Every finding on record at Odelia Healthcare

Based on a record review and interviews, the facility failed to ensure a resident received care for a diagnosis included on their hospital discharge paperwork for 1 (R #7) of 1 (R #7) residents. If the facility fails to ensure all admitting diagnoses are included in the resident's plan of care, then staff may fail to monitor and treat the condition which could lead to the adverse outcomes or re-hospitalization. The findings are: A. Record review of R# 7's Hospital Discharge paperwork, dated 06/14/2025, revealed the following: - Diagnoses of hematuria (blood in the urine) attributed to traumatic Foley catheter insertion (injury or damage to the urethra, bladder, or surrounding tissue during Foley catheter)and urinary tract infections with hematuria.- Referrals to physical and occupational therapy.-Resident to receive care for hematuria (presence of blood in the urine). B. Record review of R #7's admission Record, dated 06/14/2025, revealed the following: -admission date of 06/14/2025. -Diagnosis of metabolic encephalopathy (a reversable brain disorder of the body's chemicals). -The record did not include a diagnosis of hematuria. C. Record review of R #7's Provider Progress Note, dated 06/16/2025, revealed the notes did not contain documentation of treatment for resident's admitting diagnosis of hematuria. D. Record review of R #7's Care Plan, dated 06/17/2025, revealed the care plan did not include the resident's admitting diagnosis of a hematuria. E. Record review of R #7's Minimum Data Set (MDS) assessment, dated 06/17/2025, revealed the MDS did not contain documentation of hematuria diagnosis. F. Record review of R # 7's Change in Condition Evaluation, dated 06/19/25, revealed the following: -Significant decline in food and fluid intake.-Seems different than usual.-Tired, weak, confused or drowsy.-Since the change of condition occurred the symptoms or signs have gotten worse.-Increase confusion.-General weakness. G. Record review of R #7's Hospital Discharge documentation, dated 06/21/2025, revealed the following: -Primary diagnosis of hematuria. -readmitted for hematuria. -Resident's plan of care for hematuria. H. Record review of R #7's Progress Notes, dated 06/26/2025, revealed the following:-Resident returned from the hospital for diagnosis of hematuria.-Nursing staff observed a small amount of blood in the resident's brief, and a urinalysis ordered.-Uranalysis not yet obtained. I. Record review of R #7's Provider Notes, dated 08/20/2025, r revealed the notes did not contain documentation of treatment for resident's admitting diagnosis of hematuria. J. Record review of R #7's Change of Condition Evaluation, dated 08/21/2025, revealed the following: -Urine retention. -Bladder scan greater than 999 milliliters (ml). -Attempted catheter insertion, unsuccessful due to severe resistance and severe pain.-Abdominal tenderness. -Persistent discomfort not associated with other acute symptoms. -Decreased urine output over one to two days. -Lower severe abdominal pain. K. On 09/03/2025 at 10:23 AM during an interview, the MDS Coordinator stated the facility did not include R #7's gross hematuria diagnosis in the resident's MDS. The MDS Coordinator stated resident symptoms were not included on the active diagnoses list if the facility was not treating the condition in house. L. On 09/03/2025 at 2:59 PM during an interview, the Director of Nursing (DON) stated staff did not document R #7's hematuria diagnosis in the resident's admission record, Care Plan, and MDS. The DON stated the MDS Coordinator was responsible to include R #7's hematuria diagnosis in the resident's MDS. The DON stated staff failed to complete the urinalysis as ordered by the provider. The DON stated it was her expectation for all residents' hospital diagnoses to be entered in the resident's MDS and care plan for appropriate care.

Based on record reviews and interviews, the facility failed to provide a qualified interpreter for 1 (R #7) of 1 (R #7) residents reviewed. If a facility fails to provide interpreter services, then residents with limited English proficiency may not be able to fully understand their care plan, ask questions about their treatment, or communicate their needs effectively to staff. The findings are:A. Record review of the facility's Interpreter Services policy, dated 2003, revealed all nursing home staff with a second language ability will be identified and utilized as interpreters, as needed, to ensure non-English speaking residents can convey their needs and preferences. B. Record review of R #7's admission Record revealed an admission date of 06/14/2025. C. Record review of R #7's Care Plan, dated 06/27/2025, revealed the resident had a communication problem related to Spanish speaking. D. On 08/27/2025, at 2:33 PM, during an interview, R #7's daughter stated her father was primarily Spanish-speaking, and the facility did not provide interpreter services for her father. The daughter stated she had frequent issues caused by lack of communication regarding R #7's abdominal pain, urinary problems, and frustration over inadequate care. E. On 08/27/2025, at 5:53 PM, during an interview, R #7's spouse stated the facility did not provide interpreter services for her husband during his stay. She stated her husband had difficulty communicating concerns about his lack of urine output and inconsistent monitoring by staff. She stated the lack of interpreter services caused confusion and inadequate care. F. On 09/04/2025, at 10:08 AM, during an interview, the Social Services Assistant (SSA) stated interpreter services were not arranged for R #7 during his stay, and interpretation was primarily done by his family members present at his bedside. G. On 09/03/2025 at 2:59 PM, during an interview, the Director of Nursing (DON) stated R #7 was Spanish speaking only, and the lack of an interpreter could lead to miscommunication and affect the resident's quality of care.

Based on record reviews and interviews, the facility failed to ensure the resident's MDS (MDS; a federally mandated assessment instrument completed by facility staff) was accurately coded for 1 (R #7) of 1 (R #7) residents reviewed. If the facility fails to ensure the Federally mandated MDS is accurately coded for residents, then the facility cannot develop appropriate care plans or provide individualized treatment, which places residents at risk for unmet needs, delayed interventions, and adverse health outcomes.The findings are: A. Record review of R# 7's Hospital Discharge Orders, dated 06/14/2025, revealed the following: -Resident to receive wound care for hematuria (presence of blood in the urine). -Resident to receive physical occupational therapy for hematuria. B. Record review of R #7's admission Record, dated 06/14/2025, revealed the following: -admission date of 06/14/2025. -Diagnosis of metabolic encephalopathy (a reversable brain disorder of the body's chemicals). -The record did not include a diagnosis of hematuria. C. Record review of R #7's admission MDS (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/17/2025, revealed the record did not contain documentation of active diagnosis of hematuria. D. Record review of R #7's Change in Condition Evaluation, dated 06/19/25, revealed the following:-The resident had a significant decline in food and fluid intake.-The resident was tired, weak, confused, or drowsy.-The resident presented with increase confusion and generalized weakness. E. Record review of R #7's Hospital Discharge documentation, dated 06/21/2025, revealed the following: -Primary diagnosis of hematuria. -readmitted for hematuria. -Resident's plan of care for hematuria. F. Record review of R #7's Progress Notes, dated 06/26/2025, revealed the following:- Resident returned from the hospital for gross hematuria.- Nursing staff observed a small amount of blood in the resident's brief, and a urinalysis (UA; laboratory test on urine to detect infection) ordered.- Urinalysis not yet obtained. G. On 09/03/2025 at 10:23 AM during an interview, the MDS Coordinator stated the facility did not include R #7's gross hematuria diagnosis in the resident's MDS. The MDS Coordinator stated the resident's MDSs, dated 06/17/2025 and 06/26/2025, were correct. The MDS Coordinator stated resident symptoms were not included on the active diagnoses list if the facility was not treating the condition in house. H. On 09/03/2025 at 2:59 PM during an interview, the Director of Nursing (DON) stated R #7's diagnosis of a gross hematuria was not coded in the resident's MDS Assessment. The DON stated the MDS Coordinator was responsible to ensure R #7's diagnosis of a gross hematuria was included in the MDS.

Based on observation, interviews, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to: - Maintain the air gap on the ice machine in a manner to prevent contamination and foodborne illness, - Properly store open food with labels and dates to prevent cross contamination and outdated usage, - Sanitize dishes when staff did not maintain the dish washing machine at 120 degrees (°) Fahrenheit (F), per manufacturer's instructions, - Wash, rinse, and sanitize the food preparation sink between uses to prevent cross-contamination and the growth of food-borne pathogens, - Maintain the kitchen environment in a clean and sanitary manner, - Store clean dishes and single use plasticware in a manner to prevent contamination, - Thaw frozen food by submerging in cold running water. These failures had the potential to result in cross contamination, the growth of foodborne pathogens, and foodborne illnesses. This failure had the potential to affect all residents who ate food from the kitchen. The findings are: Maintenance of Ice Machine A. Record review of the facility's Ice Machine Operation and Cleaning policy, dated 12/2020, revealed the policy did not address the air gap (space between the drain pipe and the floor which prevents dirty water from coming in contact with the drain pipe) for the drain pipe. B. On 05/28/25 at 10:06 am, observation revealed an ice machine located in the kitchen next to the hand washing sink. Further observation revealed the ice machine did not drain through an air gap. The drain pipe to the ice machine drained below the surface of the floor. C. On 05/29/25 at 4:03 pm, during an interview with the Maintenance Director (MD), he stated the ice machine was cleaned monthly. He stated the ice machine was cleaned by a third party company. The MD stated he was responsible for maintaining the ice machine, and he inspected it monthly. The MD stated he did not know the ice machine should drain through an air gap. Unlabeled and Undated Food Items D. Record review of the facility's Food Storage policy, dated 01/21/25, revealed the following: - Foods to be frozen should be stored in airtight in the original packing containers, in plastic Ziploc storage bags, or wrapped in heavy-duty aluminum foil or special laminated papers. - Label and date all food items. - Any open products should be placed in storage containers with tight-fitting lids or plastic Ziploc storage bags. E. On 05/28/25 at 10:10 am, observation of the pantry revealed a bag of bread and hamburger bread opened and undated. F. On 05/28/25 at 10:49 am, observation of the walk-in refrigerator revealed a bin of carrots, dated 05/25/25, unprotected and open to air. G. On 05/28/25 at 10:52 am, observation of the walk-in freezer revealed vanilla ice cream unprotected and open to air. H. On 05/30/25 at 9:50 am, during an interview, the Dietary Manager (DM) stated it was her expectation for staff to place the bread in a sealed bag, labeled and dated, after it was opened. The DM stated that should be the process for all food. She stated all food should be covered and protected. Dish Washing Machine I. On 05/28/25 at 10:23 am, during an interview, the Assistance Dietary Manager (ADM) and the DM stated the kitchen dish washer used low temperatures of 120° F and quaternary ammonium (quat; sanitizing solution) to sanitize the dishes. J. Record review of the Ecolab Low Temperature Dish Machine (low temperature dish washing machines utilize chemicals for sanitation) Manufacturer's Recommendations, dated 2022, revealed the dish machine should be operated at minimum temperatures of 120° F for washing and rinsing. K. Record review of the facility's dish washing machine's manufacturer's plate attached to the dishwashing machine revealed the wash and rinse cycles to be a minimum of 120° F. L. On 05/28/25 at 10:23 am, observation the dishwasher's temperature gauge revealed the wash cycle of the facility's dishwasher measured 115° F. M. On 05/29/25 at 4:00 pm, observation of the dishwasher's temperature gauge revealed the wash cycle of the facility's dishwasher measured 115° F. Staff washed another load of dishes, and the water temperature measured 115° F. N. On 05/30/25 at 9:36 am, observation of the dishwasher's temperature gauge revealed the wash cycle of the facility's dishwasher measured 108° F. Staff ran the dishwasher again, and the water temperature of the wash cycle measured 110° F. O. On 05/30/25 at 3:02 pm, during an interview with Dishwasher #1, she stated the dishwasher should reach a temperature of 120° F during the dishwashing process. . Food Preparation Sink P. Record review of the facility's [NAME] Pot & Pan Wash Procedure, dated 2007, revealed the following: - First sink used for washing pots and pans. - Second sink used for rinsing pots and pans. - Third sink used for sanitizing pots and pans. Q. On 05/28/25 at 10:32 am and 10:54 am, observation revealed the facility's kitchen contained a three-compartment sink (a sink with three sections to wash, rinse, and sanitize dishes) and a two compartment sink (for food preparation). Further observation revealed staff washed dishes in the two compartment food preparation sink and used the sink for the resident's lunch meal preparation. Staff did not wash, rinse, or sanitize the sink between washing dishes and food preparation. R. On 05/28/25 at 10:54 am, during an interview, the ADM and the DM stated staff utilized the food preparation sink to wash dishes. The DM stated the two compartment sink was the designated food preparation sink, and staff should use the three compartment sink should for hand washing dishes. The ADM stated staff should not wash dishes in the food preparation sink, and staff should sanitize the sink after washing dishes and before using the sink for food preparation. Kitchen Cleanliness S. Record review of the facility's Cleaning Schedule policy, dated 12/2020, revealed the nutrition services staff will maintain a sanitary environment in the nutrition services department by complying with the routine cleaning schedule developed by the Nutrition services manager. - The Nutrition Service Manager will develop a cleaning schedule that includes the frequency of which equipment and areas are to be cleaned. - The Nutrition Service Manager monitored the cleaning schedule to ensure compliance. T. On 05/28/25 at 10:10 am and 10:38 am, observation revealed the following: - A bag of hamburger buns on the floor of the pantry. - Knife rack with visible accumulation brown dust like substance. - Grease accumulation on suppression system above deep fryer and on the left side panel of deep fryer. - Stove backsplash with visual oil stains. The stove was not in use. - Griddle with left over food particles and grease. The griddle was not in use. U On 05/30/25 at 9:45 am, observation revealed the following: - Grease accumulation present on the suppression system above deep fryer and on left side panel of deep fryer. - Black grease stains on floor between fryer and stove. V. On 05/30/25 at 9:45 am, during an interview, the DM and the Registered Dietician (RD) stated they were aware of the grease accumulation around the deep fryer. They stated the grease should be cleaned up. Protection of Stored Plastic Ware and Dishes W. Record review of the facility's Discarding of Chipped/Cracked Dishes and Single Service Items (plastic ware used one time and then discarded in the trash) policy, dated December 2020, revealed the following: - The nutrition services staff will discard chipped or cracked dish or glass ware. - Single service containers are discarded after use and are not reused as a storage container. - Containers used for storage will be purchased specifically for that purpose. - Storage containers will have a tight fitting lid and sanitized in the dishwashing machine. X. On 05/28/25 at 10:06 am, observation revealed the following: - Plastic lids stored unprotected. Further observation revealed multiple staff walked past the storage shelves with the unprotected lids. - Clean plates and bowls stored unprotected on a shelf in the dishwashing area. Further observation revealed multiple staff walked past the shelf with the unprotected plates and bowls. Y. On 05/30/25 at 9:40 am, observation revealed the following: - Plastic lids stored unprotected. Further observation revealed multiple staff walked past the storage shelves with the unprotected lids. - Clean plates and bowls stored unprotected on a shelf in the dishwashing area. Further observation revealed multiple staff walked past the shelf with the unprotected plates and bowls. Z. On 05/30/25 at 9:40 am, during an interview, the DM and the ADM stated it was expected for the staff to store the dishes and the plastic lids protected in order to prevent contamination. They stated the dishes on the rack in the dishwashing area used to be protected, but they did not know why they were not protected any longer. Thawing of Frozen Food AA. Record review of the facility's Food Temperatures Policy, dated 01/01/25, revealed the following: - Potentially hazardous foods, such as beef, chicken, port, etc., must not be left to thaw at room temperature. - Recommended methods to safely thaw frozen foods include: - Thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross contamination. - Completely submerge the item under cold water (at a temperature of 70° F or below) that is running fast enough to agitate and float off loose ice particles. - Thawing the item in a microwave oven, then cooking and serving it immediately afterward; or - Thawing as part of a continuous cooking process. BB. On 05/30/25 at 9:43 am, observation revealed multiple bags of frozen chicken sat in pans in the kitchen's two compartment sink. Further observation revealed the faucet was turned on and ran onto the divider between the two sinks. The bags of frozen chicken were not submerged in the water in the pan, and the cold running water did not run into the pans which contained bags of frozen chicken. CC. On 05/30/25 at 9:43 am, during an interview, the ADM and the DM stated chicken could be thawed in the refrigerator, the microwave, or under cold running water in the sink. The DM stated she was not aware the chicken should be submerged in the water and the water should run directly into the pan of chicken.

Based on observation, interview, and record review, the facility failed to provide sufficient support staff to carry out the functions of food and nutrition services at the facility. This deficient practice is likely to result in longer waits for meal service for any resident receiving a room tray during the three meals served at the facility. A. Record review of the facility's meal times revealed the following: - Breakfast 7:00 am to 8:30 am. - Lunch 12:00 pm to 1:30 pm. - Dinner 5:00 pm to 6:30 pm. B. On 05/27/25 at 2:46 pm, during an interview, R #28 stated meals were served late to his room three to four times a week. R #28 stated staff served meals up to an hour late sometimes. R #28 stated staff served the dinner room trays around 7:00 pm on 05/26/25. C. On 05/28/25 at 11:52 am, during an interview with R #24 and R #25, R #25 stated the food came out cold a lot of the time. R #24 stated staff served dinner around 7:30 pm on 05/27/25. R #25 stated sometimes staff served lunch around 1:30 or 2:00 pm. R #25 stated she was late for an activity in the past because staff served lunch late. D. On 05/28/25 at 12:05 pm, during an interview, R #66 stated staff delivered the food late almost every meal. R #66 stated staff served dinner around 8:00 pm on 05/27/25. He stated staff frequently served dinner between 7:30 pm and 8:00 pm. E. On 05/29/25 at 9:00 am, observation revealed the breakfast trays for R #49 and R #56 arrived at 9:00 am. F. On 05/30/25 at 1:55 pm, observation revealed staff delivered the lunch meal cart to the south hall for distribution. G. On 05/30/25 at 2:51 pm, during an interview with the Dietary Manager (DM) and the Assistant Dietary Manager (ADM), the ADM stated they had a late start that morning getting the room trays out. She stated room meal trays have been going out late. The DM stated the cook walked out at dinner time the other night, which caused issues with timely meal service. The DM stated part of the issue with late meals was the kitchen was short staffed. The DM stated the Dietary Department currently had six vacant positions. The DM and ADM stated they were short staffed on the weekends and at lunch time. They stated they needed more help.

Based on observation, interview, and record review, the facility failed to maintain the facility in a homelike manner when staff piled various items in an enclosed outside area near the facility. This failure had the potential to affect all residents who utilized the South 4 hallway, the Activities Room, and a courtyard near the Activities Room. If staff fail to maintain the facility in a homelike manner, then residents could feel unimportant and sad. The findings are: A. On 05/29/25 at 10:30 am, observation revealed a gated area located on the backside of the building which contained the following items: - Several metal frame beds with wooden headboards. - Wooden framed cage with metal wire. - A rolled up carpet. - Two new, still in box, hospital beds. - Two new, still in box, hospital bed mattresses. - Five cardboard boxes. - Metal scraps, buckets, medical equipment, and other items. The outside storage area was unkept and was not stored in an orderly manner. B. On 05/29/25 at 10:30 am, during an interview, the Maintenance Director (MD) stated the facility had a contractor which would take the stuff, but the area had been like that for a couple weeks. He stated they tried to ensure the items were not visible from the residnet rooms, because it did not look good and was not homelike. C. On 05/29/25 at 2:30 pm, observation revealed the enclosed storage area was visible to residents who lived on the South 4 hallway. D. On 05/29/25 at 4:15 pm, observation revealed the enclosed storage area was visible to resident who utilized the Activities Room. E. On 05/29/25 at 4:20 pm, observation revealed the enclosed storage area was visible to the residents who utilized the courtyard near the Activities Room.

