second toe which was fixed and unable to bend or straighten. The eval documented the resident's ankles were contracted. The eval was signed by the unit manager. On 07/19/18 at 9:00 a.m., the DON reported she had only been at the facility for a few weeks and could not account for what had been done for the resident before she came. She said she conducted an assessment on the resident yesterday. She said the resident had declined in ROM from what had previously been documented related to his limitations in ROM. She said the QAPI team stayed last night and assessed every resident for ROM issues. She said they identified four residents who need to be picked up for ROM services. 2. Resident #15 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A nursing evaluation, dated 02/05/18, documented the resident had limited range of motion (ROM) to his leg and foot. An admission assessment, dated 02/12/18, documented the resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, and toilet use. The assessment documented the resident required supervision with eating and personal hygiene. The assessment documented the resident had impairment on one side of his lower extremity and no impairment in his upper extremities. A quarterly assessment, dated 05/04/18 documented the resident was cognitively intact and had no rejection of care behavior. The assessment documented the resident required extensive assistance with bed mobility, transfers, dressing, and toilet use. The assessment documented the resident required supervision with eating and personal hygiene. The assessment documented the resident had impairment on one side of his lower extremities and no impairment in his upper extremities. The assessment documented the resident did not receive ROM services. The care plan, dated 03/03/18, documented physical therapy/occupational therapy (PT/OT) to evaluate and treat as indicated. The care plan documented the resident was discharged from PT/OT on 03/18/18. The care plan documented restorative services were ordered on [DATE] and discontinued on 06/20/18. The medical record did not contain any documentation the resident was offered restorative services or received restorative services. On 07/09/18 at 3:39 p.m., the resident was asked if he could straighten out his fingers. The resident was observed to place his hands on a table. His hands were observed to touch the table at the fingertips and the back of his hand by his wrist. The palms of his hands were not touching the table. The resident stated he was unable to lay his hands flat. The resident was asked if pressure was applied to his hands would his fingers lay flat. The resident attempted to push down on his hands with the other hand and he was not able to straighten his fingers. The resident said his hands had been this way when he entered the facility. The resident reported the facility had not asked him about receiving restorative services and no one had been working with him. The resident reported he did not have any splints for his hands. He said he had physical therapy when he first came into the facility. On 07/17/18 at 2:55 p.m., the restorative aide was asked if the resident had been receiving restorative services. She said the resident had not been receiving restorative services. She reported she had started doing restorative a month ago. She reported there has not been anyone doing restorative since (MONTH) (YEAR).

On 09/24/14 at 12:20 p.m., an Immediate Jeopardy situation was determined to exist due to the facility's: a) Lack of monitoring and identification of potential serious responses or side effects of [MEDICATION NAME], a blood thinning medication. b) Pattern of repeated failures to consult with a physician concerning abnormal and CRITICAL PT/INR results for [MEDICATION NAME] therapy. c) Pattern of repeated failures to obtain PT/INR labs as ordered by the physician. On 09/24/14 at 12:24 p.m., the Oklahoma State Department of Health was notified. The IJ situation was verified. At 12:43 p.m., the Administrator, the Director of Nursing and the Assistant Director of Nursing were notified of the IJ situation. At 2:45 p.m., an acceptable plan of removal was provided to the team. The plan of removal documented the following: "SCG, Oak Ridge Nursing Home September 24, 2014 at 12:50 PM... When lab results are received all physicians will be notified immediately of critical lab results by phone and fax to follow - DON/ADON will be monitoring results. If unable to notify PCP the medical director will be informed but will follow up with PCP when available. If both the MD and the PCP are unable to get in contact the physician the on call physician will be notified. Faculty has notified Medical Director of situation at on 09/24/2014 at 1:34 PM... Nursing staff failed to monitor and respond to critical PT/INR lab value. Monitoring labs and in-service was initiated on 09/24/2014 for all nursing staff to document and chart on the lab log; new nursing lab log was instituted on 09/23/2014 at 2:15 PM. On 09/24/2014 at 10:00 AM a [MEDICATION NAME]/PT/INR flow sheet was brought in place for nursing staff and inserviced. Inservice is conducted by (Name deleted), ADON and will be completed by 09/24/2014 at 6:30 PM to include adverse reactions and negative outcomes. Currently all four residents that are receiving [MEDICATION NAME] therapy are being evaluated for most recent results for PT/INR. PCP has been notified of any abnormal findings - charge nurses are to monitor for side effects and adverse reactions of anticoagulant therapy will be care planned in chart. Charge nurses will be checking logs for lab results Q shift; if results have not been received within 24-Hour period, lab will be notified for results. The physicians will be notified by phone and fax results of PT/INR. The policy and procedure will be reviewed and in-serviced to all Nurses... In-services have been completed. The charts for residents with anticoagulant therapy were reviewed on 09/24/2014 at 4 PM." The last direct care staff had been inserviced on 09/24/14 at 4:30 p.m. The IJ was removed as of 09/24/14 at 4:30 p.m., after all direct care staff had been inserviced. The deficiency remained at a level of actual harm, at a pattern that was not immediate jeopardy. Based on record review, observation, and interview, it was determined the facility failed to: a) have an effective system in place to monitor residents receiving [MEDICATION NAME], and it's side effects for one (#4) of four sampled residents who received [MEDICATION NAME] and b) follow the physician's orders [REDACTED].#4) of four sampled residents who received [MEDICATION NAME]. This caused harm to resident #4 when the resident had an abnormal amount of blood in her urine eight days after a critically high PT/INR lab was obtained. The resident had a history of [REDACTED]. The physician was not notified of the critically high PT/INR results or the abnormal UA which showed 3+ blood in the resident's urine. This had the potential to affect four residents who received [MEDICATION NAME]. Findings: The facility's policy, 'Lab and Diagnostic Test Results - Clinical Protocol', documented, "...IDENTIFYING SITUATIONS THAT WARRANT IMMEDIATE NOTIFICATION - Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: 1. The physician has requested to be notified as soon as a result is received. 2. The result is something that should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). 3. The resident's clinical status is unclear or worsening. 4. High or toxic drug levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician...OPTIONS FOR PHYSICIAN NOTIFICATION - 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, etc. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. c. For information that does not need immediate physician response, staff may use alternatives such as faxing, voicemail, or a clipboard in the facility...PHYSICIAN RESPONSES - 1. Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. a. A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab notification with a request for response (for example, by late Wednesday afternoon for a call made on Tuesday) b. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance..." 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A January 2014, monthly Physician Orders, documented "...PT/INR monthly. Range 2-3." A 'Lab Report (with history)', dated 01/08/2014, documented, "PT...*H 70.8 CRITICAL...Ref Range 10.2-13.4 second...INR...*H 6.1 CRITICAL...Ref Range...2.0-3.5...**!!Critical Value!!** Repeated for verification and called to (LPN #1's name deleted)...(laboratory staff initials deleted) 1/8/2014, 6:44 PM..." The physician was not notified of the abnormal lab results and the resident continued to receive [MEDICATION NAME] 3 mg. daily. A nurse's note, dated 01/16/14 at 10:00 a.m., documented, "Called to room by CNA, dark amber colored urine noted upon urination, UA c C&S order received, specimen collected and sent to (Hospital name deleted) lab." A urinalysis report, documented, "...Date Ordered: 01/16/14...Specimen URR Collected 01/16/14...Color Red...Blood, Urine Dipstick 3+ AB...Red Blood Cells TNTC AB...Received Time Jan. 20. 2014 9:12 AM...(date facility received results from lab). The physician was not notified of the abnormal lab results and the resident continued to receive [MEDICATION NAME] 3 mg. daily. The January 2014, MAR, documented the resident continued to receive [MEDICATION NAME] 3 mg daily through 01/31/14. A 'Lab Report (with history)', dated 02/05/2014, documented, "...PT H 42.0...Ref Range 10.2-13.4 second...INR H 3.6...Ref Range...2.0-3.5..." A physician's orders [REDACTED]. The physician was not informed of the abnormal lab results until five days later, when the physician changed the dosage of [MEDICATION NAME] to 2 mg. A PT/INR lab was not drawn on 02/24/14, as ordered. The resident continued to receive [MEDICATION NAME] 3 mg daily through 03/20/14. A 'Lab Report (with history)', dated 03/05/2014, documented, "...PT H 16.7...Ref Range 10.2-13.4 second...INR L 1.4...Ref Range...2.0-3.5..." A nurse's note, dated 03/20/14, documented, "Lab re-faxed to (physician's name deleted) R/T PT/INR..." This was 15 days after the abnormal lab results were obtained. An April 2014, monthly, 'Physician Orders', documented "...3/21/[MEDICATION NAME] 4 mg tablet 1 po daily @ HS..." A 'Lab Report (with history)', dated 05/05/14, documented, "...PT H 44.8...Ref Range 10.2-13.4 second...INR H 3.9...Ref Range...2.0-3.5..." A physician's orders [REDACTED]. The June 2014, MAR, documented the resident received [MEDICATION NAME] 4 mg on the 1st through the 5th, instead of [MEDICATION NAME] 2 mg as ordered. A 'Lab Report (with history)', dated 06/02/2014, documented, "...PT H 18.1...Ref Range 10.2-13.4 second...INR L 1.5...Ref Range...2.0-3.5..." There was no physician notification of the abnormal lab. The resident continued on [MEDICATION NAME] 2 mg. A 'Lab Report (with history)', dated 07/02/2014, documented, "...PT H 15.9...Ref Range 10.2-13.4 second...INR L 1.4...Ref Range...2.0-3.5..." There was no physician notification of the abnormal lab result. A physician's orders [REDACTED]. A quarterly assessment, dated 07/29/14, documented the resident was moderately cognitively impaired, needed assistance with ADLs and received an anticoagulant. A 'Lab Report (with history)', dated 08/06/2014, documented, "...PT H 56.7...Ref Range 10.2-13.4 second...INR H 4.9...Ref Range...2.0-3.5..." There was no physician notification of the abnormal lab result. The August 2014, MAR, documented the resident continued to receive [MEDICATION NAME] 3 mg daily through 08/31/14. The care plan, dated 08/25/14, documented, "...has HX [MEDICAL CONDITIONS]. Requires anticoagulant and is at risk of bleeding...will have reduced risk of further [MEDICAL CONDITION] by next review...Give her [MEDICATION NAME] as ordered. Draw labs as ordered. Monitor for bruising/bleeding..." The September 2014, MAR, documented the resident continued to receive [MEDICATION NAME] 3 mg through the 7th. A 'Lab Report (with history)', dated 09/08/2014, documented, "...PT *H 91.4 Critical...Ref Range 10.2-13.4 second...INR *H 7.9 Critical...Ref Range...2.0-3.5......