Based on record review, observation, and interview, the facility failed to place caution signs on the floor when the floor was wet. This failure had the potential to affect any resident who wanted to walk down the hallway. If staff fail to post caution signs on a wet floor, then residents could slip, fall, and injure themselves. The findings are: A. Record review of the facility's Housekeeping Safety Precautions, last revised on August 2020, revealed the following: - Wet mop one side of the corridor or floor at a time and make sure the first side dried before mopping the other side. - Post a Wet Floor warning sign on both ends of the wet side of the floor. B. On 05/29/25 at 10:25 am, observation revealed the floor technician used the rotary floor machine (used to clean and shine floors) in the area between the main hallway and a section of resident rooms. The floor was wet, and there were not any caution signs posted. Two unknown staff members tiptoed across the wet section of the floor. C. On 05/29/25 at 10:25 am, during an interview with one of the unknown staff members, she stated the wet section of floor did not have any wet floor signs set out. D. On 05/30/25 at 2:00 pm, during an interview, the Maintenance Director (MD) stated he supervised the floor technician. The MD stated the rotary floor machine vacuumed up some of the water when it cleaned the floor. He stated staff should have posted wet floor signs to let people know the floor was wet.

Based on record review and interviews, the facility failed to implement pharmacist recommendations for 1 (R #26) of 3 (R #9, #26 and #67) residents reviewed for unnecessary medications when staff failed to ensure R #26 had lab work completed. This deficient practice is likely to result in more than minimal harm because if residents lab work is not current then residents are likely to reach toxic levels of lithium (a mineral) or may not be receiving the correct dosage for therapeutic effects. The findings are: A. Record review of R #26's face sheet revealed an initial admission date of 07/20/15 and included the following diagnoses: - Mood disorder. - Bipolar disorder (a mental health condition characterized by significant mood swings). - Major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a range of emotional and physical problems). - Obsessive-compulsive behavior (a mental health condition characterized by uncontrollable, recurring thoughts and behaviors that the individual feels compelled to perform). - Anxiety disorder (a group of mental health conditions characterized by excessive fear, worry, and anxiety that interfere with daily life). B. Record review of R #26's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/08/25, revealed the following: - R #26 felt down, depressed, or hopeless nearly every day. - R #26 had trouble staying asleep or slept too much nearly every day. - R #26 took antipsychotic, antidepressant, and anticonvulsant medications. C. Record review of R #26's Physicians Orders, dated 08/10/23, revealed an order for lithium carbonate (a mood stabilizer used to treat or control the manic episodes of bipolar disorder) oral capsule, 150 milligrams (mg). Give one capsule by mouth one time a day for isolation and insomnia (difficulty falling asleep and staying asleep). D. Record review of R #26's Medication Regimen Review (MRR; pharmacy review of the medication a resident receives), dated 12/29/24, revealed the following: - This resident received lithium. - Recommendation for serum lithium level (measures the level of lithium in blood), electrolytes (particles that carry an electric charge and necessary for various bodily functions), and thyroid panel (measures the thyroid hormone levels) if not already done. There are no recent labs in the medical record. - Physician responded and ordered labs, lithium level, complete blood count (CBC; determines general health status, screens for, and monitors for a variety of disorders to include low iron), white blood cells and platelets (a type of blood cell), and comprehensive metabolic panel (CMP; measurement of blood sugar, electrolytes, fluid balance, kidney and liver function). Signed by facility physician on 01/01/25. E. Record review of R #26's electronic medical record revealed the record did not contain documentation to show the labs were completed as recommended by the Pharmacist and ordered by the Physician. F. On 05/29/25 at 9:10 am during an interview, the Director of Nursing stated the resident's labs were not completed as recommended by the Pharmacist and ordered by the Physician. She stated it is was her expectation staff follow-up on pharmacy review recommendations promptly.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #37) of 1 (R #37) resident reviewed for MDS assessments. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs. The findings are: A. Record review of R #37's face sheet revealed an admission date of 10/18/23 and included the following diagnoses: - Fracture (break of a bone.) -Muscle weakness (reduction in the power exerted by muscles.) B. Record review of R #37's care plan, dated 01/26/25, revealed R #37 was at a high risk for falls. C. Record review of R #37's MDS, dated [DATE], revealed health condition of injury (not major injury.) D. Record review of R #37's progress note, dated 01/21/25, revealed resident was found on the floor outside the bathroom. R #37's fall resulted in injury, and the resident was sent to the emergency room (ER). E. Record review of R #37's ER encounter notes, dated 01/21/25, revealed a fracture of the scapula (broken bone of shoulder blade.) F. On 06/02/25 at 1:48 pm, during an interview, the MDS Coordinator stated R #37's MDS, dated [DATE], was coded incorrectly. The MDS Coordinator stated staff should have coded the MDS as a fall with major injury because of the fracture.

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 1 (R #31) of 1 (R #31) resident reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents. The findings are: A. Record review of R #31's face sheet revealed an admission date of 05/18/18 with the following diagnoses: - Alcohol dependence with alcohol induced persisting dementia, primary admitting diagnosis. - Major depressive disorder, recurrent severe without psychotic disturbances. B. Record review of R #31's baseline care plan, dated 05/27/18, revealed R #31 used an antidepressant for depression. C. Record review of R #31's PASRR Level 1 Screening, dated 05/18/18, revealed staff documented R #31 did not have a diagnosis of or a suspicion of a serious mental illness. Further review revealed the instructions of the form identified mental illness from the Diagnostic and Statistical Manual of Mental Illness, edition 5 (DSM-5; a reference manual) included diagnosis such as disorders of mood, panic, anxiety, or substance-related. D. On 06/02/25 at 2:14 pm during an interview, the Director of Nursing (DON) stated the Social Services Department was responsible to complete the PASRR for all residents. E. On 06/02/25 at 2:28 pm during an interview, the Social Services Assistant (SSA) stated the Social Services Director (SSD) was out of town. The SSA stated the Social Services Department was responsible for the completion of the PASRR for each resident. The SSA stated R #31's diagnosis of major depressive disorder was a mental illness. The SSA did not review R #31's PASRR and stated if the SSD completed the form then it was correct.

Based on observation, record review, and interview the facility failed to ensure staff administered a resident's tube feeding (feeding tube; a medical device used to provide nutrition to individuals who cannot eat or drink normally) according to physician's orders for 1 (R #23) of 1 (R #23) resident. This failure could potentially cause a resident not to receive enough daily nutrition and lose weight. The findings are: A. Record review of R #23's face sheet revealed the resident was admitted on [DATE] with a traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head) and used a feeding tube for nutrition. B. Record review of R #23's physician orders, dated 11/25/24, revealed the following: - Order for Glucerna 1.5 (nutrition) every shift continuously by feeding tube. - Administer 80 milliliters (ml) per hour for 20 hours [resident's tube feeding should run for 20 hours continuously and off for four hours per day]. - Continuous every shift via pump. - Flush 65 ml water per hour for 20 hours. C. On 05/29/25 at 8:58 am, observation revealed R #23's tube feeding was turned off. D. On 05/29/25 at 3:30 pm, observation revealed R #23 sat in his chair in the hallway, and his feeding tube was not on. E. On 05/29/25 at 3:54 pm, during an interview with Nurse #5, she stated staff would lay R #23 down soon since it was almost 4:00 pm. She stated staff turned R #23's tube feeding off at 7:00 am and put him in his chair. She stated staff lay R #23 back down and turn his tube feeding on at 4:00 pm. She stated she was told to do it this way. She stated R #23 had been in his chair all day. Nurse #5 stated she was not sure what the resident's physician order said regarding the tube feeding. F. On 05/30/25 at 9:32 am, during an interview, Nurse #4 stated staff stopped R #23's tube feeding from 9:00 am to 11:00 am. She stated staff lay the resident down in bed after four hours and turn the feeding tube back on. She stated R #23 should not be off the feeding tube for longer than four hours, per the resident's physician order. G. On 05/30/25 at 2:38 pm, during an interview, the Registered Dietician (RD) stated if staff did not place R #23 back on the feeding tube after four hours, then he would likely be lower on his nutrients for the day. She stated staff will take residents off their tube feeding for a while so they could do other things, like appointments or activities.

Based on observation, record reviews and interviews, staff failed to request a new provider medication order and to ensure drug records were accurate for 1 (R #45) of 1 (R #45) residents. This deficient practice is likely to lead to potential drug misuse or diversion (medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use). The findings are: A. Record review of the facility's Medication Administration Policy, undated, revealed the following: - Nursing staff will keep in mind the seven rights of medication when administering medication which includes: - The right medication, - The right amount, - The right resident, - The right time, - The right route, - The right indication, - The right outcome. - Compare the licensed practitioner's order with the Medication Administration Record (MAR; first check). - Compare the licensed practitioner's order with the pharmacy label on the medication package (second check). - Compare the pharmacy label and MAR (third check). - Any discrepancies identified during the first, second, or third check must be resolved prior to the administration of any medication. - The licensed Nurse will chart the drug, time administered, and initial their name with each medication administration and sign full name and title on each page of the MAR. B. Record review of R #45's physician orders, dated 05/17/25, revealed an order for oxycodone (opioid pain medication) oral tablet 5 milligram (mg). Give 7.5 mg by mouth every six hours as needed for pain. C. On 05/29/25 at 8:55 am, during observation and interview, Nurse #1 poured and administered oxycodone 5 mg tablet to R #45. Nurse #1 stated R #45 preferred to receive oxycodone 5 mg instead of 7.5 mg. Nurse #1 signed R #45's MAR and entered nursing notes to reflect R #45's dosing preference of 5 mg instead of 7.5 mg oxycodone. Nurse #1 then logged the administration of 5 mg of oxycodone on R #45's Controlled Drug Record (CDR, a detailed document that tracks the movement and use of controlled substances). D. Record review of R #45's nursing notes, dated 05/29/25, revealed Nurse #1 documented the resident preferred 5 mg of oxycodone rather than 7.5 mg. Nurse #1 linked her nursing notes to the oxycodone administration record. E. On 05/29/25 at 9:00 am, during an interview, R #45 stated she preferred to receive oxycodone 5 mg instead of the prescribed dose of 7.5 mg. F. On 05/29/25 at 9:01 am, during an observation, Nurse #1 and the Assistant Director of Nursing (ADON) spoke with R #45, and the resident agreed to receive oxycodone an additional 2.5 mg of oxycodone (to total 7.5 mg as prescribed). Nurse #1 poured a 5 mg oxycodone tablet, split the tablet in half, and administered an additional 2.5 mg of oxycodone to R #45. Nurse #1 wasted (destroyed) the other half of the tablet which was not administered to the resident (2.5 mg). Nurse #1 logged the administration of an additional 2.5 mg oxycodone on R #45's CDR. G. Record review of R #45's MAR, dated 05/29/25, revealed Nurse #1 signed she administered oxycodone 7.5 mg by mouth as ordered. H. On 05/29/25 at 9:03 am, during an interview, Nurse #1 stated she was not aware she should contact the on-call provider to request a new order to match R #45's dosing preference. I. On 05/29/25 at 9:05 am, during an interview, the ADON stated she expected Nurse #1 to call the on-call provider to request a new medication order. She stated Nurse #1 should not sign the resident's MAR to indicate she administered the medication as ordered then enter into the nursing notes that the resident preferred 5 mg. J. On 05/29/25 at 9:10 am, during an interview, the Director of Nursing (DON) stated she expected Nurse #1 to call the on-call provider to request a new order. The DON stated Nurse #1 received training on The Management of Controlled Medications during Nurse #1's annual competency training. K. On 05/29/25 at 9:15 am, during an interview, the facility's Consultant Pharmacist (CP) stated she expected Nurse #1 to call the on-call provider to request a new order. The CP stated if a staff signed a medication order with a certain dose but administered a different dose, then it might lead to drug diversion due to staff not maintaining controlled medications records in order. L. On 06/02/25 at 1:03 pm, during an interview, the Medical Director (MD) stated she expected Nurse #1 to call her, request a new order, and explain the resident's preference. M. On 06/02/25 at 1:07 pm, during an interview, the Pain Management Nurse Practitioner (PMNP) stated she expected Nurse #1 to call the on-call provider and request a new order.

Based on record review, observation and interview, the facility failed to ensure meals were served at an appetizing temperature for 2 (R #59 and R #33) of 2 (R #59 and R #33) resident reviewed for meal quality. This deficient practice may decrease the resident's quality of life and have the potential to cause weight loss due to the food not being the proper temperature. The findings are: A. Record review of the facility's Food Temperatures Policy, dated 01/01/25, revealed the following: - At start of meal services hot food should be served above 135 degrees (°) Fahrenheit (F) and cold food should be served below 41° F. - If a hot food item is below 135° F, remove items and reheat on stove or in oven to bring the internal temperature above 165° F for 15 seconds. The reheating process can be done twice before food product should be discarded. B. Record review of the facility's Food and Nutrition Services Trayline/ Dining Observation, dated 05/22/25, revealed the Dietary Manager (DM) conducted an internal audit during lunch service and revealed the following: - The DM measured the temperature of the food, and it was appropriate. - The record did not state what food the DM tested or the temperature of the food tested. C. Record review of the facility's lunch schedule revealed staff served lunch between 12:00 pm and 1:30 pm. D. On 05/30/25 at 2:04 pm, during an observation and interview, the DM measured the food temperatures on R #59's lunch tray. The lunch was mashed potatoes with white gravy, mixed vegetables, cubed grilled chicken, and a piece of bread. The temperature of the mashed potatoes and white gravy measured at 110° F. The DM did not measure the rest of the temperatures for the food items on R #59's lunch tray. The DM stated the temperature for R #59's mashed potatoes with white gravy was 110° F, and it was not an acceptable temperature. E. On 05/27/25 at 10:26 am, during an interview, R #33 stated the food was cold and constantly served late past 1:30 pm. R #33 stated it was expected for staff to deliver the meals timely, and the food to be hot. F. On 5/30/25 at 2:04 pm, during an interview, R #59 stated the food was cold, and they did not like to eat cold food. R #59 stated they expected staff to serve hot food.

Based on interview and record review, the facility failed to prevent staff to resident exploitation when a staff member used a resident's bank debit card to make an unauthorized (without the account holders permission) money withdrawal or purchases for 1 (R #1) of 1 ( R #1) resident looked at for abuse, neglect, and misappropriation. This deficient practice caused undue stress and anxiety for the resident when it was discovered they had money missing. The findings are: A. Record review of a complaint received by the State Agency, dated 05/17/24, revealed allegations of misappropriation (wrongful use of another's belongings, money, etc.) of property. The alleged Perpetrator (a person who commits an illegal or harmful act) was the Transport Driver for the facility, and he allegedly stole up to $480 from the alleged victim, R #1. B. On 09/17/24 at 9:15 am, during an interview with the facility Administrator, she stated she was contacted by R #1 on 05/14/24, and the resident told her the Transport Driver took $480 US dollars from his checking account without his permission on 05/12/24. The Administrator stated R #1 told her that he did not report the incident the day it happened, because he thought the Transport Driver would pay him back. The Administrator stated she immediately filed a facility initiated report and started her investigation. The Administrator stated she asked the Transport Driver about the incident, and he stated nothing happened. The Administrator stated she immediately suspended the Transport Driver. The Administrator stated R #1 reported to her the Transport Driver asked him (the resident) for some money, because he (the Transport Driver) was late on his rent. The Administrator stated R #1 told the Transport Driver that he (the Transport Driver) could use his (the resident's) debit card to withdraw $50 dollars from his checking account, $20 for the Transport Driver and $30 for R #1. The Transport Driver withdrew the money from the resident's account, but the Transport Driver did not return the resident's debit card to him (the resident). The Administrator stated R #1 checked his bank account and noticed someone withdrew $240 twice during the night (05/13/24), totaling $480, which R #1 did not authorize. The Administrator stated R #1 showed her a text he received from the Transport Driver after the money was missing. The Administrator stated the Transport Driver texted the resident that he was very sorry for taking the money and promised to pay R #1 back. The Administrator stated R #1 contacted his bank about the theft, and they refunded all the missing money. The Administrator contacted local law enforcement and filed a report about the incident. The Administrator stated the Transport Driver was fired after she concluded her investigation. The Administrator stated the facility did ask the residents who had contact with the Transport Driver if he had asked them for money, none were identified. The facilities staff was reeducated on their exploitation policy. C. On 09/17/24 at 10:00 am, during an interview with the Transport Driver, he stated he asked R #1 for money, and R #1 agreed to give him the debit card to the resident's checking account to get $50, $20 for himself and $30 for R #1. The Transport Driver stated he withdrew the money from R #1's bank account on 05/12/24, using R #1's debit card and personal identification number. The Transport Driver stated he was supposed to return R #1's debit card, but he did not. The Transport Driver stated he did used R #1's debit card to withdraw $240 twice on 05/13/24, for a total of $480, which R #1 did not authorize.

Based on record review and interview, the facility failed to readmit 1 (R #1) of 1 (R #1) resident back to the facility after being sent to the hospital for evaluation and treatment. This deficient practice is likely to result in a resident experiencing anxiety, confusion, and despair over not being allowed to return to their residence. The findings are: A. Record review of the facility face sheet, dated 05/02/24, for R #1 revealed she was admitted on [DATE] with an admitting diagnoses of broken left leg, high blood pressure, gastro-esophageal reflux disease (GERD; heart burn), and generalized muscle weakness. B. Record review of the facility census showed R #1 was transported to the hospital on 02/28/24 after a fall in the facility. C. Record review of the hospital discharge paperwork, dated 02/28/2024, for R #1 revealed R #1 did not sustain an injury in her fall at the facility that required her to be admitted to the hospital, and it was recommended she return to the facility. D. Record review of the hospital social worker's discharge notes, dated 02/28/24, showed the hospital social worker called the facility on 02/28/24 at 11:42 pm to arrange R #1's transportation back to the facility, but the facility's social worker told the hospital social worker that R #1 could not return to the facility. The facility's social worker stated the resident could not return, because they believed the resident required a memory care unit or a sitter (one-on-one observation of a resident) due to her dementia. E. Record review of the electronic medical record for R #1 revealed the record contained a bed hold release agreement (written document explaining how long the facility will hold the residents room while they are out of the facility), dated 02/29/24. Further review revealed the document was signed by the Administrator but not by R #1 or their representative. The document contained a handwritten statement, Facility not accepting back. Patient admitted to hospital. Better suited in a memory care facility. F. On 05/02/24 at 10:14 am, during an interview with the facility's social services director (SSD), she stated she had no idea why R #1 could not come back to the facility. The SSD stated she did not remember speaking with anyone from the hospital or telling anyone R #1 could not return to the facility. The SSD looked at R #1's electronic medical record and stated she did not see a reason why R #1 could not be readmitted to the facility. G. On 05/02/24 at 11:19 am, during an interview with the Assistant Director of Nursing (ADON), she stated R #1 had a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 6 out of 15 (severe impairment) and did not have any safety awareness. The ADON stated she thought R #1 would be better cared for in a memory care facility. The ADON stated staff placed a wander guard (wearable devise that sounds an alarm and locks doors if near an exit) on R #1 on 02/23/24, because staff saw the resident go towards the front door while stating she did not want to be at the facility anymore. The ADON stated this was the only time R #1 mentioned that she wanted to leave the facility. The ADON stated the staff did not contact R #1 or her Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) while the resident was at the hospital. H. On 05/02/24 at 11:25 am, during an interview with the facility Administrator, she stated staff did not talk to R #1 or the resident's POA about the resident not returning to the facility. The Administrator stated she thought R #1 would be better cared for in a memory care facility. The Administrator reviewed the bed hold release agreement from R #1's medical record and stated she wrote the note on the document. The Administrator stated her expectation for a facility initiated discharge would be for the staff to communicate with the resident or the resident's POA during the process. I. On 05/03/24 at 12:00 pm, during an interview with the hospital social worker, she stated she called the facility to arrange for transportation for R #1 back to the facility, and she was told by someone in social services that the facility would not accept R #1 back into the facility. J. On 05/03/24 at 12:15 pm, during an interview with R #1's POA, he stated he never spoke with anyone at the facility. The POA stated he was told by the hospital staff on 02/28/24 that they contacted the facility, and the facility refused to let R #1 return. The POA stated R #1 really liked the facility, and he would have preferred for R #1 to be readmitted there.