**!!Critical Value!!** Repeated for verification and called to (LPN #1's name deleted)...(laboratory staff initials deleted) 9/8/2014, 1:16 PM..." A physician's orders [REDACTED]. There was no PT/INR drawn, as ordered on [DATE]. On 09/23/14 at 8:15 a.m., LPN #1 was asked if she received the call from the laboratory about the critical lab value on 01/08/14. She said she did. She was asked if she called the physician. She said she did not. She said she gave the information to the nurse who was taking care of the resident at that time. She said she could not remember who the nurse was. The LPN was asked how and when were the nurses supposed to notify the physician about abnormal lab results. She said they were supposed to call the physician immediately when they received the results from the lab. The LPN was asked who was responsible for following up on the labs. She said no one in particular, "Just the nurse who is taking care of the resident." At 8:35 a.m., LPN #3 was asked if he knew about the resident's critical PT/INR results on 01/08/14. He said he did not take care of the resident that day. He said he did not know about the critical lab results. He was asked what he was supposed to do when he received an abnormal lab result. He said he calls it to the physician and documents it in the nurses' notes. At 9:00 a.m., LPN #2 was asked if she remembered receiving the information about the resident's critical PT/INR results on 01/08/14. She said she did not know anything about the results. She was asked what the nurses were supposed to do when they received abnormal lab results. She said they were to call the physician and document it. She was asked if there was any one person responsible for the labs. She said, no. She was asked if she ever checked the lab books. She said no, that information was usually written on the 24 hour report sheets. On 09/23/14 at 2:45 p.m., the DON was asked when and how the physician should be notified of abnormal lab results. She said the physician should be notified by phone as soon as the results were received. She was asked if she was aware of the resident's abnormal lab results that were not called to the physician. She said she knew they were having a problem with labs and the medical records clerk had started trying to log them in a book last month. The DON was asked why the resident received [MEDICATION NAME] 4 mg instead of 2 mg on June 1st through June 5th. She said it was a med error because there was not an order for [REDACTED]. She was asked if she was aware of the resident's critical PT/INR this month and that the lab was not re-drawn three days later as ordered. She said she was not aware of the lab issues. On 09/24/14 at 9:30 a.m., the resident's physician was asked if he was aware of the 01/08/14, critical PT/INR results. He said he was not aware. He was asked when and how the facility was supposed to contact him. He said the nurses should call him as soon as they get the results the same day the lab was drawn or at the latest the next day. He said the nurses should always call and never depend on the fax for notification. The physician was shown the 01/16/14, UA results, which showed an abnormal amount of blood in the urine. The physician was asked if the blood in the urine was a direct result of the [MEDICATION NAME] dosage not being adjusted. He said not in all cases, but in this resident's case it was. The physician was asked what his interventions would have been if he had known of the blood in the UA. He said he would have held the [MEDICATION NAME] and administered vitamin K to the resident. At 11:20 a.m., the physician was asked if the facility notified him concerning the fact they did not redraw the PT/INR on 09/11/14, and continued to hold the [MEDICATION NAME] until last night. The physician voiced he was not aware the [MEDICATION NAME] was held. He said the facility needed a different protocol for PT/INR.

On 09/24/14 at 12:20 p.m., an Immediate Jeopardy situation was determined to exist due to the facility's repeated failures to inform the physician of abnormal and critical PT/INR results for resident's receiving [MEDICATION NAME]. At 12:24 p.m., the Oklahoma State Department of Health was notified. The IJ situation was verified. At 12:43 p.m., the Administrator, the Director of Nursing and the Assistant Director of Nursing were notified of the IJ situation. At 2:45 p.m., an acceptable plan of removal was provided to the team. The plan of removal documented the following: "SCG, Oak Ridge Nursing Home September 24, 2014 at 12:50 PM... When labs results are received all physicians will be notified immediately of critical lab results by phone and fax to follow - DON/ADON will be monitoring results. If unable to notify PCP the medical director will be informed but will follow up with PCP when available. If both the MD and the PCP are unable to get in contact the physician the on call physician will be notified. Faculty has notified Medical Director of situation on 09/24/2014 at 1:34 PM... Nursing staff failed to monitor and respond to critical PT/INR lab value. Monitoring labs and in-service was initiated on 09/24/2014 for all nursing staff to document and chart on the lab log; new nursing lab log was instituted on 09/23/2014 at 2:15 PM. On 09/24/2014 at 10:00 AM a [MEDICATION NAME]/PT/INR flow sheet was brought in place for nursing staff and inserviced. Inservice is conducted by (Name deleted), ADON and will be completed by 09/24/2014 at 6:30 PM to include adverse reactions and negative outcomes. Currently all four residents that are receiving [MEDICATION NAME] therapy are being evaluated for most recent results for PT/INR. PCP has been notified of any abnormal findings - charge nurses are to monitor for side effects and adverse reactions of anticoagulant therapy will be care planned in chart. Charge nurses will be checking logs for lab results Q shift; if results have not been received within 24-Hour period, lab will be notified for results. The physicians will be notified by phone and fax results of PT/INR. The policy and procedure will be reviewed and in-serviced to all Nurses. In-services have been completed. The charts for residents with anticoagulant therapy were reviewed on 09/24/2014 at 4 PM." The last direct care staff had been inserviced on 09/24/14 at 4:30 p.m. The IJ was removed as of 09/24/14 at 4:30 p.m., after all direct care staff had been inserviced. The deficiency remained at a level of actual harm, at a pattern, that was not immediate jeopardy. Based on record review, observation, and interview, it was determined the facility failed to: a. Ensure the physician was informed of a critical PT/INR lab and an abnormal UA which contained 3+ blood in the urine, for one (#4) of four sampled residents who received [MEDICATION NAME]. This caused harm when the resident had an abnormal amount of blood in her urine eight days after the critical high PT/INR lab was obtained. b. Ensure the physician was informed of abnormal PT/INR labs for three (#4 and #13) of four sampled residents who received [MEDICATION NAME]. These had the potential to affect four residents who received [MEDICATION NAME]. Findings: The facility's policy, 'Lab and Diagnostic Test Results - Clinical Protocol', documented, "...IDENTIFYING SITUATIONS THAT WARRANT IMMEDIATE NOTIFICATION - Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: 1. The physician has requested to be notified as soon as a result is received. 2. The result is something that should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). 3. The resident's clinical status is unclear or worsening. 4. High or toxic drug levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician...OPTIONS FOR PHYSICIAN NOTIFICATION - 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, etc. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. c. For information that does not need immediate physician response, staff may use alternatives such as faxing, voicemail, or a clipboard in the facility...PHYSICIAN RESPONSES - 1. Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. a. A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab notification with a request for response (for example, by late Wednesday afternoon for a call made on Tuesday) b. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance..." 1. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A January 2014, monthly physician orders, documented, "...PT/INR monthly. Range 2-3. [MEDICATION NAME] 3 mg 1 po @ 6 q day..." A 'Lab Report (with history)', dated 01/08/2014, documented, "...PT...*H 70.8 CRITICAL...Ref Range 10.2-13.4 second...INR...*H 6.1 CRITICAL...Ref Range...2.0-3.5...**!!Critical Value!!** Repeated for verification and called to (LPN #1 name deleted) by (laboratory staff initials deleted) 1/8/2014, 6:44 PM..." The physician was not notified and the resident continued to receive [MEDICATION NAME] 3 mg daily. A nurse's note, dated 01/16/14 at 10:00 a.m., documented, "Called to room by CNA, dark amber colored urine noted upon urination, UA c C&S order received, specimen collected and sent to (Hospital name deleted) lab." A urinalysis report, documented, "...Date Ordered: 01/16/14...Specimen URR Collected 01/16/14...Color Red...Blood, Urine Dipstick 3+ AB...Red Blood Cells TNTC AB...Received Time Jan. 20, 2014 9:12 AM..." (date facility received results from lab). The physician was not notified and the resident continued to receive [MEDICATION NAME] 3 mg daily. A 'Lab Report (with history)', dated 02/05/2014, documented, "...PT H 42.0...Ref Range 10.2-13.4 second...INR H 3.6...Ref Range...2.0-3.5..." A physician's orders [REDACTED]. The physician was not notified of the abnormal lab results until five days later, when the physician changed the dosage of [MEDICATION NAME] to 2 mg. A 'Lab Report (with history)', dated 03/05/2014, documented, "...PT H 16.7...Ref Range 10.2-13.4 second...INR L 1.4...Ref Range...2.0-3.5..." A nurse's note, dated 03/20/14, documented, "Lab re-faxed to (Physician's name deleted) R/t PT/INR..." This was 15 days after the abnormal lab results had been obtained. An April 2014, monthly, 'Physician Orders', documented "...3/21/[MEDICATION NAME] 4 mg tablet 1 po daily @ HS..." A 'Lab Report (with history)', dated 05/05/2014, documented, "...PT H 44.8...Ref Range 10.2-13.4 second...INR H 3.9...Ref Range...2.0-3.5..." A physician's orders [REDACTED]. A 'Lab Report (with history)', dated 06/02/2014, documented, "...PT H 18.1...Ref Range 10.2-13.4 second...INR L 1.5...Ref Range...2.0-3.5..." The physician was not notified of the abnormal lab results. The resident continued on [MEDICATION NAME] 2 mg. A 'Lab Report (with history)', dated 07/02/2014, documented, "...PT H 15.9...Ref Range 10.2-13.4 second...INR L 1.4...Ref Range...2.0-3.5..." The physician was not notified of the abnormal lab results. A physician's orders [REDACTED]. A quarterly assessment, dated 07/29/14, documented the resident was moderately cognitively impaired, needed assistance with ADLs and received an anticoagulant. A 'Lab Report (with history)', dated 08/06/2014, documented, "...PT H 56.7...Ref Range 10.2-13.4 second...INR H 4.9...Ref Range...2.0-3.5..." The physician was not notified of the abnormal lab results. The resident continued to receive [MEDICATION NAME] 3 mg daily. The care plan, dated 08/25/14, documented, "...has HX [MEDICAL CONDITIONS]. Requires anticoagulant and is at risk of bleeding...will have reduced risk of further [MEDICAL CONDITION] by next review...Give her [MEDICATION NAME] as ordered. Draw labs as ordered. Monitor for bruising/bleeding..." A 'Lab Report (with history)', dated 09/08/2014, documented, "...PT *H 91.4...Ref Range 10.2-13.4 second...INR H* 7.9 Critical...Ref Range...2.0-3.5..." A physician's orders [REDACTED]. There was no PT/INR drawn, as ordered on [DATE]. On 09/23/14 at 8:15 a.m., LPN #1 was asked if she received the call from the laboratory about the critical lab on 01/08/14. She said she did. She was asked if she called the physician. She said she did not. She said she gave the information to the nurse who was taking care of the resident