Based on record review and interview, the facility failed to ensure residents, resident representatives, and Ombudsman received a written notice of transfer as soon as practicable for 1 (R #1) of 1 (R #1) residents sampled for being discharged . This deficient practice could likely result in the resident representatives not knowing the reason for discharge, location of the resident, and when the resident can return to the facility. The findings are: A. Record review of R #1's administration progress note, dated 02/28/24, revealed R #1 was admitted to a hospital on 02/28/24. B. Record review of R #1's discharge Minimum Data Set (MDS; a federally mandated assessment instrument completed by the facility staff), dated 02/28/24, revealed the resident had an unplanned discharge to a short-term general hospital. C. Record review of R #1's hospital discharge notes written by the hospital social worker, dated 02/28/24, showed the hospital social worker called the facility on 02/28/24 at 11:42 pm to arrange R #1's transportation back to the facility, but the facility's social worker told the hospital social worker that R #1 could not return to the facility. D. On 05/02/24 at 11:19 am, during an interview with the Assistant Director of Nursing (ADON), she stated she thought R #1 would be better cared for in a memory care facility. The ADON stated the staff did not contact R #1 or the resident's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) while the resident was at the hospital. E. On 05/02/24 at 11:25 am, during an interview with the facility Administrator, she stated staff did not talk to R #1 or the resident's POA about the resident not returning to the facility. The Administrator stated she thought R #1 would be better cared for in a memory care facility. The Administrator stated her expectation for a facility initiated discharge would be for the staff to communicate with the resident and or the POA during the process. F. On 05/03/24 at 12:00 pm, during an interview with the hospital social worker, she stated she called the facility to arrange for transportation for R #1 back to the facility, and she was told by someone in social services that the facility would not accept R #1 back into the facility. G. On 05/03/24 at 12:15 pm, during an interview with R #1's POA, he stated he never spoke with anyone at the facility. The POA stated that on 02/28/24 the hospital staff told him they contacted the facility, and the facility refused to let R #1 return. The POA stated he was never contacted by the facility about R #1's discharge, never given written notice, and was not aware he could have appealed the facility initiated discharge. H. On 05/14/23 at 09:39 am, during an interview with the Ombudsman (provides advocacy and assistance by offering residents a means to voice their concerns and have their complaints addressed) for the facility, he stated the facility did not notify him in writing when they discharged R #1, but they should have.

Based on observations and interviews the facility failed to: 1. Ensure the medication carts did not contain loose medications. 2. Ensure expired supplies were not kept with unexpired supplies. 3. Ensure all medication carts were locked when not in use. These deficient practices are likely to result in all 114 residents, identified on the census list provided by the Executive Director (ED) on [DATE], receiving expired medication, having expired medical supplies used in their treatments, and allowing access to medication carts to unauthorized personnel. The findings are: Findings for loose medications found in medication carts. A. On [DATE] at 9:00 am, during observation of the north 2 medication cart, one loose white oval tablet lay under the medication cards (vertical cardboard and foil cards pre-filled with prescription medications for easy storage and dispensing) in the drawer of the cart. B. On [DATE] at 9:05 am, during an interview with registered nurse (RN) #1, she stated staff should have found the loose medication and disposed of it properly. C. On [DATE] at 9:16 am, during observation of the south 3 and 4 medication cart, a 50 mg (milligrams) trazodone (medication used to treat depression and anxiety) tablet was loose in the over-the-counter medication drawer. Observation also revealed a white capsule, imprinted with IP101, lay loose under the medication cards. D. On [DATE] at 9:17 am, during an interview with licensed practical nurse (LPN #2), she verified the loose medications should not be in the cart. E. On [DATE] at 9:24 am, during observation of the south 1 medication cart, 4 round white tablets, ,d+[DATE] (half) a white tablet, 2 round yellow tablets, 1 oval white tablet, and 1 pink tablet were loose under the medication cards. F. On [DATE] at 9:25 am, during an interview with LPN #3, he stated loose medications should not be in the medication cart. Findings for expired supplies stored with unexpired supplies. G. On [DATE] at 9:53 am, observation of the south medication and supply storage room revealed the following expired medical supplies stored with unexpired medical supplies: - One Sol-Care Luer Lock Syringe, 3 milliliters, 21 gauge (size of needle), by 1 inch, expired [DATE]; - One Zyno Medical IV Administration Set, expired [DATE]; - Two Bio Patch protective disks with chlorhexidine gluconate (CHG; disinfectant), expired [DATE]; - One Povidone-iodine swab sticks, expired ,d+[DATE]; - Fifty-one Assure ID tuberculin safety syringes, 25 gauge, by ,d+[DATE] inch, expired [DATE]. H. On [DATE] at 10:11 am, during an interview with nurse contractor (NC) #1, she verified all the supplies were expired and should not be stored with unexpired supplies. Findings for unlocked medication cart. I. On [DATE] at 1:09 pm, during observation, the north medication cart was unlocked and accessible. Observation also revealed the staff did not use or control the cart, for five minutes. Further observation revealed the nearby nurses station was also vacant during this time. J. On [DATE] at 1:15 pm during an interview with NC #1, she verified the medication cart was unlocked but should be locked at all times.

Based on observation, record review, and interview, the facility failed to maintain proper infection prevention measures by: 1. Not performing hand hygiene between resident medication pass. 2. Not performing hand hygiene between collecting resident breakfast trays and passing out resident breakfast trays. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) for all of the 114 residents who resided at the facility. The findings are: Hand hygiene at medication pass A. On 01/10/24 at 7:28 am, during observation of the medication pass on the north hallway, licensed practical nurse (LPN) #1 passed medications to an unknown resident and did not perform hand hygiene when he left the resident's room. LPN #1 went directly to his medication cart and got the medication ready for R #96. LPN #1 then walked into R #96's room and administered his medication. LPN #1 did not perform hand hygiene before he prepared or administered R #96's medication. B. On 01/10/24 at 8:00 am, during observation of the south 3 and 4 hall medication passes, LPN #2 passed medications to room [ROOM NUMBER] and did not perform hand hygiene she left the resident's room. LPN #2 walked directly to her medication cart and did not perform hand hygiene before she prepared and administered the medications for the resident in room [ROOM NUMBER]. C. On 01/10/24 at 8:57 AM, during an interview with the assistant director of nursing (ADON), she stated staff should perform hand hygiene in between residents when they pass medications. Hand hygiene between dirty and clean tasks D. During observation on 01/10/24 at 8:28 am, certified nursing assistant (CNA) #1 and CNA #2 walked in and out of resident rooms 16 through 21. The CNAs collected used, dirty trays from residents who finished eating breakfast and passed out clean trays with breakfast to other residents. The CNAs did not perform hand hygiene between collecting dirty trays and passing out the clean trays. E. On 01/10/24 at 8:57 AM, during an interview with the assistant director of nursing (ADON), she stated staff should perform hand hygiene in between residents when they picked up and passed out food trays.

Based on observation and interview, the facility failed to provide accommodation of residents' needs for 3 (R #1, R #11, and R #111) of 3 (R #1, R #11, and R #111) residents reviewed for call lights within reach. This deficient practice is likely to result in residents being unable to request assistance, with activities of daily living, transfers after falling, or other acute distress. The findings are: A. Record review of the facility's policy titled Communication Call System, revision date 10/24/22, stated call cords will be placed within the resident's reach in the resident's room. Findings for R #11: B. On 01/10/24 at 12:37 pm, during an observation and interview, Licensed Practical Nurse (LPN) #2 brought R #11 to his room. The resident sat in his wheelchair, in front of his television set. R #11 stated he needed help to adjust his table tray. Further observation showed R #11's call button was on the floor, on the far side of his bed next to the wall. R #11 was not able to reach the call light. C. On 01/10/24 at 12:42 pm, Certified Nursing Assistant, CNA #1 confirmed the call light was not within R #11's reach. Findings for R #1 D. On 01/11/24 at 12:10 pm, during an observation and interview, R #1 lay in her bed. During an interview, she stated she needed assistance to adjust herself in the bed. Further observation showed R #1's call light was located under a pillow, used to prop her left side. The resident was unable to reach her call light for assistance. E. On 01/11/24 at 12:12 pm, during an interview, the Staffing Coordinator confirmed R #1 was unable to reach her call light. Findings for R #111: F. On 01/11/24 at 1:22 pm, during an observation and an interview, R #111 stated he needed assistance, and he needed to be cleaned. The resident sat in his wheelchair, near his bedroom door, and his call light was in the center of his bed. R #111 was not able to reach the call light. G. On 01/11/24 at 1:36 pm, during an interview, CNA #4 confirmed R #111 was not able to reach his call light. She stated she was unable to place the call light within reach of R #111 where he was currently seated, because the call light was secured to the bed rail with a quick tie (a plastic cable usually used for securing items together). The CNA stated the cord was not long enough to reach R #111.

Based on interview and record review, the facility failed to provide quality care for 2 (R #65 and #115) of 2 (R #65 and 115) residents by not following physician orders to get STAT (immediately) x-rays. These deficient practices could likely cause a medical concern to go unidentified and untreated, causing the medical condition to worsen. The findings are: R #65 A. Record review of the physician orders for R #65 indicated an order, dated 12/11/23, for abdomen x-ray STAT to rule out an obstruction, for abdominal distention. B. Record review of a physician note for R #65, dated 12/11/23, indicated there was a concern of mild distention to abdomen. The note stated the resident's abdomen was soft and non-tender. C. Record review of a follow-up physician note for R #65, dated 12/13/23, indicated the following, I had also ordered an ABD (abdominal) Xray on Monday which was not completed so I ordered it again stat today and nurse is calling to get it done. D. Record review of the physician orders for R #65 indicated an order, dated 12/13/23, for an abdomen KUB (kidneys, ureters, bladder) X-ray STAT to rule out an obstruction. Further review revealed the resident's record did not contain documentation this was completed. R #115 E. Record review of the physician orders for R #115 indicated an order, dated 11/08/23, for a STAT chest x-ray to rule out aspiration. F. On 01/12/24 at 2:30 pm, during an interview with Assistant Director of Nursing (ADON), she stated they were unable to find the x-rays for R #65 and R #115. She stated she called the company that did the x-rays for the facility, and they have no record of the residents' x-rays either. She was unclear where the breakdown occurred with the two x-rays.

Based on record review, observation, and interview the facility failed to recognize a resident's deteriorated (to become worse) health status and immediately notify the Medical Provider of a change in condition for 1 (R #33) of 1 (R #33) resident reviewed for a change in condition. If the facility it not actively monitoring resident changes and notifying the Medical Provider in a timely manner, then residents are likely to not receive the care and interventions needed to maintain their highest practical well-being. The findings are: A. Record review of the face sheet for R #33 revealed, she was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . B. On [DATE] at 1:15 pm during an observation and interview with R #33, it was observed that she had just finished lunch and was in her wheelchair by the nurse's station. She was dressed in clean clothing and appeared well groomed. She was talkative and greeted others as they walked by. She was friendly and seemed happy by how she interacted with others. R #33 stated that she had a couple of concerns about how long she waits for the bathroom and that she had a rash all over her body. She confirmed that the physician knew about the rash and that it was being treated. C. On [DATE] at approximately 2:45 pm, during an observation R #33 was observed in the dining room, participating with staff and other residents in the afternoon recreational activity. D. Record review of nursing progress notes for R #33 on [DATE] from midnight until noon in their entirety revealed: 7:49 am, Staff attempted to toilet [first name of R #33] at 0700 [7:00 am] this morning as requested. She is still sleeping and refuses toileting. 8:29 am, Resident still sleepy. Tried to wake her up for medications and looks drowsy. 9:02 am Resident still in deep slumber [sleep] Saturation 86%. Oxygen per nasal cannula [tube to deliver O2 to nose] commenced (started). 9:15 am, Resident continued to deteriorate in condition. Comfort measures provided until she breathed her last at 0930 hrs. [hours, am]. 9:30 am, Resident noted to have no pulse, no resps [respirations/breathing], pupils (circular opening that allows light to enter the eye) fixed [not reactive to light] and dilated (to become larger or more open). Code status is DNR. Resident pronounced [officially declared dead] at 0930 [9:30 am]. No other nursing documentation for [DATE] was available. E. Record review of facility policy Change of Condition Notification Policy number, NP-104 not dated, revealed, in pertinent part, An acute change of condition (ACOC) is a sudden, clinically important deviation [anything away from a usual or normal], from a patient's baseline in physical, cognitive [thinking], behavioral, or functional [residents ability to perform activities of daily living such as bathing or dressing] domains. Clinically important means a deviation that, without intervention, may result in complications or death .The Licensed Nurse will notify the resident's Attending Physician when there is .deterioration in health, mental or psychosocial [the combined influence of both psychological and social factors] status .The Licensed Nurse will assess the resident's change of condition and document observations and symptoms . The Attending Physician will be notified timely with a resident's change in condition .Notification of the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs [measurement of the essential [to life] body functions of a resident most commonly, in this community in long term care, these include blood pressure, pulse, respirations, temperature and oxygen saturation] and system review focusing on the condition and/or signs and symptoms for which notification is required. F. On [DATE] at 2:28 pm, during an interview with Registered Nurse (RN) #1, he reported at about 7:30 [am on [DATE]], I told my supervisor [Unit Manager (UM) #1 that [name of R #33] was drowsy and wouldn't wake up for us. She [UM #1] said she (R #33) was always sleepy, she didn't come see her. We [nursing staff] kept an eye on her [R #33], The CNA's [Certified Nursing Assistants] and I kept checking on her. R #33 didn't take her morning meds. [medications] She didn't say, no she didn't speak [when RN #1 attempted to have her take her medication] she was just [demonstrated her action with his head lolling around in a circle] I did not tell anyone else [other than my Supervisor, UM #1] about R #33 being sleepy. She did not get her medication that morning. R #33 is DNR [Do not resuscitate, if the residents heart stops or they stop breathing do not try to revive them]. During this conversation, it was reported that she was administered [MEDICATION(S)] [an opiod drug used to relieve pain] by the night shift nurse per the documentation on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] G. Record review of the [DATE], MAR for R #33, documented she received [MEDICATION(S)] on [DATE] at midnight and 6:00 am. H. On [DATE] at 2:38 pm during an interview with the Director of Nursing (DON) she revealed, when a resident is DNR status it does not change the expectation of when or whether a nurse would notify a medical provider of a resident with a change in health condition. They [staff] are expected to let them [medical provider] know right away. I. On [DATE] at 3:10 pm, during an interview with UM #1 she stated, He [RN #1] just said she (R #33) was sleeping and didn't want to get up, which was normal for her. J. On [DATE] at 4:10 pm, during an interview with RN #2 he revealed, She (R #33) was not my patient that day, but I knew her well. She always woke up for me [when I was her nurse] she might say she didn't want to take the meds [her medications] even when she was drowsy, but she woke up. That would have triggered me that something was wrong, if she didn't wake up enough to speak. I would have been more aggressive, a sternal rub (technique performed by rubbing the knuckles of a closed fist firmly on the chest in an effort to get a response from the resident as it is painful) and immediate set of vital signs and called the doctor. At about 9:25 [am today] the CNA [CNA #2] came and said,Will you come see Mrs. [last name of R #33], She was gone [had died ] at that time . I had been in the room [the room that R #33 shared with two other residents] to see another resident about thirty to forty-five minutes before [before 9:25 am] and [first name of NA #1] said [first name of R #33] was not waking up and I just glanced over at her [from where I was in the room with another resident] and she was sleeping. He confirmed he did not go to her bedside to assess her. K. On [DATE] at 8:34 am, during an interview with R #33's medical provider, Nurse Practitioner #1 she revealed, if there was a change in condition, we should have been called . I would have wanted a call with the additional sleepiness or drowsiness [R #33 was displaying on the morning of [DATE]] and with the O2 [oxygen saturation, being lower than normal], [oxygen saturation is a measurement of the amount of oxygen being carried in the blood, normal is generally considered to be between 88 -100 percent, decreasing below normal]. L. On [DATE] at 2:51 pm , during an interview, Nursing Assistant [NA] #1 reported I get here [to the facility] about 5:40 [am] I went to see [first name of R #33] about 6:40 [am] I found her sleepy, I shook her and said, hey [first name of R #33] are you going to get up? and she was breathing okay, but she didn't wake up and talk to me like usual .I told [first name of RN #1] and [first name of CNA #2]. In report [from the night shift on [DATE]] [first name of R #33] was up until about 1:00 am and rearranging the room .They [staff] said she [R #33] was normal. M. On [DATE] at 4:19 pm, during an interview with CNA #3 she revealed, she was with R #33 at about 9:30 pm on [DATE] and R #33 was normal, talkative, didn't want to go to bed yet. N. On [DATE] at 11:53 am, during an interview with RN #1 he revealed, she (R #33) wouldn't wake up [to take her medication] it was around about 7 to 7:30 [am], that was the first I knew she was sleepy she was moving her head like refusing [back and forth for no] her speech was incoherent (unable to express oneself clearly), she was breathing normally. He stated, that NA #1 never came and told him anything about R #33 on [DATE], that CNA #2 came to him two times that morning before R #33 died the first time he [CNA #2] had given him R #33's, vital signs [and] they were, 102 [pulse rate, most often is the number of times a heart beats per minute], 24 [number of respirations, breaths in and out per minute normal rate for adults at rest is 12 -20], 97.3 [body temperature in Fahrenheit] nothing for BP [blood pressure, measure of force of blood flow against artery walls] or O2 saturation [was given to him ] I didn't have the time recorded [of when CNA #2 obtained the vital signs] .I didn't chart the vital signs. The second time [CNA #2 came to him about R #33] was just before she died when CNA #2 told him her [R #33] O2 saturation was 77, at that time he went directly to R #33's room obtained another O2 saturation reading, which was 86 percent and he stayed with her and sent CNA #2 to get oxygen supplies for R #33. He confirmed that he did not make an attempt to notify the Medical Provider of a change in condition for R #33 prior to her death on [DATE]. O. On [DATE] at 2:22 pm, during an interview with CNA #2 he revealed, me and another CNA .yes [first name of NA #1] we let the nurse [RN #1] know [first name of R #33] was sleepy, we couldn't wake her up for the bathroom, that was about 7:00 [am] .Vitals [vital signs] were turned in to the nurse [RN #1] her [R #33] blood pressure (B/P) didn't read [the machine he was using to obtain the blood pressure would not obtain it for him]. I let the nurse (RN #1) know I couldn't get her BP that I would go back and try again that was maybe about 8 [am] I was with another resident most of the time that morning so did not get back to check on R #33's blood pressure. The next time I saw her, we [RN #1 and RN #2] were all there and it was just before she died . I'm not sure of the time. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J [isolated jeopardy]to resident health and safety] being identified on [DATE] at 3:08 pm. The facility took corrective action by implementing an acceptable Plan of Removal on [DATE] at 12:00 pm which was verified onsite. Based on the Plan of Removal, the interventions included: 1. Audited for other residents who could also be affected 2. Identified staff with responsibility and actions taken 3. Conducted staff training (also known as In-Service Training) 4. Implementation of system changes 5. Monitoring for adverse (harmful or unfavorable) resident findings going forward 6. Involvement of the Medical Director 7. Involvement of the Quality Assurance Performance Improvement (QAPI) Committee 8. Assignment of responsibility for follow up on new process identified