at that time. She said she could not remember who the nurse was. The LPN was asked how and when were the nurses supposed to notify the physician about abnormal lab results. She said they were supposed to call the physician immediately when they received results from the lab. The LPN was asked who was responsible for following up on the labs. She said no one in particular, "Just the nurse who is taking care of the resident." On 09/23/14 at 8:35 a.m., LPN #3 was asked if he knew about the resident's critical PT/INR results on 01/08/14. He said he did not take care of the resident that day. He said he did not know about the critical lab results. He was asked what he was supposed to do when he received an abnormal lab result. He said he calls it to the physician and documents it in the nurses' notes. On 09/23/14 at 9:00 a.m., LPN #2 was asked if she remembered receiving the information about the resident's critical PT/INR results on 01/08/14. She said she did not know anything about the results. She was asked what the nurses were supposed to do when they received abnormal lab results. She said they were to call the physician and document it. She was asked if there was any one person responsible for the labs. She said, no. She was asked if she ever checked the lab book. She said no, that information was usually written on the 24 hour report sheets. On 09/23/14 at 2:45 p.m., the DON was asked when and how the physician should be notified of abnormal lab results. She said the physician should be notified by phone as soon as the results were received. She was asked if she was aware of the resident's abnormal lab results that were not called to the physician. She said she knew they were having a problem with labs and the medical records clerk had started trying to log them in a book last month. She was asked if she was aware of the resident's critical PT/INR this month and that the lab was not re-drawn three days later as ordered. She said she was not aware of the lab issues. On 09/24/14 at 9:30 a.m., the resident's physician was asked if he was aware of the 01/08/14, critical PT/INR results. He said he was not aware. He was asked when and how the facility was supposed to contact him. He said the nurses should call him as soon as they get the results the same day the lab was drawn or at the latest the next day. He said the nurses should always call and never depend on the fax for notification. The physician was shown the 01/16/14, UA results, which showed an abnormal amount of blood in the urine. The physician was asked if the blood in the urine was a direct result of the [MEDICATION NAME] dosage not being adjusted. He said not in all cases, but in this resident's case it was. The physician was asked what his interventions would have been if he had known of the blood in the UA results. He said he would have held the [MEDICATION NAME] and administered vitamin K to the resident. At 11:20 a.m., the physician was asked if the facility notified him concerning the fact they did not redraw the PT/INR on 09/11/14, and continued to hold the [MEDICATION NAME] until last night. The physician voiced he was not aware the [MEDICATION NAME] was held. He said the facility needed a different protocol for PT/INR. 2. Resident #13 had been admitted to the facility on [DATE]. On 07/17/14, a quarterly assessment documented the resident was cognitively intact, required limited assistance with bed mobility, transferring between surfaces, ambulation, dressing, hygiene/bathing, and was always continent of bowel and bladder. On 07/23/14, a care plan documented, "Problem: (Name deleted resident #13) receives long term anticoagulant use and is at risk for bleeding/bruising...Approach: Give [MEDICATION NAME] per MD order. Have labs drawn for PT/INR per MD order..." The September 2014, physician's orders [REDACTED]. On 09/08/14, a laboratory PT/INR was drawn, the PT was 36.3 "high". A handwritten note on the form documented it had been faxed on 09/11/14, but did not say who it was faxed to. The nurse's notes were reviewed for 09/08/14 through 09/11/14. A nurse's note dated 09/11/14, documented, "...PA made rounds et looked at labs..." The notes did not contain documentation of the physician being informed of the abnormal PT/INR results, until three days after the lab had been obtained. On 09/11/14, a telephone physician's orders [REDACTED]." On 09/23/14 at 4:25 p.m., the ADON was asked about the laboratory PT/INR results for 09/15/14 and 09/22/14. The ADON went to the computer and obtained the results from the laboratory web site. The laboratory results for 09/15/14, was PT 25.1 "high." The laboratory results for 09/22/14, was PT 36.6 "high." The ADON was asked if the facility had the results for the PT/INRs in the facility when asked by the surveyor. The ADON reported they did not. The ADON was asked if the physician had been informed of the results. She reported he had not been. On 09/23/14 at 7:50 a.m., the resident was observed sitting in a chair in the dining room, waiting for the breakfast meal.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure a resident was supervised by two staff during transportation to the shower room due to a previous fall with a head injury for one (#3) of one sampled resident who had a fall with a head injury. This caused actual harm to the resident. No other resident had a fall with a head injury in the month of January 2014, per the incident report. b) Ensure hazardous chemicals were maintained in a secure manner in one of one unlocked beauty shop. This had the potential to affect three residents identified by LPN #1 as having wandering behaviors. Findings: 1. Resident #3 was admitted to the facility on [DATE], after she had fallen at home and required orthopedic aftercare. An admission assessment, dated 12/18/13, documented the resident had been admitted from an acute hospital, had severely impaired cognitive skills for daily decision making, had long and short term memory loss, required extensive assist of two + persons for bed mobility, was totally dependent on two + persons for transfers, was totally dependent on staff for locomotion on and off unit with one person physical assist, required extensive assistance with two + person assist to dress and bathe, had impairment on one side of lower extremity, had an active [DIAGNOSES REDACTED]. receiving PRN pain medication, and had a fall with a fracture in the last month. A care plan, dated 12/11/13, documented the resident required extensive/total assist to bathe, dress or groom, transfer, ambulate and toilet. The resident would get a shower/bath 3 times per week and staff would give assistance as needed. On 01/02/14, PT had documented on the 'Discharge Summary', "...Pt will show good static/dynamic sitting balance to improve seated ADL/W/C mobility with SBA on level surfaces within nursing facility with seated functional reach assessment > 10 in. Discharge (1/2/14) W/C mobility: unable; seated functional reach assessment: 0 in. Comments: Patient has not made further improvements toward goal due to medical condition; requires frequent redirection to stay focused on task secondary to decreased cognition level and inability to follow directions with no carryover...Unable to perform return demonstration d/t to medical condition with difficulty staying focused on task secondary to cognitive status and demonstrates difficulty following commands due to decreased cognitive abilities..." On 01/02/14, OT had documented on the 'Discharge Summary', "D/C reason: Maximum potential achieved...Baseline (12/12/2013) Sitting POOR+/POOR, Discharge (1/2/2014) Sitting FAIR-/POOR+...d/c secondary to reaching Max rehab potential at this time..." A 'Resident Incident Report' dated 01/11/14, documented the following: "...Incident Type: Fall w/head injury Date/Time: 1/11/14 01:15 PM Type of Injury: Abrasion, Other Location: Hallway on unit Equipment: Wheelchair - non-motorized Property Involved: Floor - tile/wood Activity at time: To/frm shower-assist Incident Reported by: (Name deleted) CNA #1 Report Prepared by: (Name deleted) LPN #2 Narrative of incident and description of injuries: Resident was being wheeled to shower room on skilled by (Name deleted) CNA#1, when she leaned forward too far and fell out of wheelchair and hit left side of face and head. CNA was unable to catch her before she fell . Top and bottom of left side of lip swollen and bleeding, knot to left side of head, redness to left cheek and under left eye. Immediate Actions Taken: Instruct staff how to properly transfer residents...Taken to Hospital: (Name of hospital deleted)..." The care plan for risk of falls, had been revised on 01/11/14, and documented, "PT/OT eva. Instruct staff to properly transfer patient." On 03/05/14 at 9:15 a.m., another accident occurred when the resident had been placed in her W/C at the nurses' station, after she had eaten breakfast. She was found lying on the floor on her right side in front of the W/C with the wheels locked. A chair alarm was in place. Assessment of injuries had been completed and pressure had been applied to her nose. The injury included an abrasion to bridge of nose and right knee. "Immediate actions taken: Immobilized; sent to ER." When the resident returned from theER on [DATE], she was placed in a G/C. A quarterly assessment, dated 03/12/14, documented the resident had moderately impaired decision making skills, had long and short term memory loss, had an impairment on one side of LE, was totally dependent on one person for locomotion on and off unit and required physical help 2 + staff to bathe. On 03/12/14, the care plan had been revised to show the resident was in a G/C. On 03/29/14 at 12:40 p.m., the resident was observed in her room in a G/C. The resident's head was leaning to one side of the G/C unsupported and her (R) leg was off the bottom part of the G/C laying partially off the side of the G/C. The resident was rubbing her head and making expressions as if she was uncomfortable. The surveyor asked the resident if she was uncomfortable and the resident stated very softly, "Yes." The surveyor asked the resident if she could lift and move her head over, so it would be supported by the G/C. The resident was unable to move her head or her leg. CNA #3 was outside the resident's room in the hallway and he was asked if the resident could move herself to a better position in the G/C. CNA #3 came into the resident's room and physically moved the resident's body into a more comfortable position where the G/C could be used for supporting her entire body. On 03/29/14 at 1:20 p.m., LPN #2 who had been the LPN present when the resident had fallen on 01/11/14, was interviewed. LPN #2 said the resident was in a shower chair not a W/C when she fell . The LPN said CNA #1 had been wheeling the resident down the hallway to the shower room. When the CNA stopped at the shower room door, the resident had leaned forward and had fallen out of the shower chair. The LPN said the CNA was alone and had been unable to reach the front of the shower chair before the resident had fallen out of the chair and hit the floor on her face. The LPN was asked what steps she had taken to ensure the resident did not fall out of the shower chair again. The LPN reported she had instructed the aides on duty not to push the resident down the hallway in the shower chair again without a two person assist. She said the resident moved too quickly for only one person to assist. LPN #2 was asked if she had added the two person transport to the resident's care plan. She said I should have, but I don't think I did. The LPN was asked if it had been her responsibility to put a two person transport in the care plan. She reported the care plans were kept at the nurses' station and the LPNs were responsible to document things like that in the resident's care plan. On 03/29/14 at 3:45 p.m., the DON was shown the care plan. She was asked what did the care plan mean to 'properly transfer patient'. The DON said it needed to read specifically that two staff were needed to transfer, transport and bathe the resident, which it did not. At 4:15 p.m., CNA #2, who had given a shower to the resident that morning, was asked what steps she had gone through to get the resident from the G/C to the shower room. CNA #2 said first CNA #3 had helped her to lift the resident using a gait belt from the G/C to the shower chair. CNA #2 transported the resident in the shower chair down to the shower room alone, while CNA #3 went and did something else. CNA #3 later came into the shower room to assist CNA #2 to bathe the resident. One CNA transported the resident back to her room in the shower chair. CNA #2 was asked if the resident had moved around in the shower chair earlier that day. The CNA reported some days the resident was very "fidgety moving around a lot", but today she had not moved around very much. CNA #2 was asked how she knew how to transport the resident to the shower room in the shower chair. The CNA produced a 'CNA Pocket Careplan' out of her pocket. The aides care plan for the resident documented, "2 person with shower." The care plan did not address the resident required a 2 person assist when transporting the resident in the shower chair to keep her from falling out. On 03/29/14 at 5:00 p.m., the DON was informed of a CNA transporting the resident to the shower room in a shower chair by herself that morning. The DON reported, "They should know better" and went on to say, it was documented on the aides care plan that the resident required 2 staff to bathe her. The DON was informed the incident on 01/11/14, had occurred while transporting the resident to the shower room by one staff person while the resident was in a shower chair. The DON said she thought the aides care plan meant there was always two staff with her from transporting, to showering, and then back to her room. The DON said the resident was placed in a G/C on 03/05/14, due to a fall out of a W/C. The DON was informed the resident was still being transported to the shower room in a shower chair by only one staff. 2. On 03/29/14 at 9:40 a.m., an initial tour of the facility was conducted. The beauty shop located on the east hallway was observed unlocked and unsecured. In an unlocked cabinet in the beauty shop were the following items: A plastic container with a flip top lid. The label documented, "Sani Cloth Plus- Germicidal Disposable Cloths- Keep out of Reach of Children" A plastic pump spray bottle labeled, "Bye Bye odor- Keep out of Reach of Children." A plastic pump spray bottle labeled, "Envirocide- Disinfectant- Keep out of Reach of Children." A plastic gallon container without a child proof lid was labeled, "Pure Bright- Germicidal Ultra Bleach Keep out of Reach of Children." A spray can labeled, "Disinfectant Deodorant- danger- Keep out of Reach of Children." A plastic squeeze bottle of cleanser was labeled, "The Works." On 03/29/14 at 9:45 a.m., resident #4 was observed wandering down the east hall. The resident was asking staff which room was her room. A care plan for resident #4, dated 02/08/12, documented, "Problem...wanders r/t cognitive decline and is at risk for elopement... Problem: ...has short-term and long-term memory deficit due to Alzheimer's and needs assistance with decision making..." At 9:50 a.m., LPN #1 was asked if the facility had any residents with wandering behaviors. The LPN identified residents #4, #5 and #6. The LPN was asked if these residents entered other residents' rooms. The LPN reported residents #4 and #5 would enter other residents' rooms. The LPN was then asked what resident #4 and #5 did after they had entered other residents' rooms. The LPN reported resident #4 would enter the doorway looking for her mother or son. She further reported when the resident was told her mother or son was not in the room, she would leave and not disturb anything. The LPN was then asked what resident #5 did when she entered other residents' rooms. The LPN reported the resident would seek out an empty bed and go lie down. A care plan, dated 11/29/13, for resident #5 documented, "Problem...wanders abut facility all the time and at times has to be re-directed from other residents' rooms..." The LPN was then asked if either of the residents would drink items that might be setting unattended in other residents' rooms. The LPN reported the facility could not get the three wandering residents to drink the things they should drink, so she did not think the residents would drink things unattended in other residents' rooms.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure a resident who had a history of [REDACTED].#5) of two sampled residents identified with pain. This failure caused harm to resident #5. This had the potential to affect 37 residents on a pain management program, per the DON. b) Ensure an incontinent resident who had been complaining of burning in the peri area, for two days, had been assessed, monitored and a treatment obtained for one (#2) of four sampled incontinent residents. This had the potential to affect 68 residents who were incontinent of bladder, per the DON. Findings: The facility's policy and procedure for pain documented: "Pain Management ...The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes a review of each person's known [DIAGNOSES REDACTED]. management consists of alleviating the resident's pain to a level that is acceptable to the resident...Acute pain should be assessed every 30 to 60 minutes after the onset...The pain assessment consists of gathering both subjective and objective data..." 1. Resident #5 had been readmitted to the nursing facility on 03/07/13, after being discharged from the hospital. The resident's [DIAGNOSES REDACTED]. A care plan documented the resident was at increased risk for pain r/t arthritis and an old right [MEDICAL CONDITION] with contracture. Approaches included to evaluate location, frequency, duration and intensity of pain, document evaluation and report increased pain to physician. Attempt non-pharmacologic pain relief measures, administer pain medication as ordered, and document effectiveness. On 03/07/13, a 'Pain Assessment' had been completed. The assessment documented the resident had intermittent pain described as sharp, aching and throbbing pain in her hip and legs. The current pain medication was [MEDICATION NAME] 7.5mg PO Q 6 hours PRN. In the nurse's notes, for the month of March 2013, the nurses had documented the resident had been experiencing pain 'all over' or to specific locations as her 'hip' frequently at a pain level of 9-10 on a scale of 1-10 with 10 being the greatest pain. '[MEDICATION NAME] 7.5mg PO Q 6 hours PRN' at that time was controlling the resident's pain at a tolerable level. On 04/11/13, a 'Pain Assessment' had been completed. The assessment identified the resident with [DIAGNOSES REDACTED]. It documented the resident could verbalize pain and had experienced pain and had stated, "I'm hurting." Non-verbal expressions of pain were fidgeting/restless, wrinkles brows, and facial grimacing. Location of pain was checked the hip. Frequency of pain was checked 'intermittent'. Time of pain was 'intermittent'. Pain was affecting her quality of life by her being confused, her appetite had decreased and her mobility had decreased. Medications were helping relieve the pain and decrease her anxiety. On 05/11/13 at 9:30 a.m., a nurse's note documented, "Pain scale score 8. Pt C/O pain. Pain pill given." There had been no documented pain relief. A care plan dated 05/11/13, documented the resident had obtained hospice services, with SOC date on 05/11/13, due to a [DIAGNOSES REDACTED]. Hospice was to provide a nurse, a health aide and staff to keep the resident comfortable at all times. On 05/12/13 at 8:00 a.m., a nurse's note documented, "Pt C/O of all over discomfort. [MEDICATION NAME] given @ 0800." Effectiveness of the pain medication had not been documented. On 05/18/13 at 4:00 p.m., a nurse's note documented pt cont to C/O pain - Received NO to ^ [MEDICATION NAME] 7.5mg to q 4 hours routine. On 06/01/13, a "Pain Assessment" had been completed. The assessment documented the resident complained of pain daily. The resident at the time of the assessment was experiencing 'very severe' or 'excruciating' pain. The pain was located all over and the (R) hip. The pain was constant and exhausting. Movement increased the pain. Negative verbalizations included groaning, crying and screaming. The pain medications on the June 2013, MAR follows: "[MEDICATION NAME] 500 mg 1 PO q 4hrs PRN DX: Pain scale <5 5/10/13 *DC'd 6/25/13 Tylenol 650mg supp q 4 hrs. PRN DX: pain and temperature (start) 6/25/13 [MEDICATION NAME] HCL 10mg Tablet 1 PO q 4hrs PRN pain scale 6-10 5/18/13 *DC'd 6/26/13 [MEDICATION NAME] Gel 40mcg/ml Apply 1 ml every 4 hrs. PRN (started) 6/26/13 [MEDICATION NAME] 25mcg/[MEDICATION NAME] q 72 hrs. pain started 6/4/13 *DC'd 6/18/13 [MEDICATION NAME] 50mcg q 72 hrs. (started) 6/18/13" On 06/25/13 at 2:30 p.m., a nurse's note, documented, "N/O received. Comfort measures only. DC all medications and continue FSBS except (1) [MEDICATION NAME] 10mg 1 PO until 6-26-13 q 4 hours (2) [MEDICATION NAME] gel 1mg/ml apply 1 ml q 4 hours PRN Dx anxiety (3) [MEDICATION NAME] gel 40mg/ml apply a ml q 4 hours PRN pain (4) Tylenol 650mg sup/rectally q 4 hours PRN temp < 100 DC [MEDICATION NAME], Med pass, Depokote, [MEDICATION NAME], multivitamins." A significant change assessment, dated 06/25/13, documented the resident had impaired thought processes, her moods included feeling tired and a problem with concentration, was totally dependent on staff for ADL's, always incontinent of bowel and bladder, was on a SCHEDULED PAIN MED REGIMEN, RECEIVED A PRN PAIN MEDICATION, and HAD INDICATORS OF PAIN DAILY..." The' CAT Worksheet' dated 06/25/13, for pain documented, the resident had [MEDICAL CONDITION], a pressure sore, constipation, and arthritis. "(Name of resident deleted) has dementia, an OLD [MEDICAL CONDITION] WITH A CONTRACTURE and a healing stage III on her (R) heel. (Resident's Name deleted) IS HAVING PAIN DUE TO AN OLD [MEDICAL CONDITION] AND OA. She is on hospice and is on routine and prn pain medications. She has dementia and is unable to describe the pain or even let staff know she is in pain but has moaning/crying and restlessness as indicators of pain. SHE IS IN NEED OF CLOSE MONITORING OR NEED FOR CHANGE IN MEDICATION TO KEEP HER COMFORTABLE." On 06/26/13, a "Pain Assessment" had been completed. The assessment identified the resident with [DIAGNOSES REDACTED]. Resident states, "I'm hurting." Non-verbal expressions of pain were crying, fidgeting/restless, wrinkles brows, and facial grimacing. Location of pain was checked for hip and abdomen. Frequency of pain was checked daily and intermittently. Time of pain was intermittent. There were indications of the source of pain on the physical examination from the (R) leg contracture and the wound on her (R) heel. Pain was affecting her quality of life by her confusion, appetite and her mobility. Medications for pain would improve the pain and position, activity and anxiety would make her pain worse. "Unable to describe pain. Can point or touch area hurting at times. Hospice assisting c pain mgmt/comfort measures." On 06/26/13 at 1:30 p.m., a nurse's note documented, "Pain scale score 8. [MEDICATION NAME] gel doesn't seem to be giving much relief. Physician & Hospice notified, awaiting advisement..." At 10:30 p.m., a nurse's note documented, "2230 In bed HOB^. Crying out, restless in bed. C/O leg pain. Touches (R) thigh area. [MEDICATION NAME] PRN given on (R) wrist." There was no documentation the physician or the Hospice had ever responded regarding the resident's pain not being relieved by the [MEDICATION NAME] Gel. The nurses' notes through-out the day did not document the physician nor Hospice had called. On 06/27/13 at 10:00 a.m., a nurse's note, documented, "Resident HOB^ crying out C/O pain to both legs. [MEDICATION NAME] 1mg given topical as ordered...Turned and repositioned q 2 hours and PRN for comfort...Notified Hospice nurse (Name deleted) RN of condition." There was no documentation Hospice had ever notified the physician or responded regarding the resident's unrelenting pain. The June 2013, MAR and Pain administration forms, documented between 06/01/13 through 06/25/13, the '[MEDICATION NAME] HCL 10mg tablet 1 PO q 4hrs pain scale 6-10 joint replaced hip" had been given for pain a total of 53 times. Not all the times had pain effectiveness been documented. The June 2013, MAR documented '[MEDICATION NAME] Gel 40mg/ml' from the time it had been prescribed on the 26th through the 30th, had been administered a total of 8 different times. Pain effectiveness not always good with the physician and hospice being notified at least two different times without responses from the neither the physician nor hospice. The July 2013, MAR documented the resident was on the following medications for pain: [MEDICATION NAME] ([MEDICATION NAME]) 50 mcg/hr Patch 1 patch [MEDICATION NAME] q 3 days (start date) 6/18/13 *DC'd 7/10/13 [MEDICATION NAME] Patch 50 mcg q 72 hours topical (start date) 7/10/13 [MEDICATION NAME] Gel 40 mg/ml 1ml topically q 4 hrs. PRN (start date) 6/25/13 *DC'd 7/3/13 [MEDICATION NAME] Gel 40 mg/ml Apply 1ml q 4 hrs. ROUTINE for pain. Tylenol 650mg q 4 hrs. PRN DX: temp > 101 (Start date) 6/25/13 On 07/02/13 at 1:00 a.m., a nurse's note, documented, "Pain scale score 10. Pt. crying as if in pain - [MEDICATION NAME] & [MEDICATION NAME] gel given per orders...0200 Pt resting, eyes closed...0500 Pain scale score 9. Crying again & [MEDICATION NAME] applied per orders..." On 07/03/13 at 3:15 a.m., nurses' notes, documented, "Screaming and talking to self all night, administered [MEDICATION NAME] and [MEDICATION NAME] @ 0100 as prescribed. Client restless. 