Based on record review and interview, the facility failed to identify and/or prevent the development of pressure ulcers for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents reviewed for pressure ulcers. This deficient practice likely resulted in R #1 developing pressure ulcers to the coccyx area, left heel and top of right foot that was left untreated. The findings are: A. Record review of R #1's face sheet revealed, R #1 was admitted on [DATE] with bacteremia (a bacterial infection in the blood), diabetes (DM), dementia with behavioral disturbances, abnormal posture -rigid extremities (both arms and legs), dysphagia (difficulty swallowing) and paralysis agitans ([MEDICAL CONDITION]). B. Record review of R #1's outside service provider Nurse Practitioner's (NP) progress notes dated 11/02/15 revealed, nursing staff reported no acute concerns. Skin was noted as, No visible wounds noted on superficial exam. CDI (cool, dry and intact) and No skin discoloration noted. C. Record review of the facility physician progress notes [REDACTED].#1 was negative (meaning no issues) and indicated nursing reported no new issues. D. Record review of R #1's outside service provider NP's progress notes dated 12/08/15, revealed no documented nursing concerns, no development of any wound or wounds or any documentation indicating a skin assessment was performed on R #1 during this visit. E. Record review of the Weekly Skin Integrity Review reports from 10/23/15 to 12/05/15, revealed; 1. R #1 developed what was described as a, 'Coccyx scrape' on 10/23/15. 2. Documentation from 11/27/15 and 12/05/15 revealed R #1's skin to be intact with no wounds or open areas identified. F. Record review of the facilities wound log book revealed no documentation indicating R #1 had any current wounds or was receiving any treatments for any developing wound. G. Record review of the facility Interdisciplinary Progress (IDT) notes dated 12/10/15 wound meeting notes documented a Stage III (three - a pressure wound that extends into the tissue beneath the skin, forming a small crater) wound to R #1's right hip, first discovered on 12/06/15 per this note. H. Record review of the facility Daily Skilled Nurse's notes dated 11/20/15 to 12/10/15, revealed no documentation that would indicate R #1 had a Stage III pressure wound to his right hip. I. Record review of R #1's physician orders [REDACTED]. J. Record review of the hospital admission record for R #1 dated 12/09/15, revealed R #1 was transferred to the hospital emergency room due to decline in health status. Hospital history and physical (H&P) stated R #1 was noted to have [DIAGNOSES REDACTED] (redness) of the right heel and the left heel was reddened, purple in color with ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) stage I pressure ulcer. R #1 was also noted to have a sacral decubitus with an area of central necrosis (dead black skin tissue) the size of a Golf ball and stage II pressure ulcer surrounding the area. K. Record review of the hospital Wound Consult note dated 12/10/15, confirmed R #1 was admitted to the hospital with [REDACTED]. Wound assessment indicated the pressure wound to the sacral/coccyx area measured 5 centimeters (cm's) by 6 cm's, the left heel measured 3.5 cm's by 4.0cm's. Also noted was a third wound located on the top of the right foot with necrotic tissue measuring 0.5cm's by 0.5cm's. L. On 01/13/16 at 3:04 pm, during interview the Director of Nursing (DON) stated there was an order to treat a 'Shear' wound on R #1's buttock but that had resolved months ago. The nurses perform daily skin checks. They (nurses) should be looking at everything. When questioned about a 'sacral scrape' documented on 11/13/15, the DON stated she did not know about this wound and that R#1 had developed a shearing wound (friction from sliding on bed linen) but that had resolved. Then the DON confirmed the Weekly Skin Integrity Review reports from 11/27/15 and 12/05/15 indicating R #1's skin to be intact with no wounds or open areas identified. When presented with a copy of the hospital admission Wound Consult note for R #1 dated 12/10/15, the DON stated, she (meaning a staff nurses) didn't mark it on there?, there's nothing there and you would think it would show an opening or something. The DON then stated, if a resident is bed or chair bound she would expect that resident to be turned frequently and have heels floated (elevated on a cushion or use of cushioned boots) to prevent pressure wounds.

Based on observation, interview and record review, the administration of the facility failed to manage and coordinate resident care in a manner that would enable each resident to attain or maintain his or her highest practicable physical, mental and psychosocial well being, for all 106 residents in the facility as identified on the Alphabetical Census provided by the Administrator on 10/19/15 by: 1. A failure to ensure that safe water temperatures were maintained in resident rooms. 2. A failure to ensure that a diabetic resident received the correct dosage of insulin. 3. A failure to ensure that the physician was notified of a change in condition. These deficient practices likely contributed to poor resident outcomes with respect to quality-of-life, quality-of-care, health, safety and comfort. One deficient practice, the failure to ensure that water in resident rooms was maintained at a safe temperature, resulted in an Immediate Jeopardy at a scope and severity of L being identified at the facility on 10/19/15 at 12:38 pm. The facility administrator was notified at that time. The facility took corrective action by providing an acceptable Plan of Removal on 10/19/15 at 12:50 pm. Based on the Plan of Removal, interventions included: 1. The Maintenance Director decreased the boiler temperatures to 108 degrees Fahrenheit. 2. Two new digital thermometers were obtained. 3. Temperatures checked hourly on 10/19/15 to ensure that they are at the correct temperature. 4. Temperature checks will be completed daily and documented to ensure correct temperatures. 5. The Dietary Manager will in-service the Maintenance Director on thermometer calibration. Based on the Plan of Removal and interview, the IJ was lifted on 10/19/15 at 12:50 pm. This resulted in the scope and severity being reduced from level L to level F. A second deficient practice, resident neglect related to incorrect insulin administration for a diabetic resident, resulted in an Immediate Jeopardy at a scope and severity of J being identified at the facility on 10/23/15 at 2:18 pm. The facility took corrective action by providing an acceptable Plan of Removal on 10/23/15 at 4:04 pm. The plan of removal included: 1. Resident (R #87) was assessed and the physician was notified of the change in condition. Insulin orders have been clarified. 2. Current resident receiving insulin will be audited to ensure insulin orders are correct and followed. Current residents receiving [MEDICAL TREATMENT] will be monitored to ensure they receive meals- to-go on [MEDICAL TREATMENT] days. Admission assessments will be reviewed to ensure they mirror the orders. 3. Licensed staff in-serviced on the need to inform the physician of a change of condition, CBGs (capillary blood glucose test) will be completed per physician order, and [MEDICAL TREATMENT] residents will receive meals-to-go on [MEDICAL TREATMENT] days. Dietary staff will be in-serviced on having meals-to-go prepared for [MEDICAL TREATMENT] patients the night before for early morning [MEDICAL TREATMENT] patients and placed in the refrigerator in the front area. The driver will be in-serviced to ensure he/she picks up those meals before each transport. 4. DCS (Director of Clinical Services)/designee will audit insulin orders to ensure accuracy and that the insulin is being administered per physician order. Will monitor daily for 30 days then weekly for 2 months. Dietary M Manager will monitor meal pick up for [MEDICAL TREATMENT] patients and will review daily with DSC/designee. Residents identified during daily clinical meeting and/or 24 hour comprehensive report process as having a change of condition will be audited to ensure physician and POA (power of attorney) notification. 5. Above plan will be reviewed by the Adhoc QAPI (Quality Assurance and Performance Improvement) Committee and audits will be reviewed to ensure substantial compliance is maintained. Based on the Plan of Removal and interview, the IJ was lifted on 10/23/15 at 4:04 pm. This resulted in the scope and severity being reduced from level J to level G. The findings are: Findings related to unsafe water temperatures (See F323) : A. On 10/19/15 at 11:05 am, during observation in room [ROOM NUMBER] (R #126) room the hot water in the bathroom sink was 123 degrees Fahrenheit. B. On 10/19/15, during observation on Unit South 2, the following was observed: 1. At 11:07 am, the water temperature in room [ROOM NUMBER] (R #41) was 122.2 degrees F. 2. At 11:12 am, the water temperature in room [ROOM NUMBER] (R #2) was 121.8 degrees F. 3. At 11:14 am, the water temperature in room [ROOM NUMBER] (R #24) was 122.2 degrees F. 4. At 11:30 am, the water temperature in room [ROOM NUMBER] (R #69) was 123.4 degrees F. C. On 10/19/15, during observation on the North Unit, the following was observed: 1. At 11:23 am, the water temperature in room [ROOM NUMBER] (R #133) was 123 degrees F. 2. At 11:25 am, the water temperature in room [ROOM NUMBER] (R #34) was 120.6 degrees F. 3. At 11:27 am, the water temperature in room [ROOM NUMBER] (R #7) was 120.7 degrees F. 4. At 12:23 pm, the water temperature in room [ROOM NUMBER] (R #32) was 124.2 degrees F. 5. At 12:24 pm, the water temperature in room [ROOM NUMBER] (R #29) was 123.6 degrees F. 6. At 12:26 pm, the water temperature in room [ROOM NUMBER] (R #122) was 122 degrees F. 7. At 12:30 pm, the water temperature in room [ROOM NUMBER] (R #3) was 121 degrees F. D. 10/19/15 at 12:13 pm, during interview with the MD, he stated that he was informed that the thermometers that were reading 20 degrees when being calibrated were too low and that he was going to purchase new digital thermometers. The MD was unable to answer how the facility was ensuring that water temperatures were maintained at a safe temperature when his thermometers were providing low temperature readings. Findings related to incorrect insulin administration (See F224): E. Record review of Physician Orders dated 10/19/15 indicated the following: 1. Insulin Human Regular sq (subcutaneous, in the layer of fat just under the skin) per sliding scale: If BS (blood sugars) are less than 300, no insulin. Blood sugar greater than 400, give 5 units and call MD (medical doctor). BS less than 60, give juice or D ([MEDICATION NAME]) 50 (50%) IV (intravenous) solution or [MEDICATION NAME] (a medication that raises the concentration of glucose in the bloodstream)1 ampoule subcutaneous. 2. Insulin human ([MEDICATION NAME]) 70/30, 8 units subcutaneous daily for Diabetes F. Record review of Daily Skilled Nurse's Note dated 10/19/15, revealed the following: Resident has DM (Diabetes Mellitus). Bld (blood) sugar 457 noted, 8 U (units) [MEDICATION NAME] 70/30 per order at HS (at bedtime) given. Physician orders were to administer 5 units of sliding scale insulin for BS greater than 400 and call physician. The documentation on the nurse's note indicated R #87 received the incorrect insulin for BS greater than 400. R #87 received [MEDICATION NAME] when she should have received Regular Insulin per sliding scale. No documentation was found to indicate that the physician was notified of the BS result. G. Record review of the October 2015 MAR(Medication Administration Record), did not indicate an order for [REDACTED]. H. Record review of Daily Skilled Nurse's Notes dated 10/19/15 through 10/23/15, revealed inconsistent monitoring of R #87's blood sugar. Documentation indicated that R #87's blood sugar was checked a total of 3 times during the time R #87 was in the facility I. On 10/23/15 at 2:28 pm, during interview with Unit Manager #1, he stated that at about 7:30 am that morning, he was paged to the R #87's room and that the resident was slow to respond, was tracking with her eyes, but was lethargic. Unit Manager #1 stated that the call came from OT (occupational therapy). The Unit Manager #1 stated that he tapped R #87 on her chest to see how she was responding and the resident began talking to him right away. Unit Manager #1 stated that he then checked R #87's vital signs and assessed the resident who was responding slowly. J. On 10/23/15 at 11:38 am, during interview with the Director of Nursing (DON), she stated that the medications on the physician orders did not coincide with the medications reflected on the MAR and stated, There are some I'm not seeing on the MAR. They are not on the MAR. I'm going to assume the MAR is incorrect. The DON verified that the sliding scale insulin was not reflected on the MAR and that the staff should also be checking CBGs (blood glucose). The DON confirmed CBG results should be on the MAR. When asked how she was able to track R #87's diabetes, the DON stated I can't. Regarding R #87 being an uncontrolled diabetic, the DON stated that she was concerned about R #87 not receiving the correct insulin and the fact that R #87 had no consistent CBG readings. Findings related to failing to notify the physician (See F157): L. No documentation was found to indicate that the physician was notified of R #87's CBG of 457 on 10/19/15. J. No documentation was found to indicate that R #87's provider was notified of her incidence of lethargy and slow response on 10/23/15. J. On 10/23/15 at 2:33 pm, during interview with the Physician Assistant (PA), he stated that he was not aware of any interruption in R #87's medication, but that when he spoke to her that morning, she complained that she was not getting her medications. The PA stated that he was not informed of any incident in the morning with the resident being lethargic and unresponsive.

During resident room observations, it was found that the facility failed to ensure that the hot water in resident bathrooms were kept at a safe temperature of less than 120 degrees Fahrenheit (F). This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at a scope and severity of L on 10/19/15 at 12:38 pm. The facility Administrator, Director of Nursing and Maintenance Director were notified at this time. On 10/19/15 at 12:50 pm, the Administrator delivered a plan of removal which was accepted. Based on the plan of removal, interventions included: 1. The Maintenance Director decreased the boiler temperatures to 108 degrees F. 2. Two new digital thermometers were obtained. 3. Temperatures checked hourly on 10/19/15 to ensure that they are at the correct temperature. 4. Temperature checks will be completed daily and documented to ensure correct temperatures. 5. The Dietary Manager will in-service the Maintenance Director on thermometer calibration. Based on the plan of removal, the IJ was lifted on 10/19/15 at 12:55 pm. This resulted in the scope and severity being reduced from a scope and severity of L to level 2, scope and severity F. Based on observation, interview and record review, the facility failed to ensure hot water temperatures were maintained and kept at a safe temperature of less than 120 degrees F to prevent injuries. This deficient practice has the potential to affect all 106 residents as identified on the Resident Census List provided by the Administrator on 10/19/15 who receive showers and/or use the bathroom facilities. If hot water temperatures are not maintained, residents are likely to experience thermal burns while using restroom sinks or bathing facilities. The findings are: A. On 10/19/15 at 11:05 am, during observation in Room 15 (R #126) the hot water in the bathroom sink was 123 degrees F. B. On 10/19/15, during observation on Unit South 2, the following was observed: 1. At 11:07 am, the water temperature in Room 8 (R #41) was 122.2 degrees F. 2. At 11:12 am, the water temperature in Room 9 (R #2) was 121.8 degrees F. 3. At 11:14 am, the water temperature in Room 10 (R #24) was 122.2 degrees F. 4. At 11:30 am, the water temperature in Room 7 (R #69) was 123.4 degrees F. C. On 10/19/15, during observation on the North Unit, the following was observed: 1. At 11:23 am, the water temperature in Room 26 (R #133) was 123 degrees F. 2. At 11:25 am, the water temperature in Room 27 (R #34) was 120.6 degrees F. 3. At 11:24 am, the water temperature in Room 28 (R #7) was 120.7 degrees F. 4. At 11:26 am, the water temperature in Room 29 (R #was 124.4 degrees F. 5. At 11:27 am, the water temperature in Room 30 (R # 165) was 124 degrees F. 6. At 11:28 am, the water temperature in Room 31 (R #127) was 122 degrees F. 7. At 11:29 am, the water temperature in Room 32 (R #23) was 123.4 degrees F. 8. At 11:31 am, the water temperature in Room 33 (R #51) was 122.4 degrees F. 9. At 12:23 pm, the water temperature in Room 34 (R #32) was 124.2 degrees F. 10. At 12:24 pm, the water temperature in Room 35 (R #29) was 123.6 degrees F. 11. At 12:26 pm, the water temperature in Room 36 (R #122) was 122 degrees F. 12. At 12:30 pm, the water temperature in Room 37 (R #3) was 121 degrees F. D. Record review of the facility Maintenance Logbook documentation for October 2015 indicated water temperatures in resident rooms of no more than 104 degrees F. E. On 10/19/15 at 11:53 am, during interview with the Maintenance Director (MD), he stated that he checks temperatures weekly and that the highest reading that he'd been getting was 105 degrees F. The MD stated that he calibrated his thermometer in a glass of ice and did this prior to taking temperatures each time. F. On 10/19/15 at 12:00 pm, during temperature reading in Room 15 (R #115), the MD's thermometer read the water temperature at 105 degrees F. The Surveyor's thermometer read the water temperature at 120.7 degrees F. G. On 10/19/15 at 12:07 pm, during thermometer calibration, the MD's thermometer was read 20 degrees. The Surveyor's digital thermometer read 32.3 degrees F. The MD retrieved a second thermometer from the dietary department that was calibrated correctly. H. On 10/19/15 at 12:10 pm, during interview with the Dietary Manager (DM), she stated that the thermometers should be calibrated in ice water (not ice alone) and that when calibrated, the thermometer should read 32 degrees. The DM stated that the two facility thermometers that were reading 20 degrees were too low and needed to be calibrated again because any readings would be too low and inaccurate. I. On 10/19/15 at 12:13 pm, during interview with the MD, he stated that he was informed that the thermometers that were reading 20 degrees when being calibrated were too low and that he was going to purchase new digital thermometers. The MD was unable to answer how the facility was ensuring that water temperatures were maintained at a safe temperature when his thermometers were providing low temperature readings. J. On 10/19/15 at 12:15 pm, during observation of the South Unit boiler room, the temperature was set at 116 degrees F. K. On 10/19/15 at 12:22 pm, during observation of North Unit boiler room, the temperature was set at 122 degrees F. L. On 10/19/15 at 12:22 pm, during interview with the MD, he stated that the boiler temperatures of 116 and 122 were too high and should be set at no more than 110 degrees F.