1830 Hospice here to see pt. N.O. received to change [MEDICATION NAME] & [MEDICATION NAME] to routine..." On 07/04/13 at 12:10 a.m., a nurse's note, documented, "Pain 5. Awake, confused. C/O hurting all over. Color pale. [MEDICATION NAME]/[MEDICATION NAME] gel applied topical...0100 asleep..." On 07/06/13 at "1000", a nurse's note, documented, "Pain 6-10. Awake. C/O constant pain. [MEDICATION NAME] q 4 hours..." There were no nurses' notes x 4 days. On 07/10/13, (no time documented) a nurse's note, documented, "[MEDICATION NAME] got wet in shower & fell off, physician notified, N.O. received to apply new patch..." On 07/11/13 at 9:00 a.m., a nurses' note, documented, "Hospice nurse here to assess. Request more medication for pain will call Dr. (Name deleted) to ask for recommendation. Pt has crying spells that last hrs @ a time - Repositioning tried, pt dry et HOB^ - Lungs CTA..." At 9:10 a.m., the resident was observed crying out very loudly. Surveyor walked towards the resident's room. Another resident was observed in a W/C. The other resident was wheeling down the hallway next to resident #5's room. The resident asked the surveyor what was wrong with the "poor lady" (resident #5). She seemed very concerned and wheeled on to the nurses' station. At 11:00 a.m., a nurse's note documented, "1100 Call to Dr's office again to get ^ in medication or change medication for pain. Awaiting call back (from 9:00 a.m.)." The LPN #1 reported the physician and hospice had never called back regarding the resident being in excruciating pain. The LPN reported the night shift had told her the resident had cried all night from being in pain. While interviewing LPN #1, the resident continued to cry. On 07/11/13 at 1:30 p.m., LPN #1 stated, "Right now I am trying to find another hospice for the resident per family request." The nurse continued to say the hospice service the resident had right then was not addressing the resident's pain issues. At 1:45 p.m., the medical director was in the facility visiting with the surveyors. A nurses' note, dated 07/11/13 at 2:00 p.m., documented, "1400 Pt cont to cry very loud - tried repositioning without success 1 on 1 c someone holding her hand without success. Call to Hospice (Name deleted) for further recommendation. Awaiting call back." On 07/11/13 at 2:30 p.m., LPN #4 was asked why she had not asked the Medical Director to intercede and look at the resident in pain. The LPN said he was not the resident's physician, so she didn't know to involve the Medical Director. At 5:00 p.m., a nurse's note, documented, "1700...(Medical Director's Name deleted) is going to call (Hospice's Name deleted) & they will call me back. N.O. was received to ^ [MEDICATION NAME] to 100mcg, apply 50mcg patch now, patch applied per orders..." At 5:30 p.m., a nurse's note documented, "1730 (Name of Hospice) nurse here, orders written to ^ [MEDICATION NAME] Patch to 100mcg, [MEDICATION NAME] 20mg/ml give 1ml sublingual q 2 hours, will await arrival from pharmacy." The above order took 8.5 hours to obtain, from 9:00 a.m., when the facility first tried to get in contact with the physician and the hospice, until 5:30 p.m., when hospice came into the facility. The resident had been in excruciating pain the whole time period. At 6:15p.m., a nurse's note, documented, "1815 Pt still crying as if in pain. I called Hospice again. Hospice stated, "[MEDICATION NAME] is on its way." N.O. received to give extra dose of [MEDICATION NAME] now. [MEDICATION NAME] applied..." At 6:35 p.m., a nurse's note documented, "1835 family here to sit c pt..." On 07/11/13 at 7:20 p.m., the Corporate RN documented, "1920 Return call from (Name deleted) c (Name of Hospice deleted). Reports med will be delivered in 30 minutes. Family remains @ bedside. Resident continues to cry at times...massage attempted. Effective for short time." At 7:30 p.m., the Corporate RN documented, "1930 Rec'd call from Hospice Director confirms that med will be delivered in 30 min." At 7:40 p.m., the Corporate RN documented, "1940 Hospice Nurse, (Name deleted) called stated meds to be delivered in 20 min." At 7:45 p.m., the Corporate RN documented, "1945 (Name deleted pharmacist) with (Name deleted pharmacy) called. (Name deleted pharmacy) will deliver med if not delivered by Hospice p order obtained." On 07/11/13 at 8:00 p.m., the Corporate RN documented, "Driver for hospice called by (Name deleted) will arrive in 15 min." On 07/11/13 at 8:00 p.m., a nurse's note documented, "Routine pain & [MEDICATION NAME] given still having little effort awaiting [MEDICATION NAME] to come..." At 8:15 p.m., a nurse's note documented, "Dr. (Name of resident's physician deleted) called and informed of [MEDICATION NAME] not being in facility. Asked for another hardscript to be sent to (Name deleted pharmacy) so we could get the medication for the resident. Dr. (Name of resident's physician deleted) refused and stated he already gave Hospice a hard copy and refused to give another stated we needed to call hospice." At 8:50 p.m., a nurse's note documented, "(Medical Director's Name deleted) paged regarding resident and inability to obtain med." On 07/11/13 at 9:00 p.m., a nurse's note documented, "Spoke with (Medical Director's Name deleted) he agreed to call (Name deleted pharmacy) and order [MEDICATION NAME]." At 9:10 p.m., a nurse's note documented, "(Name of pharmacy deleted) arrived c [MEDICATION NAME] 20mg 1ml given sublingual @ 2111. Family at bedside..." From the time the new medication [MEDICATION NAME] had been ordered, until the time the medication arrived it had been 3 hrs and 40 minutes. The resident continued to have excruciating pain the entire time. At 9:15 p.m., a nurse's note documented, "Notified (Medical Director's Name deleted) that med had arrived from hospice and cancelled order from (Medical Director's Name deleted)." At 9:30 p.m., the Corporate RN documented, "[MEDICATION NAME] has had no noted effect on res. cont to cry and holler out. Consulted c (Pharmacy's Name deleted) for med review..." On 07/11/13 at 10:05 p.m., the Corporate RN documented, "(Resident's physician's Name deleted) notified by hospice nurse. States resident is having an acute psychotic episode. Rec'd new order for [MEDICATION NAME] 5mg IM now & [MEDICATION NAME] 50mg PO at HS." At 9:20 p.m., the Corporate RN, documented in the nurses' notes, "LATE ENTRY Hospice nurse, (Name deleted) RN in facility to assess resident." At 10:10 p.m., the ADON documented in the nurses' notes, "Call placed to (Name deleted pharmacy). IM injection and [MEDICATION NAME] ordered..." At 10:30 p.m., a nurse's note documented, "Family at bedside...cont. (resident) to moan and cry out." At 11:00 p.m., the ADON wrote a nurse's note documenting, "Pt cont to cry out...Appears to be having hallucinations." At 11:30 p.m., a nurse documented, "IM [MEDICATION NAME] 5mg admin via hospice nurse (Name deleted)..." At 11:45 p.m., a nurse documented, "Pt conts to be restless et tossing and turning in bed, repositioned for comfort...Pt cont to moan..." On 07/12/13 at 1:00 a.m., a nurse documented, "Pt is not crying, but talking...all of a sudden patient would cry out..." At 5:00 a.m., a nurse documented, "...Pt. began screaming and grabbed her (L) foot L leg. Foot appears drawn up like a possible 'Charlie horse." PRN [MEDICATION NAME] given @ 5:30 a.m." At 5:40 a.m., a nurse documented, "Spoke with family physician. Rec'd order to send to ER..." At 6:20 a.m., a nurse documented, "Pt transferred to (Name deleted ER)..." The following reports were documented in the hospital's medical records: On 07/12/13 at 6:37 a.m., a hospital ER nurse documented, "...Pt in severe pain unable to control w/[MEDICATION NAME], roxinal, or [MEDICATION NAME]; pt crying out, stating, "Oh lord it hurts. It hurts; pt grabbing at left leg..." "06:44 The patient presents with pain, that is acute. The complaints affect the left foot. The problem was sustained at a nursing home...Onset: The symptoms/episode began/occurred yesterday...The symptoms are alleviated by nothing, the symptoms are aggravated by movement...Severity of symptoms: At their worst the symptoms were incapacitating..." "06:47 Nursing Diagnosis: [REDACTED]. pt crying aloud mumbling. Pt reaching grabbing at left LE upon arrival; Left leg wrapped in warm blanket Foot massaged. Cooler temp noted to left LE than right..." "07:37 Drug: [MEDICATION NAME] 50 mcg; Route: IVP..." "07:59...Pain is decreased" Resident was admitted to the hospital on [DATE]. On 07/12/13 at 7:45 a.m., CNA #6 was asked how resident #5 had been the night before. The CNA stated, "She was hurting all night. She was sent to the hospital before 8." On 07/12/13 at 8:00 a.m., the corporate nurse was interviewed regarding resident #5. The nurse said she (the nurse) had stayed at the facility until 3 a.m. She stated, "The [MEDICATION NAME] didn't help." The nurse stated, "The hospital took an X-ray of (Resident's Name deleted) leg. They said it couldn't be causing the pain." On 07/12/13 at 8:30 a.m., LPN #1 was interviewed. She was asked about contacting the hospice nurse yesterday morning. LPN #1 said the hospice (Name deleted) nurse had called the morning of 07/11/13, and had told LPN #1 she did not think the resident was in pain. LPN #1 was asked if the hospice nurse had been in the facility yesterday morning (07/11/13). LPN #1 stated, "She never came on the day shift. (Resident's Name deleted) cried all the night before and into yesterday." On 07/12/13 at 8:55 a.m., CNA #6 was interviewed. The CNA had taken care of resident #5 the day before. The CNA was asked what had been going on with the resident the day before. The CNA stated, "She was crying out loud." She said she had transported another resident and had not returned until 2:00 p.m. She stated, "I went in there (the resident's rm) and tried to comfort her." She hurt so bad and was crying. The CNA said when she asked resident #5 what was wrong. The resident responded that her hip and legs and her stomach hurt. The CNA reported the resident's hip and leg had been broken twice. CNA #6 was asked if she thought the resident was hurting. She stated, "Yes, I think she was hurting. I've known her all my life. She has never been like that. It really upset me to listen to her cry." At that time, the CNA began to get tearful. The CNA was asked if the resident had ever had mental issues. The CNA stated, "No." CNA #6 was asked how long had the resident been hurting or crying. The CNA stated, "For awhile she has been crying every time you touch her. She (the resident)will kick that one leg all the time when she hurts." On 