During record review it was found that the facility failed to ensure sliding scale insulin (a hormone that regulates glucose in blood) coverage per physician orders for an identified uncontrolled diabetic resident. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at a scope and severity of J on 10/23/15 at 2:18 pm. The facility took corrective action by providing an acceptable Plan of Removal on 10/23/15 at 4:04 pm. The plan of removal included: 1. Resident (R #87) was assessed and the physician was notified of the change in condition. Insulin orders have been clarified. 2. Current residents receiving insulin will be audited to ensure insulin orders are corrected and followed. Current residents receiving [MEDICAL TREATMENT] will be monitored to ensure they receive meals-to-go on [MEDICAL TREATMENT] days. Admission assessments will be reviewed to ensure they mirror the orders. 3. Licensed staff were in-serviced on the need to inform the physician of a change in condition; CBGs (Capillary Blood Glucose) will be completed per order; and [MEDICAL TREATMENT] residents will receive meals-to-go on [MEDICAL TREATMENT] days. Dietary staff will be in-serviced on having meals-to-go prepared for [MEDICAL TREATMENT] patients the night before early morning [MEDICAL TREATMENT] and placed in the refrigerator in the front area. The driver will be in-serviced to ensure he/she picks up those meals before each transport. 4. DCS (Director of Clinical Services)/designee will audit insulin orders to ensure they are accurate and that the insulin is being administered per physician order. DCS will monitor daily for 30 days then weekly for 2 months. Dietary manager will monitor meal pick up for [MEDICAL TREATMENT] patients and will review daily with the DSC/designee. Residents identified during daily clinical meeting and/or 24 hour comprehensive report process having a change of condition will be audited to ensure physician and POA (power of attorney) notification. 5. Above plan will be reviewed by the Adhoc Quality Assurance Performance Improvement (QAPI) committee and audits will be reviewed to ensure substantial compliance is maintained. At this time, the scope and severity was lowered to a G. Based on observation, record review, and interview the facility failed to ensure that residents were free from neglect for 1 (R #87) of 1 (R #87) resident reviewed for neglect, by not providing sliding scale insulin (a hormone that regulates glucose in blood) coverage per physician orders for an identified uncontrolled diabetic resident. This deficient practice likely resulted in R #87 not receiving adequate insulin coverage when needed and could result in her experiencing complications including unconsciousness, [MEDICAL CONDITION], coma, or death. The findings are: A. Record review of the Admission Notification Form dated 10/19/15, revealed 70 y/o (year old) female readmit from (Name of Hospital) w/dx (with diagnoses) of s/p (status [REDACTED]. Diet: Regular/ADA (American Diabetes Association) and a malnutrition dietary consult. B. On 10/22/15 at 2:52 pm, during interview with R #87, she stated They (staff) didn't give me no breakfast. They gave me four pieces of chicken today because I raised hell. I was pretty darn hungry when I got back (R #87 was at [MEDICAL TREATMENT]). I was shaky. They (staff) have to give me food when I go to [MEDICAL TREATMENT]. R #87 confirmed she had not received a sack lunch or breakfast before leaving to her [MEDICAL TREATMENT] appointments. C. On 10/22/15 at 3:12 pm, during interview and observation with R #87, she was observed to be shaking uncontrollably in her arms and hands. R #87 stated that she didn't feel good and that she had the shakes. At that time, Licensed Practical Nurse (LPN) #3 walked in R #87's room and told her that she would be back with her pills. D. On 10/22/15 at 3:54 pm, during interview LPN #3 stated She (R #87) was admitted three nights ago (10/19/15). We just got the complete order up yesterday. LPN #3 was asked about medications that were circled, she stated She did not get them. All the circled medications were not given because they (medications) were not in the building. E. Record review of the Admission/Readmission Data Collection dated 10/19/15, revealed Cognition: alert, oriented to person, place, and time. Uncontrolled diabetes, elevated temperature and/or infection processes. F. Record review of the Physician's admission orders [REDACTED] 1. Insulin human regular sq (subcutaneous). Inject units sliding scale if BS (blood sugars) < (less than) 300 no insulin. BS > (greater than) 400 (give) 5 units and call MD (medical doctor). BS < 60 give juice or D ([MEDICATION NAME]) 50 (50%) IV (intravenous) solution or [MEDICATION NAME] (medication given in response to low blood glucose levels) 1 amp (ampoule) Subq (subcutaneous). Review of R # 87's medical chart did not reveal any documentation indicating R #87 received the medications mentioned above. 2. Insulin human ([MEDICATION NAME]) 70/30, 8 units subcutaneous daily for Diabetes. G. Record review of the Physician's admission orders [REDACTED] [MEDICATION NAME] (an anticoagulant (blood thinner) that prevents the formation of blood clots) 5,000 units SQ Q12 hrs (every 12 hours). The MAR indicated, [MEDICATION NAME] QD (everyday), but the Physician order is Q12 (once every 12 hours). H. Record review of the Physician's admission orders [REDACTED]. The Physician's order did not indicate how many times a day to check R #87's blood sugar. Review of the Daily Skilled Nurse's Notes dated 10/19/15 to 10/22/15, indicated R #87's blood sugar was checked and documented a total of 3 times. I. Record review of Care Plan Book located at the South unit nurses station, revealed R #87 did not have an interim care plan to address R #87's uncontrolled diabetes. J. Record review of Daily Skilled Nurse's Note dated 10/19/15, revealed Resident has DM (Diabetes mellitus) Bld (blood) sugar 457 noted, 8 U ([MEDICATION NAME]) 70/30 per order at HS (at bedtime) given. Physician orders are to administer 5 units of sliding scale insulin for BS greater than 400 and call MD. The nurse's note indicated R #87 received the incorrect dosage of insulin. There was no documentation to indicate that the MD was notified of the high BS and the incorrect dose of insulin. K. Record review of Interdisciplinary Progress Notes indicated the following: 1. 10/24/15 at 2300 (11:00 pm): Certified Nursing Assistant (CNA) reported that something was wrong with resident .CBG low. 1 ml [MEDICATION NAME] administered SQ, blood re-check 25 (CBG). Emergency medical team was immediately contacted. Resident was sent to hospital. Resident was not responding at the time. 2. 10/24/15 at 2330 (11:30 pm): CBG checked at 2000 (8:00 pm) was 300. L. On 10/23/15 at 11:38 am, during interview the Director of Nursing (DON), she confirmed that the Physician admission orders [REDACTED]There are some I'm not seeing on the MAR. The DON was asked about R #87's insulin and she stated that there are two orders for insulin, one is sliding scale and one is to be given every day (human insulin). The DON verified that the sliding scale insulin was not on the MAR and that staff should be checking blood sugars. When asked how she tracks R #87's diabetes, the DON stated I can't. For short term insulin, I do need fingersticks. I'm going to have them clarify everything. The DON stated that she was concerned about R #87 not receiving the correct insulin. She stated The doctor didn't even order CBGs. They should be ordering CBGs. M. On 10/23/15 at 1:54 pm, during interview, R #87 confirmed she was a diabetic and has been for [AGE] years. Regarding her diabetes, R #87 stated I have terrible sugars. They fluctuate. Like this morning they (staff) couldn't wake me up. They were beating me up in the chest. He (referring to the nurse) said 'I couldn't wake her (R #87) up.' He was scared because he couldn't wake me up. He was punching me in my chest. I told he was hurting me, it was causing me to not breathe. It was because I had low blood sugar. They go high, low, high, low. They don't stay in one level. R #87 was asked how her blood sugar was since she's been here, she stated I don't know because they just started to give me the level (referring to the dose of insulin) I'm supposed to get. I hope it's right. R #87 stated that staff check her blood sugars, but not consistently. My sugar is supposed to get checked everyday, before I eat and they aren't doing that. It's every now and then. It scares me. R #87 stated that when her blood sugar is too high/low, I pass out. I get so low that I crash. There ain't nothing I can really do because they in control. I'm not in control. N. On 10/23/15 at 2:28 pm, during interview with Unit Manager #1, he stated that at about 7:30 am, he was paged to the resident's (R #87) room and the resident was slow to respond, was tracking with her eyes but was lethargic. The Unit Manager #1 stated that he tapped on R #87's chest to see how she was responding. O. On 10/23/15 at 2:30 pm, during interview with Registered Nurse (RN) #3, she stated that she did not check R #87's CBGs and that she would typically only check this if the resident lost consciousness. RN #3 stated that, I should have re-taken it (the CBG). RN #3 stated that if an incident like this occurred, she would usually document this in the nurse's note in the medical record but that she did not document this. P. On 10/23/15 at 3:10 pm, during interview with Licensed Practical Nurse (LPN) #3, she stated that she did the admission for this resident (R #87) but was busy that night and had a new nurse orienting with her who took the orders and transcribed these to the MAR. LPN #3 stated that usually, two nurse's check admission orders [REDACTED]. LPN #3 stated that when reviewing the chart, she noticed that there were medications missing on the MAR and that she filled these out when she saw this. LPN #3 stated that CBGs were checked on this resident on 10/21/15 and that she called the PA to let him know that her blood sugar was high at 456. LPN #3 stated that she checked the resident's CBG on the evening of 10/22/15, but did not recall what the result was and that, I thought I documented it but I guess I didn't. Q. On 10/23/15 at 3:38 pm, during interview with RN #2, she stated that LPN #3 was having problems interpreting some of the admission orders [REDACTED]. RN #2 stated that she wrote out some of the medications on the MAR but needed some clarification regarding the other insulin. RN #2 stated that she informed LPN #3 that she needed to clarify the insulin orders. RN #2 stated that the following night, the insulin dose was still not clarified and that the day after that, the nurses were still trying to clarify the insulin order. R. Record review of the Blood Glucose Monitoring Policy and Procedure dated 11/30/14, revealed A resident's blood glucose level shall be monitored through blood glucose testing. Procedure: Obtain and verify doctor order .Document result in nurse's notes and on Medication Administration Record (MAR) with any insulin administered. S. Record review of the General Dose Preparation and Medication Administration Policy dated 01/01/13, revealed Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including but not limited to the following: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct time, and for the correct resident .confirm that the MAR reflects the most recent medication order .Document necessary medication administration/treatment information (e.g., when medications are given, injection site of a medication, if medications are refused, PRN medications) on appropriate forms.

Based on record review, observation, and interview the facility failed to implement their written policies and procedures prohibiting neglect for 1 (R #87) of 1 (R #87) resident reviewed for neglect. This deficient practice likely caused R #87 to experience dangerous diabetic complications which, when severe and left untreated, can lead to unconsciousness, [MEDICAL CONDITION], coma, or death as evidenced by: a failure to monitor blood sugar results, have all ordered medications on the Medication Administration Record (MAR) and administer the correct dose of insulin. The findings are: A. Record review of the Blood Glucose Monitoring Policy and Procedure dated 11/30/14, revealed: A resident's blood glucose level shall be monitored through blood glucose testing. Procedure: Obtain and verify doctor order .Document result in nurse's notes and on Medication Administration Record (MAR) with any insulin administered. B. Record review of the General Dose Preparation and Medication Administration Policy dated 01/01/13, revealed: Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including but not limited to the following: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct time, and for the correct resident .confirm that the MAR reflects the most recent medication order .Document necessary medication administration/treatment information (e.g., when medications are given, injection site of a medication, if medications are refused, PRN medications) on appropriate forms. C. Record review of the facility Resident Abuse Policy and Procedure dated 11/30/14, revealed It is inherent in the nature and dignity of each resident that he/she be afforded basic human rights, including the right to be free from abuse, neglect, and mistreatment .Neglect: failure to provide adequate nutrition and fluids, failure to take precautionary measures to protect the health and safety of the resident, failure to provide services that result in harm to the resident, failure to notify a resident's legal representative in the event of a significant change in the resident's physical, mental or emotional condition that a prudent person would recognize. D. Record review of the Admission Notification Form dated 10/19/15, revealed 70 y/o (year old) female readmit from (Name of Hospital) w/dx (with diagnoses) of s/p (status [REDACTED]. Diet: Regular/ADA (American Diabetes Association) and a malnutrition dietary consult. E. On 10/22/15 at 3:12 pm, during interview and observation with R #87, she was observed to be shaking uncontrollably in her arms and hands. R #87 stated that she didn't feel good and that she has the shakes. At this time, Licensed Practical Nurse (LPN) #3 walked in R #87's room and told her that she would be back with her pills. F. On 10/22/15 at 3:54 pm, during interview LPN #3 stated She (R #87) was admitted three nights ago (10/19/15). We just got the complete order up yesterday. LPN #3 was asked about medications that were circled, she stated She did not get them. All the circled medications were not given because they (medications) were not in the building. G. Record review of the Physician's admission orders [REDACTED] 1. Insulin human regular sq (subcutaneous). Inject units sliding scale if BS (blood sugars) < (less than) 300 no insulin. BS > (greater than) 400 (give) 5 units and call MD (medical doctor). BS < 60 give juice or D ([MEDICATION NAME]) 50 (50%) IV (intravenous) solution or [MEDICATION NAME] 1 amp (ampoule) Subq (subcutaneous). 2. Insulin human ([MEDICATION NAME]) 70/30 8 units SQ QD (every day) for DM (Diabetes Mellitus). H. Record review of the MAR (not dated) did not indicate an order for [REDACTED]. Further review of the MAR revealed [MEDICATION NAME]70/30 8 U SQ BID (twice daily) however, the physician's order for [MEDICATION NAME]is QD (everyday). I. Record review of Daily Skilled Nurse's Note dated 10/19/15, revealed Resident has DM (Diabetes Mellitus) Bld (blood) sugar 457 noted, 8 U ([MEDICATION NAME]) 70/30 per order at HS (at bedtime) given. Physician orders are to administer 5 units of sliding scale insulin for BS greater than 400 and call MD. The nurse's note indicated R #87 received the incorrect dosage of insulin. There was no documentation to indicate that the MD was not notified of the high BS. J. Record review of the Physician's admission orders [REDACTED]. The Physician's order did not indicate how many times a day to check R #87's blood sugar. Review of the Daily Skilled Nurse's Notes dated 10/19/15 to 10/22/15, indicated R #87's blood sugar was checked and documented a total of 3 times. L. Record review of Interdisciplinary Progress Notes indicated the following: 1. 10/24/15 at 2300 (11:00 pm), revealed Certified Nursing Assistant (CNA) reported that something was wrong with resident .CBG low. 1 ml [MEDICATION NAME] (medication given in response to low blood glucose levels) administered SQ, blood re-check 25 (CBG). Emergency medical team was immediately contacted. Resident was sent to hospital. Resident was not responding at the time. 2. 10/24/15 at 2330 (11:30 pm), revealed CBG checked at 2000 (8:00 pm) was 300. M. On 10/23/15 at 11:38 am, during interview the Director of Nursing (DON), she stated that the Physician admission orders [REDACTED]There are some I'm not seeing on the MAR. The DON was asked about R #87's insulin, she stated that there are two orders for insulin, one is sliding scale and one is to be given every day (human insulin). On this order, (physician order) it says QD, unless they changed it, it should say QD. I'm gonna assume the MAR is incorrect. The DON verified that the sliding scale insulin was not on the MAR and that staff should be checking blood sugars. When asked how she tracks R #87's diabetes, the DON stated I can't. For short term insulin, I do need fingersticks. I'm going to have them clarify everything. The DON stated that she was concerned about R #87 not receiving the correct insulin. She stated The doctor didn't even order CBGs. They should be ordering CBGs. N. On 10/23/15 at 1:54 pm, during interview, R #87 confirmed she was a diabetic and had been for [AGE] years. Regarding her diabetes, R #87 stated I have terrible sugars. They fluctuate. Like this morning they (staff) couldn't wake me up. They were beating me up in the chest. He (referring to the nurse) said 'I couldn't wake her (R #87) up.' He was scared because he couldn't wake me up. He was punching me in my chest. I told he was hurting me, it was causing me to not breathe. It was because I had low blood sugar. They go high, low, high, low. They don't stay in one level. R #87 was asked how her blood sugar was since she's been here, she stated I don't know because they just started to give me the level (referring to the dose of insulin) I'm supposed to get. I hope it's right. R #87 stated that staff check her blood sugars, but not consistently. My sugar is supposed to get checked everyday, before I eat and they aren't doing that. It's every now and then. It scares me. R #87 stated that when her blood sugar is too high/low, I pass out. I get so low that I crash. There ain't nothing I can really do because they in control. I'm not in control. O. On 10/23/15 at 2:30 pm, during interview with Registered Nurse (RN) #3, she stated that she did not check R #87's CBGs and that she would typically only check this if the resident lost consciousness. RN #3 stated that, I should have re-taken it (the CBG). RN #3 stated that if an incident like this occurred, she would usually document this in the nurse's note in the medical record but that she did not document this. P. On On 10/23/15 at 3:10 pm, during interview with Licensed Practical Nurse (LPN) #3, she stated that she did the admission for this resident (R #87) but was busy that night and had a new nurse orienting with her who took the orders and transcribed these to the MAR. LPN #3 stated that usually, two nurse's check admission orders [REDACTED]. LPN #3 stated that when reviewing the chart, she noticed that there were medications missing on the MAR and that she filled these out when she saw this. LPN #3 stated that CBGs were checked on this resident on 10/21/15 and that she called the PA to let him know that her blood sugar was high at 456. LPN #3 stated that she checked the resident's CBG on the evening of 10/22/15, but did not recall what the result was and that, I thought I documented it but I guess I didn't. Q. On 10/23/15 at 3:38 pm, during interview with RN #2, she stated that LPN #3 was having problems interpreting some of the admission orders [REDACTED]. RN #2 stated that she wrote out some of the medications on the MAR but needed some clarification regarding the other insulin and that she told the other nurse that she would need to get the other orders clarified. RN #2 stated that she informed LPN #3 that she needed to clarify the insulin orders. RN #2 also stated that the following night, the insulin dose was still not clarified. RN #2 stated that the next day (after the admission) the nurses were still trying to clarify the insulin order.