07/12/13 at 10:12 a.m., CNA #1 was interviewed. The CNA reported she had worked there several months. CNA #1 was asked if she knew what had happened with (Resident #5 Name deleted) yesterday. The CNA stated, "She has been in a lot of pain lately. She says her stomach or legs hurt." The CNA was asked how long had the resident complained of pain. The CNA stated, "Her legs hurt constantly since she broke that leg. That's the one she complains about." She reported the leg turns inward from the break. CNA #1 was asked if the resident ever got up out of her bed. The CNA stated, "Not much anymore. She will scream like she is in pain when she is up." She reported her pain would be like a "20" when you try to get her up. The CNA reported the resident had fallen and broken her hip last year. The CNA was asked if that was when the pain had started. The CNA stated, "Yeah. She acts like it has been hurting ever since. It's sad to see her in pain all the time. They said the doctor took away all the extra pain meds last week." CNA #1 was asked what interventions had they used to try and relieve the pain besides medications. The CNA reported they would turn her from side to side to reposition her. The CNA stated, "She will scream when we get her up to the chair." The CNA was asked if yesterday was worse than usual. The CNA stated, "Yesterday she did have a bad day." The CNA reported some days are worse than others and she cries and screams. The CNA stated, "They said she cried all night three nights ago. Her eyes were red." On 07/12/13 at 10:30 a.m., CNA #7 was asked what days she worked. She stated, "I work Monday through Friday." She reported she had been working in the facility for [AGE] years. CNA #7 was asked if (Resident #5 Name deleted) always cried. The CNA stated, "Yesterday it was worse." The CNA reported the resident's facial expressions were like she was in pain. The CNA stated, "I am not used to seeing her like that." The CNA was asked where the resident's pain was located. The CNA stated, "Her belly and head. It is different on different days." CNA #7 was asked what interventions would she use when the resident was in pain. She stated, "I sat by her bed yesterday for 20 minutes. I sang, stroked her hair, talked. It helps for 3 to 5 minutes, then she starts again." The CNA was asked what she had seen the nurses' do for the resident. The CNA stated, "Some go in and talk to her, some just go put in meds." 2. Resident #2 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan, dated 06/07/11, documented, "Problem...has episodes of incontinence... Approach...Monitor skin condition for signs of breakdown or [MEDICATION NAME] 40 mg qd X 7. [MEDICATION NAME] 500 qd X 10 days..." A quarterly assessment, dated 04/23/13, documented the resident had moderately impaired cognition, usually understood others, required extensive assistance with bed mobility, transferring between surfaces, all ADL care, was not ambulatory, was always incontinent of bladder and frequently incontinent of bowel. A laboratory test, dated 06/26/13, documented, "Urine Culture Result: Proteus Mirabilis isolated..." A care plan, dated 06/29/13, documented, "Problem: (Name deleted resident #2) has UTI..." The July 2013, physician's orders [REDACTED]. On 07/08/13 at 9:30 a.m., during the initial tour the resident was observed lying in his bed. The resident was complaining to the room mate that he was burning "down there," pointing toward his perineal area. On 07/09/13 at 11:05 a.m., CNA #2 and CNA #3 were observed providing incontinent care for the resident. The resident was complaining of burning in his perineal area. CNA #3 told the resident the LPN would be in and put some medication on the area. CNA #3 was asked how long the resident had been complaining of the burning. The CNA reported one to two weeks. She then stated, "I think he has a bladder infection." The nurses' notes were reviewed. The last note was dated 06/26/13, and documented, "Urinalysis faxed to Dr..." The treatment sheet, for July 2013, was reviewed. There had been no new orders or existing orders for any treatments related to the resident's complaint. At 10:30 a.m., LPN #2 was interviewed. The LPN was asked if she had knowledge of the resident's complaint of burning in his perineal area. The LPN stated, "I think it maybe burning from urination. He has a UTI, but the doctor is trying to hold off giving antibiotics, because he just got over [MEDICAL CONDITION]." She also reported she had applied a barrier cream to the resident's perineal area. LPN #2 then stated, "He doesn't complain all the time, just mainly when he is wet or with urination." The LPN was asked if she had contacted the physician due to complaints of burning for the last two days. She reported she had not, but she would try to get hold of the physician.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure the facility's policy and procedure for 'Administering Pain Medications' was followed including performing assessments by licensed nurses prior to and after the administration of pain medication for one (#16) of nine sampled residents identified with pain. This caused harm to resident #16 and had the potential to affect 50 residents on a pain management control program, per the 'Resident Census and Conditions Of Residents' form. b) Ensure a medical rationale had been documented for the [MEDICATION NAME] dosage being increased from 25 mcg/hr to 50 mcg/hr and ensure any adverse side effects had been assessed and monitored in regard to the increased dosage for one (#16) of three sampled residents identified with [MEDICATION NAME]es ordered for pain. This caused harm to resident #16 and had the potential to affect 50 residents on a pain management control program, per the 'Resident Census and Conditions Of Residents' form. c) Ensure physician's orders [REDACTED].'s <70 for one (#1) of six sampled residents identified with DM. This had the potential to affect 27 residents identified by the DON as having a [DIAGNOSES REDACTED]. d) Ensure FSBS parameters were ordered for when to contact the physician for one (#1) of six sampled residents identified with DM. This had the potential to affect 27 residents identified by the DON as having a [DIAGNOSES REDACTED]. e) Ensure the physician had been contacted regarding the exacerbation of the redness to the perineal and buttocks areas, including a newly opened area which had been identified by a CNA and had been reported to the charge nurse for one (#4) of one sampled resident with excoriation to the perineal and buttock areas. This had the potential to affect 46 residents receiving preventive skin care per the 'Resident Census and Conditions of Residents' form. f) Ensure a physician's orders [REDACTED].#3) of two sampled residents with indwelling urinary catheters. This had the potential to affect three residents identified by the DON with indwelling urinary catheters. g) Ensure a FSBS had been obtained and insulin had been administered per the physician's orders [REDACTED]. This had the potential to affect 27 residents identified by the DON as having a [DIAGNOSES REDACTED]. Findings: The facility's policy and procedure, documented the following: "Administering Pain Medications: The purpose of this procedure is to provide guidelines for screening the resident's level of pain prior to administering [MEDICATION NAME] pain medication...'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals...Acute pain should be screened every 30 to 60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief is obtained. The pain screening consists of gathering both subjective and objective data...Conduct a pain screen as indicated. Evaluate and document the effectiveness of non-pharmacologic Interventions...Document the following in the resident's medical record: results of the pain assessment, medication, dose, route of administration, results of medication (adverse or desired)." The facilities's policy and procedure documented, "...The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management..." 1. Resident #16 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan dated 01/24/12, documented the resident had a problem with pain. Approaches included to evaluate location, frequency, duration and intensity of pain, and report increased pain to the physician. Interventions included to administer pain medication as requested and document the effectiveness and observe for any adverse side effects, lethargy, over sedation, N/V, and rash. The resident had noted impaired thought processes with delusional thoughts at times with approaches including to monitor for any cognitive decline and notify physician as needed. A 14 day assessment, dated 01/29/12, documented the resident had difficulty communicating but was usually able to make self understood, was usually able to understand others, was severely cognitively impaired, received PRN pain medication and non-medication interventions for pain. The resident had complained of pain in the last 5 days, but was unable to voice how much of the time she had experienced pain over the last 5 days, had exhibited vocal complaints of pain and had facial expressions daily and weighed 101 pounds. The February 2012, MAR indicated [REDACTED]. The resident had rated her pain from 8 to 10 on a scale of 1/10. The resident had reported relief from the pain as 2-3/10 after the [MEDICATION NAME] had been administered. The MAR indicated [REDACTED]'s policy and procedure 'Administering Pain Medications.' A physician's telephone order, dated 02/10/12, documented the resident was to receive [MEDICATION NAME] 0.25 mg TID prn for anxiety. A physician's telephone order, dated 02/16/12, documented the following, "[MEDICATION NAME] 15 mg po q 2 hrs PRN [MEDICATION NAME] 25 mcg/hr 1 patch topically q 72 hrs. DX: pain." The March 2012, physician's orders [REDACTED]. "[MEDICATION NAME] 0.25 mg TID PRN for [MEDICATION NAME] 0.25 mg 1 po TID for [MEDICATION NAME] 5/500 1 tab po q 4 hrs for [MEDICATION NAME] 5/500 2 tabs po q 4 hrs PRN for [MEDICATION NAME] 15 mg 1 po q 2 hrs PRN for [MEDICATION NAME] 25 mcg/hr 1 patch topically q 72 hrs for pain..." The MAR for March 2012, documented the pain medications had been administered by a CMA and the pain had not been assessed by an LPN prior to and after the administration of the PRN medication per the facility's policy and procedure 'Administering Pain Medications.' On 03/03/12, at 7:00 a.m., a nurse's note documented, "...Salad speech noted..." The 'Individual Patient's Narcotics Record', on 03/10/12 and 03/11/12, documented the resident had received [MEDICATION NAME] 15 mg po two times in addition to the [MEDICATION NAME] 25 mcg/hr patch. The medications had been administered by a CMA and the pain had not been assessed by an LPN prior to and after the administration of the PRN medication per the facility's policy and procedure 'Administering Pain Medications.' On 03/12/12, a telephone physician's orders [REDACTED]. On 03/14/12, a telephone physician's orders [REDACTED]. Dx: anxiety. Change [MEDICATION NAME] to 5/500 mg 2 rectally q 4 hrs prn pain. Change [MEDICATION NAME] to 15 mg 1 rectally q 2 hrs PRN pain. Hold all po meds until able to take orally." The MAR indicated [REDACTED]. The medical record did not contain documentation of a licensed nurse overseeing the administration of the narcotic medications. On 03/15/12, an 'Interdisciplinary Progress Note', had been faxed to the physician, from (Name deleted) hospice documenting, "...C/O pain but unable to say where pain is...Refusing to take pills. May we have [MEDICATION NAME] gel 2 mg/ml apply topically to cover [MEDICATION NAME] and [MEDICATION NAME] gel 20 mg/ml apply topically to cover [MEDICATION NAME] 15 mg orally. Also [MEDICATION NAME] 25 mcg does not appear to be covering her pain. Would it be possible to increase [MEDICATION NAME] 50 mcg so maybe she will not require so much break through meds..." On 03/15/12, a telephone physician's orders [REDACTED]. Change to [MEDICATION NAME] 50 mcg/hr 1 patch topically q 72 hrs for pain." The resident's medical record did not contain documentation of the resident's pain not being relieved by the [MEDICATION NAME] 25 mcg/hr pain patch every 72 hours and the PRN [MEDICATION NAME] 15 mg. The record did not contain a medical rationale for the [MEDICATION NAME] being increased from 25 mcg/hr to 50 mcg/hr. On 03/15/12 at 7:00 p.m., the MAR indicated relief", rated at a 2. On 03/17/12 at 8:00 a.m., a 'Individual Patient's Narcotics Record', documented, "[MEDICATION NAME] 50 mcg, dosage 1 q 72 hrs." This was the first dose after the [MEDICATION NAME] dose had been doubled and had been applied by a CMA. There was no documentation in either the MAR indicated [REDACTED]'s policy and procedure. At 5:00 p.m., a nurse's note documented, "...Call placed to (Name deleted) hospice...Re: updated condition & verify code status confirmed res is full code & hospice to meet c family..." The nurses' notes did not contain documentation of the change of the resident's condition. On 03/18/12, the MAR indicated [REDACTED]. The [MEDICATION NAME] 25 mcg/dl had been increased to 50 mcg/hr. The MAR, documented CMA's had administered the medications rectally. The medications had been administered by a CMA and the pain had not been assessed by an LPN prior to and after the administration of the PRN medication, per the facility's policy and procedure 'Administering Pain Medications.' At 5:15 p.m., an on-call nursing note from hospice, documented the resident had decreased LOC and did not speak when spoken to. At 9:30 p.m., a nurse's note documented, "Temp 96.2, Pulse 69, Respirations 14, B/P 99/60...Condition conts to decline, decreased LOC. Resp shallow unable to swallow. Call placed to 911 c orders from Dr. (Name deleted) to send for eval..." On 03/18/12, a physician's telephone order, documented the resident was to be sent to the ER for evaluation and possible admission. At 9:50 p.m., a nurse's note documented, "Out of facility..." On 03/18/12 at 10:25 p.m., a hospital record documented, "B/P 80/54, Resp 16, Temp 98... Pain 0/10..." At 11:35 p.m., "...The patient appears frail, lethargic..." A 'History and Physical' report, dated 03/19/12, from the hospital documented, "...presents via EMS for altered mental status. She was put on hospice care 5 days ago, at which time she was put on a new pain medication for her [MEDICAL CONDITION]. She was put on a [MEDICATION NAME] 25 mcg, and as well as [MEDICATION NAME] and [MEDICATION NAME]. Twenty-four hours ago, her [MEDICATION NAME] was moved up to 50 mcg per hospice. This communication happened, and she was not stopped on her [MEDICATION NAME]. She received several doses of pain medication and anxiety medication, although she was not eating very well for the last 2 days and had a decrease in response. She does have significant baseline dementia. She had difficulty speaking at all. She was also rather hypotensive upon presentation. Her blood pressure was 82/54, 95/70 with a [MEDICAL CONDITION] rate...We will admit to the ICU for observation. The patient was given [MEDICATION NAME] in the ER and responded to that as well... She also had a UTI with 4+ bacteria in the ER... Also contact hospice as to her discharge medication regime TO PREVENT EXCESSIVE USE OF OPIOIDS, all while controlling her [MEDICAL CONDITION]." A 'Physician Chart', dated 03/19/12, from the hospital documented, "...Disposition Summary...ACCIDENTAL DRUG OVERDOSE...Patient was recently started on rectal benzo's and [MEDICATION NAME] was increased 2 days ago, per the nursing home records." On 06/08/12 at 2:35 p.m., CMA #2 was interviewed. She was asked what steps she would take when a resident had a complaint of pain. She stated she would report it to the charge nurse. She was asked how she determined what pain medication to administer. She said she could tell by the way the resident acted and per the facial expressions if the resident could not verbally speak. At 2:45 p.m., CNA #6 was interviewed regarding general information related to the resident. She reported the resident was confused, that she had been friendly at first, then stayed depressed and wanted to go home. She stated the resident cried because she didn't want to be in the facility. The CNA was asked if the resident appeared to be in pain during personal care. She reported she gave the resident W/P's and the resident never seemed to be in any pain. On 06/08/12 at 3:15 p.m., LPN #2 was interviewed regarding the CMA's administering rectal medications. She reported they were allowed to administer all rectal medications except Roxinal and [MEDICATION NAME], to her knowledge. At 4:00 p.m., the DON was interviewed regarding the lack of pain assessments by a LPN prior to and after the administration of pain medications by CMA's, per the facility's policy and procedure. The DON reported the resident's pain should have been assessed by a LPN before and after the administration of the pain medications by the CMA's. She was also asked about the CMA's administering narcotics rectally. The DON reported she was not aware of the facility's policy related to CMA's administering pain medications rectally, but would find out and inservice her staff. She was shown the physician's orders [REDACTED]. There had been no documentation of the resident experiencing pain the day the patch dosage had been increased. The DON reported she was not aware of the resident's condition because she had not been the DON at that time. On 06/08/12 at 6:15 p.m., CMA #2 and CMA #4 were interviewed regarding the administration of rectal medications. Both of the CMAs stated they did not administer suppositories or pills rectally. The CMA's were then asked if they administered PRN medications. They reported they administered PRN medications when the medications were needed. 2. Resident #1 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. "[MEDICATION NAME] R Sliding Scale: Insulin Human Regular 100 U/ml. Frequency: Sliding Scale before meals & at bedtime. Low Dose Sliding Scale: Less than 70 mg/dL- [DIAGNOSES REDACTED] protocol.... Blood Glucose Check, reference range= 70-120 mg/dl... before meals, at bedtime and midnight..." A care plan, dated 06/01/12, documented, "Administer medications as per physician's orders [REDACTED]. A 'Daily FSBS Results' flow sheet documented the resident's FSBS's to include the following: On 06/02/12 at 11:00 a.m., registered 57 mg/dL, no medications were administered, but was given "Juice with sugar." On 06/04/12 at 11:00 a.m., registered 55 mg/dL. On 06/04/12 at 4:00 p.m., registered 64 mg/dL. On 06/05/12 at 11:00 a.m., registered 67 mg/dL. The nurses' notes were reviewed for documentation regarding the low FSBS on the above dates. The nurses' notes did not document the physician had been notified regarding the low FSBS's nor had a '[DIAGNOSES REDACTED] Protocol' been ordered by the physician and been implemented by the facility. On 06/05/12 at 11:40 a.m., LPN #1 was observed obtaining a FSBS from the resident. The glucometer read 67 mg/dL. At 12:45 p.m., an hour later, the resident was observed just receiving his lunch tray. On 06/06/12 at 9:30 a.m., the corporate nurse was interviewed. She was asked for the facility's '[DIAGNOSES REDACTED] Protocol.' The corporate nurse reported the facility did not have a '[DIAGNOSES REDACTED] Protocol.' She stated the physician's orders [REDACTED]. they did not have such a protocol. On 06/06/12 at 2:00 p.m., the corporate nurse presented a telephone physician's orders [REDACTED]. "Late entry for 6-1-12 FSBS AC & HS [MEDICATION NAME] R S/S 70-130- 0 unit 131-180- 2 u. 181-240- 4 u. 241-300- 6 u. 301-350- 8 u. 351-400- 10 u. >400- give 12 u & notify PCP." The corporate nurse was then asked if the physician had been contacted regarding the documented low FSBS's. She reported she could not see where he had been. She was then asked if the facility had a physician's orders [REDACTED]. She stated they did not have FSBS parameters on when to contact the physician and they did not have a [DIAGNOSES REDACTED] protocol. 3. Resident #4 had a history of [REDACTED]. The body evaluation tool documented the following: On 02/21/12, "Excoriation inside bilat thighs. Examination to buttock." On 02/28/12, "Excoriation to inside bilat thighs. Excor. (excoriation) to buttocks improving." On 03/06/12, "Excoriation to inside bilat thighs. Cont's c minute excor. buttock." On 03/13/12, "Minute excoriation inside bilat legs. Minute excor. buttock." On 03/20/12, "Cont c excor to thighs between bilat legs. Cont's c excor. to buttock." A significant change assessment, dated 03/16/12, documented the resident had short and long term memory loss, required assistance of one to turn in bed, required assistance of one for personal hygiene, was frequently incontinent of bowel and bladder and was at risk for pressure sores. A physician's telephone order, dated 03/25/12, documented to treat the extensive excoriation to the resident's coccyx region with [MEDICATION NAME]. The treatment record for the month of March 2012, documented [MEDICATION NAME] had been administered to the peri-area for burning on the 27th, 28th, 29th and the 30th, and [MEDICATION NAME] had been administered to the buttock and (R) upper inside thigh three times a day. Body audit forms documented the following: On 04/03/12, "No noted excoriation to buttock. Continues c some excoriation to (R) inner thigh but improving c [MEDICATION NAME] applied as ordered. Buttock c chronic discoloration brown et light beige skin patches to bilat thighs et buttocks." On 04/10/12, "Minute spot of healing excoriation (R) inner thigh 2.5cm x 2.5cm in size. [MEDICATION NAME] continues." On 04/17/12, "Site #1 continues improving. Will cont encourage to lay down p lunch in attempt continue heal excoriation to (R) inner thigh." On 04/23/12, "Continues c excoriation to (R) inner thigh. Refers to lay down c medicine applied as ordered. Will cont. encourage to lay down p meals." A nurse's note, dated 04/25/12, documented, "...gualded areas on buttocks and inner thighs..." On 04/25/12, a physician's hard copy order, documented, "[MEDICATION NAME] buttock paste. Disp 120 gms Apply to perineal area c each cleaning." The treatment record for the month of April 2012, documented no [MEDICATION NAME] had been administered in April and [MEDICATION NAME] had been applied three times a day all month. On 05/01/12, a body audit form, documented, "Site #1 resolved. New Tx order appears to help heal excoriation. Client has been coop (cooperating) c laying down between meals." On 05/08/12, a physician's orders [REDACTED]." On 05/08/12, a body audit form, documented, "Site #1, #2, #3 are dry scabbed over sites..." On 05/08/12, a weekly wound documentation form, for the medial thigh, documented, "Non-PU 0.75 x 1..." On 05/15/12, a body audit form, documented, "Site #1, #2 et #3 continues healing." On 05/15/12, a weekly wound documentation form, for the medial thigh, documented, "Non-PU 0.3 x 0.6..." On 05/22/12, a body audit form, documented, "Dry scabs to left inner thigh resolved. Due to diarrhea c Dx [MEDICAL CONDITION] noted c excoriation to buttock and groin area. [MEDICATION NAME] Tx continues." On 05/22/12, a weekly wound documentation form, for the medial thigh, documented, "Site resolved." On 05/29/12, a body audit form, documented, "Continues with loose stools and excoriation to buttock et groin [MEDICATION NAME] continues." A revised care plan, documented the following: "Problem Onset: 07/14/2009 (Resident's Name deleted) has history of pressure ulcers, decreased mobility and is frequently incontinent and is at increased risk of skin breakdown. Goal and Target date: 06/17/12 (Resident's Name deleted) will not have any new red or open areas through next review. Approaches: Monitor intakes for proper nutrition. Topical txs as ordered by physician to coccyx as preventive. Encourage to turn and reposition often when in bed or chair Cleanse perineal area with soap and water or wipes following each incontinence episode. Report to nurse any red or open areas. 