Apply changes identified for the same findings in the previous citations. Based on record review and interview, the facility failed to provide care and services for the highest level of well-being for 3 (R #53, 72, 87) of 5 (R #s 2, 53, 72, 87 and 170) residents reviewed for [MEDICAL TREATMENT], pain and neglect by: 1. Failing to palpate (to examine by touch) R #53's A/V (arteriovenous) graft (an artificial vein that can be used repeatedly for needle placement and blood access during [MEDICAL TREATMENT]) for thrill (vibration of blood going through going through the access) each shift and document the findings. 2. Failing to auscultate (listen to the internal sound) R #53's A/V graft bruit (audible sound associated with obstructed blood flow) each shift and document the findings. 3. Failing to complete ongoing pain assessments per the care plan for R #72, 4. Failing to ensure that a diabetic resident received insulin and blood glucose monitoring for R #87 This deficient practice has the potential to prevent identification of complications with the A/V graft such as blockage or infection, delay identification and treatment of [REDACTED].#87 being sent out to the hospital with a critically low blood glucose reading due to not receiving the correct insulin coverage. The findings are: Findings for R #53 A. Record review of the [MEDICAL TREATMENT] Care Plan dated 08/12/15 indicated the following: Problem: [MEDICAL TREATMENT] Goal: resident will be free of complications at [MEDICAL TREATMENT] Interventions: monitor labs as ordered, medications as ordered, monitor blood pressure as ordered, monitor weights, monitor for [MEDICAL CONDITION], monitor for pain, provide frequent rest periods as needed, fluid restrictions as ordered, monitor for fluid imbalance, [MEDICAL TREATMENT] with A/V shunt-monitor access site each shift, palpate for pulse and thrill, observe site for infection, bleeding, [MEDICAL CONDITION], monitor bruit and thrill each shift. [MEDICAL TREATMENT] with central line access: Monitor site q (every) shift, observe for infection, bleeding, [MEDICAL CONDITION]. B. Record review of R #53's medical chart, Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation to indicate that R #53's A/V shunt was being assessed each shift per the care plan. C. On 10/21/15 at 1:13 pm, during interview with LPN (Licensed Practical Nurse) #2, she stated that she had not been documenting the assessment of R #53's shunt and that it looks like it (the assessments) haven't been getting done. D. On 10/21/15 1:16 pm during interview with Unit Manager (UM) #1, he stated that for residents on [MEDICAL TREATMENT], the AV shunt is assessed for pain, redness, swelling or anything that would indicate a problem. UM #1 stated that nurses should be assessing the [MEDICAL TREATMENT] shunt daily and that this should be documented on the TAR. UM #1 stated that he was unable to provide documentation to indicate that the AV shunt had been assessed as nothing regarding the assessment was found on the TAR. E. On 10/21/15 at 1:48 pm, during interview with the DON (Director of Nursing), she stated that assessment of [MEDICAL TREATMENT] site should be done on every shift and this should be documented on the TAR. The DON stated that the nursing staff would need the documentation of AV shunt assessment to ensure that the site is problem free and to identify any problems that arise with the site. Findings for R #72 G. Record review of the Care Plan dated 10/16/15 indicated the following: Focus: Discomfort Goals: Will experience a decrease in pain as evidenced by 1-2 requests for pain medication daily Interventions: pain assessment quarterly and significant change, complete pain flow record, determine precipitating factors to pain, medications as ordered by physician, attempt non-pharmacological interventions. H. Record review of the medical chart and Medication Administration Record (MAR) did not reveal any documentation to indicate that an ongoing pain assessment was completed and no Pain Flow Record was found. I. On 10/23/15 at 11:08 am, during interview with RN #1, she verified that the R #72 did not have a pain flow sheet in her chart or MAR and that she was not sure if the pain assessments had been completed. J. On 10/23/15 at 11:17 am, during interview with the Director of Nursing (DON) she stated that residents should be assessed for pain at least once a shift and that this and that this should be documented On the Pain Flow Sheet which is filed with the MAR. The DON verified that this had not been done for R #72. K Record review of the Admission/Readmission Data Collection dated 10/19/15, revealed Cognition: alert, oriented to person, place, and time. Uncontrolled diabetes. L. On 10/22/15 at 2:52 pm, during interview with R #87, she stated They (staff) didn't give me no breakfast. They gave me four pieces of chicken today because I raised hell. I was pretty darn hungry when I got back (R #87 was at [MEDICAL TREATMENT]). I was shaky. They (staff) have to give me food when I go to [MEDICAL TREATMENT]. R #87 confirmed she had not received a sack lunch or breakfast before leaving to her [MEDICAL TREATMENT] appointments. M. On 10/22/15 at 3:12 pm, during interview and observation with R #87, she was observed to be shaking uncontrollably in her arms and hands. R #87 stated that she didn't feel good and that she has the shakes. At this time, Licensed Practical Nurse (LPN) #3 walked in R #87's room and told her that she would be back with her pills. N. On 10/22/15 at 3:54 pm, during interview LPN #3 stated She (R #87) was admitted three nights ago (10/19/15). We just got the complete order up yesterday. LPN #3 was asked about medications that were circled, she stated She did not get them. All the circled medications were not given because they (medications) were not in the building. O. Record review of the Physician's admission orders [REDACTED]Insulin human regular sq (subcutaneous). Inject units sliding scale if BS (blood sugars) < (less than) 300 no insulin. BS > (greater than) 400 (give) 5 units and call MD (medical doctor). BS < 60 give juice or D ([MEDICATION NAME]) 50 (50%) IV (intravenous) solution or [MEDICATION NAME] 1 amp (ampoule) Subq (subcutaneous). P. Record review of the Physician's admission orders [REDACTED]. The physician's orders [REDACTED].#87's blood sugar. Review of the Daily Skilled Nurse's Notes dated 10/19/15 to 10/22/15, indicated R #87's blood sugar was checked and documented a total of 3 times. Q. Record review of Care Plan Book located at the South unit nurses station, revealed R #87 did not have a care plan. R. Record review of Daily Skilled Nurse's Note dated 10/19/15, revealed Resident has DM Bld (blood) sugar 457 noted, 8 U ([MEDICATION NAME]) 70/30 per order at HS (at bedtime) given. Physician orders [REDACTED]. The nurse's note indicated R #87 received the incorrect dosage of insulin. There was no documentation to indicate that the MD was notified of the high BS and the incorrect dose of insulin. S. Record review of Daily Skilled Nurse's Note dated 10/20/15, revealed 2-10 shift, Resident awake but sluggish .BS 104-evening dose of insulin held. PO meds (medications) that were available were given. T. Record review of Interdisciplinary Progress Notes indicated the following: 1. 10/24/15 at 2300 (11:00 pm), revealed Certified Nursing Assistant (CNA) reported that something was wrong with resident .CBG low. 1 ml [MEDICATION NAME] (medication given in response to low blood glucose levels) administered SQ, blood re-check 25 (CBG). Emergency medical team was immediately contacted. Resident was sent to hospital. Resident was not responding at the time. 2. 10/24/15 at 2330 (11:30 pm), revealed CBG checked at 2000 (8:00 pm) was 300. U. On 10/23/15 at 11:38 am, during interview the Director of Nursing (DON) confirmed the Physician admission orders [REDACTED]There are some I'm not seeing on the MAR. The DON was asked about R #87's insulin, she stated that there are two orders for insulin, one is sliding scale and one is to be given every day (human insulin). The DON verified that the sliding scale insulin was not on the MAR and that staff should be checking blood sugars. When asked how she tracks R #87's diabetes, the DON stated I can't. For short term insulin, I do need finger sticks. I'm going to have them clarify everything. The DON stated that she was concerned about R #87 not receiving the correct insulin. She stated The doctor didn't even order CBGs. They should be ordering CBGs. V. On 10/23/15 at 1:54 pm, during interview, R #87 confirmed she is a diabetic and has been for [AGE] years. Regarding her diabetes, R #87 stated I have terrible sugars. They fluctuate. Like this morning they (staff) couldn't wake me up. They were beating me up in the chest. He (referring to the nurse) said 'I couldn't wake her (R #87) up.' He was scared because he couldn't wake me up. He was punching me in my chest. I told he was hurting me, it was causing me to not breathe. It was because I had low blood sugar. They go high, low, high, low. They don't stay in one level. R #87 was asked how her blood sugar was since she's been here, she stated I don't know because they just started to give me the level (referring to the dose of insulin) I'm supposed to get. I hope it's right. R #87 stated that staff check her blood sugars, but not consistently. My sugar is supposed to get checked everyday, before I eat and they aren't doing that. It's every now and then. It scares me. R #87 stated that when her blood sugar is too high/low, I pass out. I get so low that I crash. There ain't nothing I can really do because they in control. I'm not in control. W. On 10/23/15 at 2:28 pm, during interview with Unit Manager #1, he stated that at about 7:30 am, he was paged to the resident's (R #87) room and the resident was slow to respond, was tracking with her eyes, but was lethargic. The Unit Manager #1 stated that he tapped on her chest to see how she was responding. X. On 10/23/15 at 2:30 pm, during interview with Registered Nurse (RN) #3, she stated that she did not check R #87's CBGs and that she would typically only check this if the resident lost consciousness. RN #3 stated that, I should have re-taken it (the CBG). RN #3 stated that if an incident like this occurred, she would usually document this in the nurse's note in the medical record but that she did not document this. Y. On 10/23/15 at 3:10 pm, during interview with Licensed Practical Nurse (LPN) #3, she stated that she did the admission for this resident (R #87) but was busy that night and had a nurse orienting with her and that this was the nurse that took the orders and transcribed these to the MAR. LPN #3 stated that usually, two nurse's check admission orders [REDACTED]. LPN #3 stated that when reviewing the chart, she noticed that there were medications missing on the MAR and that she filled these out when she noticed this. LPN #3 stated that CBGs were checked on this resident and that she called the PA on 10/21/15 to let him know that her blood sugar was high at 456. LPN #3 stated that she checked the resident's CBG on the evening of 10/22/15, but did not recall what the result was and that, I thought I documented it but I guess I didn't. Z. On 10/23/15 at 3:38 pm, during interview with RN #2, she stated that LPN #3 was having problems deciphering some of the admission orders [REDACTED]. RN #2 stated that she wrote out some of the medications on the MAR but needed some clarification regarding the other insulin and that she told the other nurse that she would need to get the other orders clarified. RN #2 stated that she informed LPN #3 that she needed to clarify the insulin orders. RN #2 also stated that the following night, the insulin dose was still not clarified. RN #2 stated that the next day (after the admission) the nurses were still trying to clarify the insulin order. AA. Record review of the Blood Glucose Monitoring Policy and Procedure dated 11/30/14, revealed A resident's blood glucose level shall be monitored through blood glucose testing. Procedure: Obtain and verify doctor order .Document result in nurse's notes and on Medication Administration Record (MAR) with any insulin administered. BB. Record review of the General Dose Preparation and Medication Administration Policy dated 01/01/13, revealed Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including but not limited to the following: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct time, and for the correct resident .confirm that the MAR reflects the most recent medication order .Document necessary medication administration/treatment information (e.g., when medications are given, injection site of a medication, if medications are refused, PRN medications) on appropriate forms. CC. Record review of the facility Resident Abuse Policy and Procedure dated 11/30/14, revealed It is inherent in the nature and dignity of each resident that he/she be afforded basic human rights, including the right to be free from abuse, neglect, and mistreatment .Neglect: failure to provide adequate nutrition and fluids, failure to take precautionary measures to protect the health and safety of the resident, failure to provide services that result in harm to the resident, failure to notify a resident's legal representative in the event of a significant change in the resident's physical, mental or emotional condition that a prudent person would recognize.

Based on record review and interviews, the facility failed to follow 1 (R #6) of 1 (R #6) physician's comprehensive plan of care which resulted in the resident being transferred from the bed to a wheelchair by use of a Hoyer lift (an assistive device that allows patients to be transferred between a bed and a chair) with only one person instead of two (as was indicated to use two persons in the care plan). This deficient practice likely caused the resident to fall backwards in her wheelchair hitting her head and sustaining a hematoma (swelling with containing blood), bruising and a contusion (an injury caused by a blow to the body characterized by swelling, discoloration and pain) to the back of the head. The findings are: A. Record review and interviews for Resident R #6 revealed the following information: 1. Comprehensive Plan of Care dated 10/17/12 indicated the resident has a self-care deficit with lower extremity activities of daily living (ADLs) related to a [DIAGNOSES REDACTED]. Interventions are for staff to use a Hoyer lift with two people for transfers. The Care Plan also indicated the resident is at risk for falls related to a history of falls and staff is to again use two persons for transfers with a Hoyer lift. 2. Annual Minimum Data Set ((MDS) dated [DATE] indicated, the resident requires two + persons physical assistance for transfers and bed mobility. 3. Annual history and physical examination [REDACTED]. 4. Nurse's Notes dated 09/23/13 indicated, "Pt. (patient) fell backwards in her wheelchair this morning when Certified Nursing Assistant (CNA) (who was identified as CNA #1) lifted patients legs. Patient hit the occipital region (area of the back of the head) that resulted in a hematoma. Patient reports mild pain at the site of the hematoma. Examination was positive for hematoma and contusion. 5. Root Cause Analysis for fall dated 09/23/13 indicated, "Were appropriate number of assists used? No ...Was proper technique used? No ...Did resident sustain injury? Yes. What was the injury ...Swelling to back of head." 6. On 09/27/13 at 11:00 am, during interview R #6 stated, "All I know is that I fell off the wheelchair and was picked up off the floor and I have a big knot on my head now. From what I remember, one man was helping me from the bed to my wheelchair. He was using a Hoyer lift to lift me. When this happened, he was the only aide who got me out of bed and put me in the wheelchair and I fell straight back onto my head." 7. On 09/27/13 at 11:05 am, during interview CNA #1 stated, "I was transferring (name of R #6) with the Hoyer lift into her wheelchair and when she got into her w/c she was slipping forward. I was transferring her from the bed to the wheelchair by myself. She was very heavy and we need a lot of help to get her up. As she was trying to help me push herself up in the w/c, I was pushing her legs and she fell straight back in her w/c and hit her head on the floor. I knew I needed two people to transfer her from the bed to her w/c. I was supposed to be using two people assist with the Hoyer lift. The problem was I was busy getting people up for breakfast. I knew it was my fault and I know it was our policy to always use two people to transfer her in the Hoyer lift." 8. On 09/27/13 at 11:45 am, during interview Licensed practical Nurse (LPN) #1 stated, "I was getting report from the night nurse and the CNA (identified as CNA #1) told me (name of R #6) was on the floor. So I went in her room and the w/c was on its back and she was lying right next to it on her back. The CNA told me he was lifting the resident into the w/c with the Hoyer lift by himself and he was trying to pull her up in the wheelchair and the wheelchair tipped over and she fell out. She (referring to R #6) did tell me that she hit her head. She did have a knot at the base of her neck. After that we got neuro-checks and she went to breakfast." 9. On 09/27/13 at 12:00 noon, during interview the Director of Nursing (DON) stated that the resident (referring to R #6) requires maximum assistance to get to her bed and to the toilet and back to her wheelchair. She further indicated that she does require the use of two persons when using the Hoyer lift. 10. On 09/27/13 at 12:20 pm, during interview the Corporate Clinical Ambassador stated, "We even had an inservice on mobility transfers back in February of this year and that CNA (referring to CNA #1) did attend and he should have known better than to do this. I'm not happy about this right now." 11. On 09/27/13 at 1:40 pm, during interview the Administrator stated, that in this case the care plan was not being followed and there was harm done to the patient ... "In my opinion, there was neglect to follow the plan of care and neglect to follow our own policy." 12. On 09/27/13 at 2:00 pm, during interview, CNA #2 stated, "She (referring to R #6) was on the ground when I walked in. I saw the wheelchair on its back and she was laying on it. I have worked with her before and normally we are supposed to have two people for every lift that we are doing. There always has to be two people." B. Review of the facility's Policy and Procedure regarding Hoyer Lifts revised 01/03/13 indicated, "The Hoyer Lift is used for residents who do not bear weight or walk; or those residents who may be too heavy for you to transfer safely ...Hoyer Lift is a 2 person assist transfer."

Based on record review and interviews, the facility failed to ensure 1 (R #6) of 1 (R #6) residents received adequate supervision and assistance to prevent an accident in which the resident was being transferred from the bed to a wheelchair by use of a Hoyer lift (an assistive device that allows patients to be transferred between a bed and a chair) with only one person instead of the required two. This deficient practice likely caused the resident to fall backwards in her wheelchair hitting her head and sustaining a hematoma (swelling with containing blood), contusion (an injury caused by a blow to the body characterized by swelling, discoloration and pain) and bruising to the back of the head. The findings are: A. Record review and interviews for R #6 revealed the following information: 1. Comprehensive Plan of Care dated 10/17/12 indicated the resident has a self-care deficit with lower extremity activities of daily living (ADLs) related to a [DIAGNOSES REDACTED]. Interventions are for staff to use a Hoyer lift with two people for transfers. The Care Plan also indicated the resident is at risk for falls related to a history of falls and staff is to again use two persons for transfers with a Hoyer lift. 2. Annual Minimum Data Set ((MDS) dated [DATE] indicated, the resident requires two + persons physical assistance for transfers and bed mobility. 3. Annual history and physical examination [REDACTED]. 4. Nurse's Notes dated 09/23/13 indicated, "Pt. (patient) fell backwards in her wheelchair this morning when Certified Nursing Assistant (CNA) (who was identified as CNA #1) lifted patients legs. Patient hit the occipital region (area of the back of the head) that resulted in a hematoma. Patient reports mild pain at the site of the hematoma. Examination was positive for hematoma and contusion." 5. On 09/27/13 at 11:00 am, during interview R #6 stated, "All I know is that I fell off the wheelchair and was picked up off the floor and I have a big knot on my head now. From what I remember, one man was helping me from the bed to my wheelchair. He was using a Hoyer to lift me. When this happened, he was the only aide who got me out of bed and put me in the wheelchair and I fell straight back onto my head." 6. On 09/27/13 at 11:05 am, during interview CNA #1 stated, "I was transferring (name of R #6) with the Hoyer lift into her wheelchair and when she got into her w/c she was slipping forward. I was transferring her from the bed to the wheelchair by myself. She was very heavy and we need a lot of help to get her up. As she was trying to help me push herself up in the w/c, I was pushing her legs and she fell straight back in her w/c and hit her head on the floor. I knew we needed two people to transfer her from the bed to her w/c. We were supposed to be using two people assist with the Hoyer lift. The problem was I was busy getting people up for breakfast. I knew it was my fault and I know it was our policy to always use two people to transfer her in the Hoyer lift." 7. On 09/27/13 at 11:45 am, during interview Licensed practical Nurse (LPN) #1 stated, "I was getting report from the night nurse and the CNA (referring to CNA #1) told me (name of R #6) was on the floor. So I went in her room and the w/c was on its back and she was lying right next to it on her back. The CNA (referring to CNA #1) told me he was lifting the resident into the w/c with the Hoyer lift and he was trying to pull her up in the wheelchair and the wheelchair tipped over and she fell out. She did tell me that she hit her head. She did have a knot at the base of her neck. After that she went to breakfast." 8. On 09/27/13 at 1:40 pm, during interview the Administrator stated, "In this case, our care plan was not being followed and there was harm done to the patient...In my opinion, there was neglect to follow the plan of care and neglect to follow our own policy...and the resident (referring to R #6) did sustain actual harm." 9. On 09/27/13 at 2:00 pm, during interview, CNA #2 stated, "She (referring to R #6) was on the ground when I walked in. I saw the wheelchair on its back and she was laying on it. I have worked with her before and normally we are supposed to have two people for every lift that we are doing. There always has to be two people." B. Review of the facility's Hoyer Lift Policy and Transfers Policy revealed the following information: 1. Hoyer Lift Policy dated 01/03/13 indicated, "Hoyer Lift is a 2 person assist transfer." 2. Transfers Policy revised on 09/01/2011 indicated, "Purpose is to enable the resident to transfer safely...Follow specific orders as to type of transfer to be performed."