5/8/12 - [MEDICATION NAME] to buttocks q shift." On 06/05/12 at 11:40 a.m., CNA #4 and CNA #5 both gowned, gloved and placed a face cover over their nose and mouth, before entering the resident's room to provide incontinent care. CNA #4 told the surveyor the resident had [MEDICAL CONDITION]. During the incontinent care, an opened area was observed on the (R) gluteal fold. The remainder of the buttocks and perineal areas were a deep purplish and reddish in color. On 06/06/12 at 11:00 a.m., the resident's medical record was reviewed for any documentation regarding the opened area. There was no documentation regarding the newly opened area or that the physician had been notified. On 06/07/12 at 1:40 p.m., pressure sore treatment was observed performed by LPN #2. The opened area was on the (R) gluteal fold. The opened area was pointed out to the LPN. She was asked if she had known it was opened. She stated, "No, but I knew she was excoriated." The LPN stated no one had told her about the area being opened. At that time, CNA #4 walked into the resident's room. The CNA had been the CNA who had discovered the opened area two days ago while providing incontinent care for the resident. The CNA was asked if she had reported the opened area to the charge nurse. She stated she had told several nurses about the opened area including the charge nurse. A nurse's note, dated 06/07/12 at 2:00 p.m., documented, "...Conts to have freq diarrhea c severe excoriation to peri-area/inner thighs. Call placed to Dr. (Name deleted) et updated on pt's status, states 'Send to ER'." The opened area had first been identified on 06/05/12, and the physician had not been notified. Surveyor: Cox, Genie K. 4. The medical record for resident #3 documented the resident had been admitted to the facility on [DATE], and readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident had moderately impaired decision making skills, required limited assist with transfers, bathing, hygiene/toileting, and was occasionally incontinent of urine. An entry on the care plan, dated 03/04/12, documented the resident had a UTI and was to be treated with [MEDICATION NAME] twice daily for two weeks. Another entry on the care plan, dated 04/12/12, documented the resident had a UTI and was treated with [MEDICATION NAME] 500 mg daily for seven days. The approaches included encouraging fluids and providing good peri care. A physician's orders [REDACTED]. An admission nurse's note, dated 06/01/12, documented, "F/C patent and draining...dx acute [MEDICAL CONDITION] c fluid retention, UTI, [MEDICAL CONDITIONS]." The resident's physician's orders [REDACTED]. On 06/05/12 at 4:15 p.m., the resident was observed in her bed. The indwelling urinary catheter drainage bag was observed attached to the bed frame. The resident was resting with her eyes closed. Family members were at the bedside. At 4:20 p.m., LPN #3 was asked if she could locate the order for the resident's catheter. The LPN reviewed the medical record and reported she did not see an order for [REDACTED]. At 4:25 p.m., LPN #4, who admitted the resident, was asked if she had written an order for [REDACTED]. 5. The medical record for resident #8 documented the resident had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A quarterly assessment dated [DATE], documented the resident was cognitively intact, required limited assistance with ADLs and had a [DIAGNOSES REDACTED]. The resident's care plan, dated 02/08/12, documented the resident was a diabetic. The resident's physician's orders [REDACTED]. The 'Insulin Record' form for 03/25/12 at 8:00 p.m., and 03/29/12 at 6:00 a.m., were left blank. It could not be determined if the FSBS had been completed or if the resident had received any insulin on those two days. The 'Insulin Record' form, dated 04/28/12 at 6:00 a.m., was left blank. At 4:00 p.m., the resident's FSBS was documented at 223. There was no insulin documented as having been administered per the physician's orders [REDACTED]. On 06/07/12 at 8:45 a.m., the resident was observed in her room in a recliner. The resident was friendly and answered questions appropriately. On 06/07/12 at 10:30 a.m., the DON was interviewed regarding the lack of documentation of the FSBS and insulin administration. The DON reported there should not be any blanks.

Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure appropriate fall interventions had been put into place after falling five times, with the last fall resulting in a head injury for one (#16) of six sampled residents identified with falls. This had the potential to affect three residents identified with falls during the month of February 2012, and 31 residents with falls in the month of March 2012, per the DON. This failed practice resulted in harm to resident #16 who had repeated falls and had experienced a fall resulting in a head injury. b) Ensure a shower room on the skilled unit did not contain an unsecured gallon of 'Pure Bright- germicidal ultra bleach' for one of one shower room on the skilled unit. This had the potential to affect 20 residents identified by the DON as residing on the skilled unit with no wandering residents. Findings: 1. Resident #16 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan dated 01/24/12, documented one of the problems was the resident being at risk for falls. Interventions included a chair alarm, assist with one staff member for all ambulation, and an alarm while in the chair and bed. A 14 day assessment, dated 01/29/12, documented the resident had difficulty communicating but was usually able to make self understood, was usually able to understand others, was severely cognitively impaired, required assistance when transferring between surfaces, walking, locomotion in W/C, and toilet use, was occasionally incontinent of urine, was always incontinent of bowel and had no falls since admission or prior to admission. The February 2012, TAR documented the resident utilized 1/2 bed rails for bed mobility, had a floor mat next to bed due to high fall risk, had a bed alarm due to high fall risk and had a chair alarm when in W/C due to high fall risk. On 02/28/12, at 6:15 a.m., a first fall was documented on an incident report: "Crawling on floor. Location of occurrence- front of nurses desk. Activity @ time- sitting in W/C. Mobility alarm- on, sounding. Mental- alert et oriented to self. Resident got out of W/C et started crawling on floor 0 injuries noted. Immediate action taken to minimize reoccurrence: Continue to monitor frequently..." On 02/29/12 at 8:00 p.m., a second fall, this time with an injury, was documented on a incident report: "Found on floor. Location of incident: resident's room. Mobility alarm: on, in use, sounding. Meds taken during last 8 hrs: psychotropics/antipsychotics, cardiovascular/antihypertensives, analgesics/narcotics. Heard alarm from another residents room found resident on floor S/T 2 cm x 2 cm to (R) arm, S/T 1 cm x 1 cm & .5 cm x .5 cm to (L) arm..." The care plan had been revised and documented: Problem: Found on floor...Approaches...Falling star..." The March 2012, physician's orders [REDACTED]. Xanax 0.25 mg TID prn for anxiety...Xanax 0.25 mg 1 po TID for anxiety...Hydrocodone 5/500 1 tab po q 4 hrs for pain...Hydrocodone 5/500 2 tabs po q 4 hrs prn for pain...Morphine Sulfate 15 mg 1 po q 2 hrs prn for pain...May have floor mat next to bed due to high fall risk...Duragesic 25 mcg/hr 1 patch topically q 72 hrs for pain...Bed alarm due to high fall risk...May have chair alarm when in W/C due to high fall risk..." On 03/05/12 at 5:45 a.m., a 3rd fall was documented on an incident report: "Witnessed fall. Location of occurrence: in front of nurses desk. Activity at time: getting out of chair. Mobility alarm: on, in use, sounding...Does not understand limitations. Resident got out of W/C unaided...Chair alarm was on chair but did not sound till resident was already on floor. 0 new injuries noted. Immediate action taken to minimize reoccurrence: Continue to monitor closely." The fall on 03/05/12, was the second incident of the resident falling in the early morning hours. The resident had been identified as being occasionally incontinent of bladder when assessed in January 2012. The medical record did not contain documentation the resident was being toileted or placed on a toileting plan. The care plan had been revised and documented: "Problem: Found on floor...Approaches:...Cont c chair alarm, Falling Star visual checks..." These were not new interventions to prevent the reoccurrence of falls. On 03/07/12, at 6:30 p.m., a fourth fall, was documented on an incident report: "Skin tear/bruise. Location of occurrence: resident's room. Mobility alarm: on, in use, sounding...confused & disoriented. Current conditions: fall history, inability to understand directions, arthritis/osteoporosis, confusion/disorientation, incontinency. Called to room by CNA resident found on floor in door way of room MAEW, 0 s/s of pain or discomfort. S/T x3 noted to (R) arm... Immediate action taken to minimize reoccurrence: (area was blank). The care plan had been revised and documented, "Found on floor cont to monitor. Refer to hospice." On 03/08/12, the day after the most current fall, a therapy note documented, "...Walked 200 ft today..." A physician's telephone order, dated 03/15/12, documented, "DC Duragesic 25 mcg/hr 1 patch. Change to Duragesic 50 mcg/hr 1 patch topically q 72 hrs for pain." On 03/16/12 at 4:00 p.m., a nurse's note, documented a fifth fall with a head injury: "B/P 102/68... Called to east hall by CNA pt found on floor lying on back small knot noted to back of head upon palpation 5 cm x 3 cm scrape & .5 cm x .5 cm scrape noted to (R) upper arm. Cleansed c NSS TAO applied & dry dressing applied. Dr notified rec'd order to monitor & do neuro checks. Grimacing & holding head noted pain medication given per orders family notified. Neuro checks initiated WNL's c exception of pupils constricted bilat unable to asses grips d/t pt confused. Resp e/u 0 s/s of distress. All needs met. Call light in reach, chair alarm on & sounding when pt found on floor." At 6:00 p.m., an on-call nursing note from hospice, documented, "Problem: post fall f/u. Interventions/teaching: Sitting up in W/C in room, sm skin tear noted to (R) upper arm c steri strips & stretch gauze in place. 3x3 raised area to back of head. 0 open area noted. Lt bruising present. Neuro checks in progress. Pupils constricted. Alert. Responds to verbal stimuli. Confusion noted. c/o pain to head. CN notified. Pain med given. 0 acute distress noted..." The incident on 03/16/12, had been reported to OSDH with the steps to prevent reoccurrence as keeping the resident in view of the nurses desk when up in W/C. The falls on 02/28/12 and 03/05/12, had occurred while the resident was sitting in her W/C at the nurses' desk. On 06/08/12 at 2:30 p.m., housekeeper #1 was interviewed regarding general information related to the resident. She reported the resident was always confused, had an alarm that was going off continually and the resident cried missing her family. On 06/08/12 at 4:00 p.m., the DON was interviewed regarding the resident's repeated falls and the lack of appropriate steps to prevent reoccurrence being put in place after each fall. The DON was also informed of the resident being assessed as occasionally incontinent of urine, had ambulated 200 ft with therapy and the failure of documenting the resident was being toileted or assessed for possible reasons for the falls. The DON reported she was not aware of the resident's falls and interventions, because she had not been the DON at that time. 2. On 06/05/12 at 9:45 a.m., an initial tour of the skilled unit was conducted. The skilled unit's shower room door was observed locked. A key hanging by the door opened the shower room. In the shower room was an unlocked cabinet, under the sink. The door was not locked so the surveyor opened the door. Inside the cabinet was a gallon of "Pure Bright- germicidal ultra bleach." The side of the container documented, "Keep out of reach of children." LPN #1 was present at the time of the observation. She was asked if there were any residents who wandered and could unlock the shower room door and take the lid off the bleach bottle. The LPN reported there were no residents who wandered residing on the skilled unit, but the bleach should not have been left there.