Based on record review, interview and observation, the facility failed to ensure that injuries of unknown source were investigated and reported immediately to the State survey and certification agency for 1 (#1) of 1 sampled residents (#1) who presented with bruising to the forehead, arms and legs for which the cause was not determined by the facility. There was no report sent to the State survey and Certification Agency. There was also no evidence that the resident was protected from additional bruising of unknown source. The failure to investigate the causes of the bruising is likely to have resulted in the lack of recognition of the resultant Disseminated Intravascular Coagulopathy (DIC-a serious medical condition that develops when the normal balance between bleeding and clotting is disturbed...excessive bleeding and clotting injures body organs and causes [MEDICAL CONDITION] or death). The findings are: A. Review of Resident #1's medical record from [DATE] to [DATE] revealed the following: 1. Progress Note, dated [DATE] indicated "a large bruise (purple in color) behind her left knee, unable to tell what could have caused it." 2. Nurse's Note, dated [DATE], indicated, "a large bruise to her forehead, unknown of where it occurred or how." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 3. Nurse's Note, dated [DATE] indicated, "a large bruise to top of right foot, unknown of where it occurred or how." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 4. Nurse's Note, dated [DATE] indicated, "a large bruise (approximately 4" in diameter) to left antecubital area (front of elbow)." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 5. Nurse's Note, dated [DATE] indicated that a family member had been in to visit and claimed that the resident was "behaving withdrawn." 6. Nurse's Note, dated [DATE] indicated, "still has a hematoma (a semisolid mass of blood in the tissues, caused by injury, disease, or a clotting disorder) to entire left arm. Now entire left arm all the way down to the hand is discolored. (Resident #1's) arm elevated with pillow, bruised all over. Physician notified." 7. Nurse's Note, dated [DATE] indicated, "... Hematoma present to left antecubital (inside elbow area, where it bends)." There continued to be no documentation that an investigation was completed to determine the cause of the bruising. 8. Nurse's Note, dated [DATE] indicated, "radial pulse very faint, very lethargic, presence of blood tinged urine inside Foley catheter noted. Notified physician, who ordered resident ( Resident #1) to be sent immediately to the hospital for further evaluation." B. Review of Resident #1's acute care hospital emergency room Physician History and Physical, dated [DATE] at 7:00 pm, revealed that Resident #1 was admitted due to 12 hours of altered mental status. The resident was admitted to the Medical Intensive Care Unit (MICU) with a [DIAGNOSES REDACTED]. C. Hospice admission and discharge documentation indicated that the resident was released from the acute care hospital and admitted to hospice on [DATE] where she died on [DATE]. D. On [DATE] at 4:30 pm, during interview, the Physician Assistant (PA) stated that she had never been made aware of the bruising to the legs, feet and forehead of Resident #1. The PA said that any resident who is on [MEDICATION NAME] and [MEDICATION NAME] must be monitored very closely for any signs of bleeding such as bruising which are critical indicators that the resident could be "spontaneously bleeding out." She then said, "Nursing should be able to assess the resident and determine if signs and symptoms and changes of condition warrant sending the resident to the hospital to seek immediate treatment. Had I been made aware of the extent of the bruising, especially the mass bruising to the left arm and forehead, I would have ordered the resident (Resident #1) to be sent immediately to the hospital." E. On [DATE] at 5:15 pm, during interview, Registered Nurse (RN) #2 stated that she remembered (Resident 1's) whole arm being bruised. She said she was not aware that a bruise of unknown origin needed to be reported by completing a form and that the process was to try to determine what might have caused the injury. RN #2 then stated that had she known this, she would have completed the form and reported to her supervisor. F. On [DATE] at 4:45 pm, during interview, RN #3 stated that when a bruise of unknown origin is found, there is a form that is completed and the information is placed on the "24 hour report" (report of all changes of condition and incidents of unknown origin within a 24 hour period). She said that the information is then discussed at the next scheduled "stand-up meeting" (a daily morning meeting where all department heads attend). She said she was not sure what happened to the information at that point. G. Review of a facility document dated ,[DATE], titled "POLICIES AND PROCEDURES-Resident Abuse revealed the following: 1. "All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Clinical Services. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Clinical Services as Abuse Coordinator." 2. "All incidents of resident abuse are to reported immediately of the Clinical Nurse in Charge, Director of Clinical Services and the Executive Director. Once reported to one of those three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation...The abuse coordinator is responsible for reporting to appropriate officials in accordance with Federal and State Regulations." 3. "...Upon completion of the investigation, a detailed report shall be prepared."

Based on record review, interview and observation, the facility failed to follow their policy on Resident Abuse by failing to ensure that injuries of unknown source were reported to appropriate facility staff, investigated and reported to the State Survey and Certification Agency for 1 (#1) of 1 sampled residents (#1) who presented with bruising to the forehead, arms and legs for which the cause was not determined by the facility. There was no report sent to the State survey and Certification Agency. There was also no evidence that the resident was protected from additional bruising of unknown source. The failure to investigate the causes of the bruising is likely to have resulted in the lack of recognition of the resultant Disseminated Intravascular Coagulopathy (DIC-a serious medical condition that develops when the normal balance between bleeding and clotting is disturbed...excessive bleeding and clotting injures body organs and causes [MEDICAL CONDITION] or death). The findings are: A. Review of a facility document dated 03/2012, titled "POLICIES AND PROCEDURES-Resident Abuse indicated the following: 1. "All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Clinical Services. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Clinical Services as Abuse Coordinator." 2. "All incidents of resident abuse are to reported immediately of the Clinical Nurse in Charge, Director of Clinical Services and the Executive Director. Once reported to one of those three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation...The abuse coordinator is responsible for reporting to appropriate officials in accordance with Federal and State Regulations." 3. "...Upon completion of the investigation, a detailed report shall be prepared." B. On 01/16/13 at 5:15 pm, during interview, Registered Nurse (RN) #2 stated that she remembered (Resident 1's) whole arm being bruised. She said she was not aware that a bruise of unknown origin needed to be reported by completing a form and that the process was to try to determine what might have caused the injury. RN #2 then stated that had she known this, she would have completed the form and reported to her supervisor. C. On 01/17/13 at 4:45 pm, during interview, RN #3 stated that when a bruise of unknown origin is found, there is a form that is completed and the information is placed on the "24 hour report" (report of all changes of condition and incidents of unknown origin within a 24 hour period). She said that the information is then discussed at the next scheduled "stand-up meeting" (a daily morning meeting where all department heads attend). She said she was not sure what happened to the information at that point. D. Interviews with RNs on 01/16/13 and 01/17/13 indicated that the nursing staff had inconsistent and/or incomplete knowledge of the facility policy regarding Resident Abuse. The policy was not followed after three separate incidents of bruising of unknown origin to three different areas on the resident. E. Review of Resident #1's medical record from 09/03/12 to 11/16/12 revealed the following: 1. Progress Note, dated 10/02/12 indicated "a large bruise (purple in color) behind her left knee, unable to tell what could have caused it." 2. Nurse's Note, dated 10/04/12, indicated, "a large bruise to her forehead, unknown of where it occurred or how." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 3. Nurse's Note, dated 10/06/12 indicated, "a large bruise to top of right foot, unknown of where it occurred or how." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 4. Nurse's Note, dated 10/11/12 indicated, "a large bruise (approximately 4" in diameter) to left antecubital area (front of elbow)." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 5. Nurse's Note, dated 10/13/12 indicated that a family member had been in to visit and claimed that the resident was "behaving withdrawn." 6. Nurse's Note, dated 10/17/12 indicated, "still has a hematoma (a semisolid mass of blood in the tissues, caused by injury, disease, or a clotting disorder) to entire left arm. Now entire left arm all the way down to the hand is discolored. (Resident #1's) arm elevated with pillow, bruised all over. Physician notified." 7. Nurse's Note, dated 10/25/12 indicated, "... Hematoma present to left antecubital (inside elbow area, where it bends)." There continued to be no documentation that an investigation was completed to determine the cause of the bruising. 8. Nurse's Note, dated 11/16/12 indicated, "radial pulse very faint, very lethargic, presence of blood tinged urine inside Foley catheter noted. Notified physician, who ordered resident ( Resident #1) to be sent immediately to the hospital for further evaluation." F. Review of Resident #1's acute care hospital emergency room Physician History and Physical, dated 11/16/12 at 7:00 pm, revealed that Resident #1 was admitted due to 12 hours of altered mental status. The resident was admitted to the Medical Intensive Care Unit (MICU) with a [DIAGNOSES REDACTED].

Based on record review, interview and observation, the facility failed to ensure that injuries of unknown source were investigated and reported immediately to the State survey and certification agency for 1 (#1) of 1 sampled residents (#1) who presented with bruising to the forehead, arms and legs for which the cause was not determined by the facility. There was no report sent to the State survey and Certification Agency. There was also no evidence that the resident was protected from additional bruising of unknown source. The failure to investigate the causes of the bruising is likely to have resulted in the lack of recognition of the resultant Disseminated Intravascular Coagulopathy (DIC-a serious medical condition that develops when the normal balance between bleeding and clotting is disturbed...excessive bleeding and clotting injures body organs and causes [MEDICAL CONDITION] or death). The findings are: A. Review of Resident #1's medical record from [DATE] to [DATE] revealed the following: 1. Progress Note, dated [DATE] indicated "a large bruise (purple in color) behind her left knee, unable to tell what could have caused it." 2. Nurse's Note, dated [DATE], indicated, "a large bruise to her forehead, unknown of where it occurred or how." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 3. Nurse's Note, dated [DATE] indicated, "a large bruise to top of right foot, unknown of where it occurred or how." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 4. Nurse's Note, dated [DATE] indicated, "a large bruise (approximately 4" in diameter) to left antecubital area (front of elbow)." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 5. Nurse's Note, dated [DATE] indicated that a family member had been in to visit and claimed that the resident was "behaving withdrawn." 6. Nurse's Note, dated [DATE] indicated, "still has a hematoma (a semisolid mass of blood in the tissues, caused by injury, disease, or a clotting disorder) to entire left arm. Now entire left arm all the way down to the hand is discolored. (Resident #1's) arm elevated with pillow, bruised all over. Physician notified." 7. Nurse's Note, dated [DATE] indicated, "... Hematoma present to left antecubital (inside elbow area, where it bends)." There continued to be no documentation that an investigation was completed to determine the cause of the bruising. 8. Nurse's Note, dated [DATE] indicated, "radial pulse very faint, very lethargic, presence of blood tinged urine inside Foley catheter noted. Notified physician, who ordered resident ( Resident #1) to be sent immediately to the hospital for further evaluation." B. Review of Resident #1's acute care hospital emergency room Physician History and Physical, dated [DATE] at 7:00 pm, revealed that Resident #1 was admitted due to 12 hours of altered mental status. The resident was admitted to the Medical Intensive Care Unit (MICU) with a [DIAGNOSES REDACTED]. C. Hospice admission and discharge documentation indicated that the resident was released from the acute care hospital and admitted to hospice on [DATE] where she died on [DATE]. D. On [DATE] at 4:30 pm, during interview, the Physician Assistant (PA) stated that she had never been made aware of the bruising to the legs, feet and forehead of Resident #1. The PA said that any resident who is on [MEDICATION NAME] and [MEDICATION NAME] must be monitored very closely for any signs of bleeding such as bruising which are critical indicators that the resident could be "spontaneously bleeding out." She then said, "Nursing should be able to assess the resident and determine if signs and symptoms and changes of condition warrant sending the resident to the hospital to seek immediate treatment. Had I been made aware of the extent of the bruising, especially the mass bruising to the left arm and forehead, I would have ordered the resident (Resident #1) to be sent immediately to the hospital." E. On [DATE] at 5:15 pm, during interview, Registered Nurse (RN) #2 stated that she remembered (Resident 1's) whole arm being bruised. She said she was not aware that a bruise of unknown origin needed to be reported by completing a form and that the process was to try to determine what might have caused the injury. RN #2 then stated that had she known this, she would have completed the form and reported to her supervisor. F. On [DATE] at 4:45 pm, during interview, RN #3 stated that when a bruise of unknown origin is found, there is a form that is completed and the information is placed on the "24 hour report" (report of all changes of condition and incidents of unknown origin within a 24 hour period). She said that the information is then discussed at the next scheduled "stand-up meeting" (a daily morning meeting where all department heads attend). She said she was not sure what happened to the information at that point. G. Review of a facility document dated ,[DATE], titled "POLICIES AND PROCEDURES-Resident Abuse revealed the following: 1. "All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Clinical Services. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Clinical Services as Abuse Coordinator." 2. "All incidents of resident abuse are to reported immediately of the Clinical Nurse in Charge, Director of Clinical Services and the Executive Director. Once reported to one of those three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation...The abuse coordinator is responsible for reporting to appropriate officials in accordance with Federal and State Regulations." 3. "...Upon completion of the investigation, a detailed report shall be prepared."

Based on record review, interview and observation, the facility failed to follow their policy on Resident Abuse by failing to ensure that injuries of unknown source were reported to appropriate facility staff, investigated and reported to the State Survey and Certification Agency for 1 (#1) of 1 sampled residents (#1) who presented with bruising to the forehead, arms and legs for which the cause was not determined by the facility. There was no report sent to the State survey and Certification Agency. There was also no evidence that the resident was protected from additional bruising of unknown source. The failure to investigate the causes of the bruising is likely to have resulted in the lack of recognition of the resultant Disseminated Intravascular Coagulopathy (DIC-a serious medical condition that develops when the normal balance between bleeding and clotting is disturbed...excessive bleeding and clotting injures body organs and causes [MEDICAL CONDITION] or death). The findings are: A. Review of a facility document dated 03/2012, titled "POLICIES AND PROCEDURES-Resident Abuse indicated the following: 1. "All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Director of Clinical Services. Patterns or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Clinical Services as Abuse Coordinator." 2. "All incidents of resident abuse are to reported immediately of the Clinical Nurse in Charge, Director of Clinical Services and the Executive Director. Once reported to one of those three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation...The abuse coordinator is responsible for reporting to appropriate officials in accordance with Federal and State Regulations." 3. "...Upon completion of the investigation, a detailed report shall be prepared." B. On 01/16/13 at 5:15 pm, during interview, Registered Nurse (RN) #2 stated that she remembered (Resident 1's) whole arm being bruised. She said she was not aware that a bruise of unknown origin needed to be reported by completing a form and that the process was to try to determine what might have caused the injury. RN #2 then stated that had she known this, she would have completed the form and reported to her supervisor. C. On 01/17/13 at 4:45 pm, during interview, RN #3 stated that when a bruise of unknown origin is found, there is a form that is completed and the information is placed on the "24 hour report" (report of all changes of condition and incidents of unknown origin within a 24 hour period). She said that the information is then discussed at the next scheduled "stand-up meeting" (a daily morning meeting where all department heads attend). She said she was not sure what happened to the information at that point. D. Interviews with RNs on 01/16/13 and 01/17/13 indicated that the nursing staff had inconsistent and/or incomplete knowledge of the facility policy regarding Resident Abuse. The policy was not followed after three separate incidents of bruising of unknown origin to three different areas on the resident. E. Review of Resident #1's medical record from 09/03/12 to 11/16/12 revealed the following: 1. Progress Note, dated 10/02/12 indicated "a large bruise (purple in color) behind her left knee, unable to tell what could have caused it." 2. Nurse's Note, dated 10/04/12, indicated, "a large bruise to her forehead, unknown of where it occurred or how." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 3. Nurse's Note, dated 10/06/12 indicated, "a large bruise to top of right foot, unknown of where it occurred or how." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 4. Nurse's Note, dated 10/11/12 indicated, "a large bruise (approximately 4" in diameter) to left antecubital area (front of elbow)." There was no documentation to indicate that an investigation was completed to determine how the bruise occurred. 5. Nurse's Note, dated 10/13/12 indicated that a family member had been in to visit and claimed that the resident was "behaving withdrawn." 6. Nurse's Note, dated 10/17/12 indicated, "still has a hematoma (a semisolid mass of blood in the tissues, caused by injury, disease, or a clotting disorder) to entire left arm. Now entire left arm all the way down to the hand is discolored. (Resident #1's) arm elevated with pillow, bruised all over. Physician notified." 7. Nurse's Note, dated 10/25/12 indicated, "... Hematoma present to left antecubital (inside elbow area, where it bends)." There continued to be no documentation that an investigation was completed to determine the cause of the bruising. 8. Nurse's Note, dated 11/16/12 indicated, "radial pulse very faint, very lethargic, presence of blood tinged urine inside Foley catheter noted. Notified physician, who ordered resident ( Resident #1) to be sent immediately to the hospital for further evaluation." F. Review of Resident #1's acute care hospital emergency room Physician History and Physical, dated 11/16/12 at 7:00 pm, revealed that Resident #1 was admitted due to 12 hours of altered mental status. The resident was admitted to the Medical Intensive Care Unit (MICU) with a [DIAGNOSES REDACTED].

Based on record review and interview, the facility failed to thoroughly investigate an injury of unknown source and submit a five day follow-up investigation to the State Survey and Certification Agency for 1 (Resident - R #162) of 1 (R #162) resident who sustained a [MEDICAL CONDITION] left femur (left upper leg bone). The facility also failed to investigate and determine the cause of how the resident sustained [REDACTED]. If injuries of unknown source are not investigated, the facility is unable to determine what happened in order to prevent it from re-occurring. If the five day follow-up investigation is not submitted, the State Survey and Certification Agency is not able to determine whether or not a thorough investigation was completed to ensure resident safety. The findings are: A. Review of a Health Facility Licensing & Certification (HFL&C) Incident Report alleged that R #162 sustained an Injury of Unknown Origin (fracture of left upper leg) on 11/21/11. B. Review of the closed medical record for R #162 revealed the following: 1. Admission Data Collection and Initial Plan of Care form dated 11/17/11, indicated that the resident was, "Cognitively Impaired with poor decision making skills, not able to make herself understood and not able to understand questions." 2. Facility Progress Notes dated 11/20/11 indicated, "Complains of left leg pain..." 3. Radiology Report dated 11/21/11 indicated, "There is a nondisplaced [MEDICAL CONDITION] (farthest from the center or trunk) left femur, extending into the left distal femoral arthroplasty (artificial joint)." C. Interviews revealed the following information: 1. On 03/19/12 at 4:00 pm, upon request of the facilities 5 day follow up investigation, the Director of Nurses (DON) stated that the incident should have been thoroughly investigated and a 5 day follow-up should have been submitted. "I don't think one (5-day follow up investigation) was done." 2. On 03/19/12 at 4:15 pm, Staff #16, Unit Manager/Licensed Practical Nurse (LPN) stated, "I didn't do a 5 day follow up investigation."

Based on record review and interview, the facility failed to follow policies and procedures for an injury of unknown origin 1 (Resident - R #162) of 1 (R #162) resident who sustained a [MEDICAL CONDITION] left femur (upper leg bone). This deficient practice presents a risk injuries of unknown origin not being investigated and reported to the state agency. The findings are: A. Review of a Health Facility Licensing & Certification (HFL&C) Incident Report alleged that R #162 sustained an Injury of Unknown Origin (fracture of left upper leg) on 11/21/11. B. Review of the facilities Administrative Manual Abuse Prevention Program & Reporting Policy 14.1 revised 11/2011 revealed: "Each employee is responsible to report any suspected abuse. Each incident will be investigated, and required reporting completed." 1. Section 14.1.4 Reporting: revealed, "Notify the Shift Supervisor immediately...Notify the...responsible family member...immediately...Notify the Physician immediately...Report results of investigation to the proper authorities as required by state law." C. On 03/19/12 at 4:00 pm, upon request of the facility's 5 day follow up investigation, the Director of Nurses (DON) stated, "It would have been the unit managers that would have been responsible for submitting the 5 day follow-up to the state." The DON was not able to produce a 5 day follow-up investigation report. She confirmed that policies and procedures were not followed.

Based on record review and interview, the facility failed to follow the physician's written plan of care for 1 (Resident - R #162) of 1 (R #162) resident who was identified by the physician as being non weight bearing, and was supposed to be transferred with a Hoyer lift (Mechanical lift with sling). This deficient practice likely caused the resident to sustain a [MEDICAL CONDITION] left femur (upper leg bone). The findings are: A. Review of the medical record for R #162 revealed the following information: 1. Hospice Interdisciplinary Team Plan of Care/Comprehensive assessment dated [DATE] indicated that the resident had increasing confusion, was totally dependent on staff for all activities of daily living (ADLs), was chair-bound and required Hoyer lift transfers due to continued residual left sided weakness from [MEDICAL CONDITIONS]. 2. Hospice Admission physician's orders [REDACTED]." 3. Hospice Nursing Clinical Note from the admitting Hospice Registered Nurse (RN) dated 11/17/11 indicated, "The resident is dependent on staff for all ADLs and Hoyer lift for transfers." B. Interviews for R #162 revealed the following information: 1. On 03/19/12 at 4:15 pm, during interview, Staff #16 (Unit Manager - LPN) stated, "...She was just a one person transfer...I honestly don't know how they were transferring her." 2. On 03/20/12 at 1:45 pm, during interview, Staff #11 (Certified Nursing Assistant - CNA) stated, "...When we did transfer her, we would put a gait belt around her and stand her up. We could pivot her with two people." 3. On 03/20/12 at 3:15 pm, during interview, Staff #18 (RN) stated, "...I don't think she could bear any weight." 4. On 03/20/12 at 4:30 pm, during interview, Staff #19 (CNA) stated, "When I toileted her, I would stand her up. I don't remember anyone ever saying anything to me about her being a Hoyer lift." 5. On 03/21/12 at 8:25 am, during interview, Staff #20 (LPN) stated, "She was a one person assist." 6. On 3/21/12 at 9:15 am, during interview, Staff #14 (CNA) stated, "She was transferring with a 2 person assist. She was a stand pivot transfer, with two people and the gait belt." 7. On 03/22/12 at 10:20 am, during interview, Staff #12 (CNA) stated, "... I don't think we ever used a lift on her. I was only told she was a two person stand pivot transfer. We didn't use the Hoyer lif." 8. On 03/22/12 at 3:25 pm, during interview, Staff #25 (CNA) stated, "I was not informed how she transfers...maybe a Hoyer lift or a two person transfer." 9. On 03/23/12 at 4:00 pm, during interview, a Physician with Hospice stated, "She (referring to R #162) was very debilitated. The transfer was such that they were to only have a Hoyer lift to transfer her. That is why I specifically ordered a Hoyer lift to be used." Based on record review, and interview the facility failed to follow the physician's written plan of care for 1 (R #44) of 1 (R #44) resident who was required to have a resting hand splint in place for his right upper extremity (RUE) due to right [MEDICAL CONDITION] (paralysis of half of the body) from a [MEDICAL CONDITIONS]. This deficient practice had the potential to result in the resident sustaining further contractures of the right hand. The findings are: A. Review of the medical record for R #44 revealed the following information: 1. Face Sheet dated 03/09/12 indicated, [DIAGNOSES REDACTED]. 2. Physician's Progress Notes dated 10/06/11 and 02/28/12 indicated contractures of the right hand. 3. Physician's Recapitulation Orders dated December 2011 through March 2012 indicated that the resident, "Requires resting hand splint for RUE due to right [MEDICAL CONDITION] from [MEDICAL CONDITION] will reduce the risk of contracture and increase hygiene." 4. January, February, and March 2012 treatment record indicated, "Resident requires resting hand splint for RUE due to right [MEDICAL CONDITION] from [MEDICAL CONDITION]. This will reduce the risk of contracture and increase hygiene." 5. Occupational Therapy Plan of treatment for [REDACTED]. The patient will tolerate donning/doffing (putting on/taking off) right upper extremity wrist hand orthosis (splint) improving to stand by assistance in order to complete hygiene and grooming tasks." B. Interviews for R #44 revealed the following information: 1. On 03/22/12 at 2:45 pm, Staff #22 (Restorative Aide - RA) stated, "I have not had (name of R #44) on my caseload since June of last year." 2. On 03/23/12 at 9:45 am, Staff #23 (Physical Therapist - PT) stated, "One would assume that if there is a physician's orders [REDACTED]." 3. On 03/26/12 at 9:55 am, Staff #20 (LPN) stated, "I've never known him to have a splint device in place." 4. On 03/26/12 at 10:35 am, Staff #24 (Occupational Therapist - OT) stated, "... I've been here since last August (2011) and I've never had him on my caseload for a splint or anything else." Based on record review and interview, the facility failed to follow physician's orders [REDACTED].#88) resident. Resident #88 had a [DIAGNOSES REDACTED]. The facility was not administering the insulin as ordered by the physician. This deficient practice had the potential to result in abnormal blood sugar levels which could likely cause diabetic complications for R #88. The findings are: A. Review of the Medical Record (MR) for R #88 revealed the following information: 1. physician's orders [REDACTED]. 2. Medication Administration Record (MAR) for January 2012 - March 2012 indicated that the resident had not received the Insulin as ordered: a. March 2012 (1st - 23rd) the facility missed 18 opportunities to administer the medication. b. February 2012 - the facility missed 13 opportunities to administer the medication. c. January 2012 - the facility missed 3 opportunities to administer the medication. B. Interviews for R #88 revealed the following information: 1. On 03/23/12 at 12:20 pm, after reviewing the MAR and verifying that the Insulin had not been given, Staff #27 (Unit Manager - LPN) stated, "He should be getting that ([MEDICATION NAME]) every night." 2. On 03/26/12 at 2:20 pm, the Director of Nursing (DON) stated, "She space out Insulin for a month and a half ...that's a med error. If he was getting his routine dose he may not have needed the sliding scale Insulin administration as much." 3. On 03/26/12 at 2:45 pm, Staff #3 (LPN) confirmed that the insulin had not been given every night as ordered. Staff #3 stated, "Oh my gosh, I just didn't see it." Surveyor: Moorhead Lopez, Rach

Based on record review and interview, the facility failed to ensure that 1 (R #162) of 1 (R #162) resident's highest practicable physical and mental well-being was maintained by not ensuring the proper transfer according to the physician's written plan of care, which was for the resident to only be transferred using a Hoyer lift. This deficient practice likely resulted in the resident sustaining a fracture of the distal left femur (upper leg bone). The findings are: A. Review of the closed medical record for resident (R #162) revealed the following: 1. Hospice Interdisciplinary Team Plan of Care Comprehensive assessment dated [DATE], indicated that the resident had increasing confusion, was totally dependent on staff for all activities of daily living (ADLs), was chair-bound, required Hoyer lift transfers due to continued residual left sided weakness secondary to a history of a cerebrovascular accident (CVA - Stroke). 2. Hospice Admission physician's orders [REDACTED]." 3. Hospice Nursing Clinical Note from the admitting Hospice Registered Nurse (RN) dated 11/17/11 indicated, "The resident is dependent on staff for all ADLs and Hoyer lift for transfers." 4. Facility Progress Notes dated 11/18/11 indicated, "Up in wheelchair...requires 1 person assist with ADLs and transfers (which is contrary to Hospice orders)." 5. Facility Progress Notes dated 11/20/11 indicated, "Complains of left leg pain." 6. Radiology Report (that was requested by Hospice) dated 11/21/11 indicated, "There is a nondisplaced fracture of the distal (farthest from the center or trunk) left femur, extending into the left distal femoral arthroplasty (artificial joint)." B. Interviews for R #162 revealed the following information: 1. On 03/20/12 at 1:45 pm, Staff #11 (Certified Nursing Assistant - CNA) stated, "She was fine when she came here. I was off over the weekend. When I came back to work on Monday (21st), she was in a lot of pain from one leg...she kept telling me in Spanish that her leg was really hurting. She was not able to put any weight on her left leg. She was in agonizing pain." 2. On 03/20/12 at 2:35 pm, Staff #17 (Licensed Practical Nurse-LPN) stated, "I do recall coming in on Sunday morning (11/20/11)...I documented that she was having left leg pain. I don't recall any swelling...When the aides were adjusting her in the wheelchair she was complaining of pain in her left leg." 3. On 03/20/12 at 2:55 pm, the RN stated, "When I admitted her (to the facility) on Thursday the 17th, she was fine. On Monday the 21st, I got a call from her daughter stating that her mother's left leg was extremely swollen, painful, and that she couldn't move it. I called the facility and they didn't know what had happened to her. There was no note in the chart as to what happened. When I admitted her to the facility, there was no swelling and no pain. When the daughter came in on Monday she was very angry and talked to the DON and the Administrator. No one could tell me or her what happened. After she (the resident) returned home, I ordered an X-ray. The results came back as a non-displaced fracture...she was in a great amount of pain." 4. On 03/20/12 at 3:15 pm, Staff #18 (RN) stated, "I remember she had one day when her leg was really swollen from her thigh down...I don't think she could bear any weight." 5. On 03/20/12 at 4:00 pm, the Administrator stated, "I was having conversations with the daughter because she was highly upset. No one could tell me what happened. That is as far as I was involved with this investigation. At one time, I recall her leg was hurting. The Hospice Nurse came to talk to me and said 'You broke her leg'.'' 6. On 03/20/12 at 4:30 pm, Staff #19 (CNA) stated, "When I toileted her and showered her, I would stand her up. When she stood up, she shuffled her feet real slowly...When she was in the shower the day prior to her discharge, the CNA pushed her in the shower room in her wheelchair and I stood her up. I don't remember anyone ever saying anything to me about her being a Hoyer lift." 7. On 03/20/12 at 4:45 pm, the resident's daughter stated, "... I got a call from the personal caregiver on Sunday saying that my mom's leg was very swollen down to her foot. The next day (Monday) I went to pick her up and I was very surprised how swollen her leg was. I went to the head nurse and asked what had happened. She said 'I don't know.'...Her leg was swollen from the groin to the knee... the nurse knew nothing. I looked at her chart (written medical record) and there wasn't anything written about what happened. I brought her home still not knowing her leg was broken. She would yell out. I called Hospice. Hospice came and said they would do an X-ray. They told me her femur bone (upper leg bone) was broken. We took her to the hospital and they did a second X-ray to make sure." 8. On 3/21/12 at 9:15 am, Staff #14 (CNA) stated, "I remember working with her on Friday...she was fine...when I returned back to work on Sunday, she was complaining of pain to her left leg. She was not her normal self. She was in a lot of pain...she just moaned in pain...she was in a lot of pain!" 9. On 03/22/12 at 10:20 am, Staff #12 (CNA) stated, "We would assist her to the bathroom. We would do a stand pivot transfer with her. I do remember her leg hurting...on Sunday (11/20/11) her leg was really swollen...she was hurting. I think we were short staffed that day...when I worked with her we would always transfer her using a stand pivot transfer...to toilet her, we would turn her and sit her down. On Sunday I remember giving her a shower. We pivoted her to the shower chair...she complain of pain...On Monday she was screaming...We couldn't even touch her...We didn't use the Hoyer lift." 10. On 03/22/12 at 3:25 pm, Staff #21 (CNA) stated, "...I was never informed how she transfers...I didn't see a Hoyer sling... I took her to the bathroom. I put a gait belt on her..she was able to stand pivot for me...the personal caregiver told me in Spanish she does not walk. When I worked with her I was not told about what type of transfer she was... she was in a lot of pain in her leg when she left" 11. On 03/21/12 at 3:50 pm, the Hospice CNA stated that she worked with the resident on Friday at the facility and did not notice anything abnormal at that time. "It was a normal routine visit...when she got home on Monday, she was in extreme pain...her leg was really swollen." 12. On 03/23/12 at 4:00 pm, the Hospice Physician stated, "She (referring to R #162) was very debilitated. The transfer was such that they were to only use a Hoyer lift to transfer her. I specifically ordered a Hoyer lift to be used. She couldn't walk or bear any weight...after she had already returned home on Monday, the Hospice nurse let me know that the resident was having a great deal of pain and that her leg was very swollen. I ordered an x-ray. It did show a fracture."

Based on record review and interviews, the facility failed to investigate, immediately report and submit a follow-up investigation for a resident who sustained a six and a half inch skin tear (injury of unknown origin) and experienced pain for 1 (#1) of 5 residents (#1- #5). These 5 residents were selected from the Resident Census and Condition Report provided by the Administrator on 02/17/11. The 5 chosen residents conditions matched resident #1's focused areas. These areas included: falls, fractures, cognitive impairment, activities of daily living decline, pain/comfort, incontinence, hospice and psychoactive medications. It was later determined that Resident #1 had sustained an acute impacted [MEDICAL CONDITION] supracondylar femur with mild displacement, which was determined to be an injury of unknown origin. The findings are: A. On 02/03/11 at 10:37 am, the State Central Complaint Hotline received a complaint that while staff were trying to transfer Resident #1 she was screaming out in pain. Further review of the complaint revealed allegations that the resident had been crying out in pain and that she had ultimately sustained a fracture above the knee. B. Review of the Medical Record revealed the following: 1. Nurses Notes dated 01/17/11, at 5:00 am "Res (resident) complained of pain to L (left) knee. Mild redness and slightly swollen... Resident states painful. Shower done. Frequently requesting to go to bed." 2. Nurses Notes dated 01/17/11, at 12:21 pm, "Resident c/o (complained of) pain to L (left) knee and femur. Yelling she is in pain. Notified nurse on duty of resident yelling and complaints of pain." 3. Nurses Notes dated 01/17/11, at 12:50 pm, "Wound nurse here reported resident complained of pain... Resident was yelling out and complaining of pain stated, 'I need orange juice.' After giving OJ (orange juice) continued to complain of pain when repositioned." 4. Nurses Notes dated 01/18/11, (no time indicated), "Resident continued to call out... Resident yells out louder when left knee touched." 5. Nurses Notes dated 01/18/11, at 4:20 pm, "Yelling out non-stop complaining it's hurting. Yelling when repositioned. Screaming-yelled out non-stop. Yelling out is not a new behavior..." 6. On 01/18/11 at 6:50 pm, "X-ray results show she has an acute impacted fracture (Fx) with mild displacement." 7. Hospice Nursing Notes, dated 01/18/11, indicated "severe pain (about 4 days ago per family)." C. Review of the Incident/Accident Log did not indicate that the facility had reported the incident nor did they conduct an internal investigation. D. On 02/17/11 at 3:24 pm, during an interview, the Director of Nursing (DON) stated, "There was no possible way the resident could have fallen or gotten out of bed on her own. Nothing out of the ordinary happened to her. If there were obvious signs of abuse, our protocol is that we would immediately start an investigation and we would have reported it." E. On 02/17/11 at 4:00 pm, during an interview, the resident's family member, Family member #1 stated, "My concerns were that the facility did not tell us how she fractured her leg. She also had a very big bruise on her hand that went all the way from her thumb and all the way across her hand from her knuckles to her wrist and it was black and blue... When we went to visit she was in excruciating pain. She was just screaming. I told the nurse that she was having pain and she kept saying she has dementia and there is nothing wrong with her. When we touched her anywhere on that left side she would just scream. Nothing was ever told to us by the facility as to what happened. Nothing was ever explained to us. We were very upset. I'm saying no one told us and she got hurt." F. On 02/17/11 at 4:34 pm, during an interview, Family member #2, who is also the Power of Attorney for Resident #1 stated, "When we stopped by, we could hear hear her screaming from the nurses station. Her door was shut as we stood outside. At this time, a nurse came out storming mad saying, 'She didn't let me get her up.' As we went in her room she said her leg was killing her. Every time they moved her she was in pain. There was no way she could have fallen out of bed. The nurse kept saying she was just having low calcium." G. On 02/17/11 at 5:23 pm, during an interview, Registered Nurse (RN) #1 stated, "Everyone knew she had a broken leg." H. On 02/17/11 at 5:42 pm, during an interview, Licensed Practical Nurse (LPN) #1 confirmed the resident had a large skin tear. "If you have an injury, then I would have called the family." I. On 02/18/11 at 9:00 am, during an interview, LPN #2 confirmed the resident had a bad skin tear on her hand. She stated, "Her whole hand was black. A couple of days went by. The family was concerned. About 2-3 hours later, the DON came to me saying we need an x-ray." LPN #2 verified the x-ray report came back identifying a fracture. She stated, "I informed the DON that an unwitnessed fracture is a sentinel event and you better call someone to report it." J. On 02/18/11 at 9:57 am, during an interview, Certified Nursing Assistant (CNA) #2 stated, "When I came on shift Monday morning 1/17/11 she was complaining of a lot of pain when we tried to get her dressed. As I was turning her towards me, she was screaming out in pain. She would say where it hurts and she would scream when I touched her leg. I called the nurse (identified as LPN #2) who walked into the residents room with me and another CNA (identified as CNA #1) and I asked "Do you see the discoloration? The day went on and she continued to complain of pain. I also told the wound nurse (identified as LPN #4) that she was complaining of a lot of pain." The CNA stated, "The next day (Tuesday 01/18/11) when I came on shift, she was still in a lot of pain. She complained and did not want to get up. She stayed in bed the whole day on Tuesday. I know she had a skin tear on her hand. That is when I started thinking something happened." K. On 02/18/11 at 10:15 am, during an interview, referring to the night of Sunday 01/16/11, CNA #3 stated, "I was doing rounds at 8:15 pm. When I turned her on her left side she made a yelp which alarmed me, was worse than usual and I told the nurse. She was crying more than usual. I remember because of her screaming. She would say 'my leg' but when I touched her hip and around her knee area she screamed." CNA #3 indicated that on the early morning of Monday 01/17/11 at 5:00 am she and LPN #5 transferred the resident into a shower chair. (Name of LPN #5) showered her, she was crying and screaming. After the shower we transferred her and she was yelping. The nurse did say she is crying more than usual." L. On 02/18/11 at 9:00 am, during a telephone interview, the Complaints Manager with the State Agency stated that the facility should have reported the incident as an injury of unknown origin. M. On 02/18/11 at 1:45 pm, during an interview, the Administrator stated that, the incident should have been reported. She also stated that a follow-up investigation should have been completed by the facility. N. On 02/22/11 at 11:00 am, during a telephone interview, CNA #5 stated, "I checked and saw the back of the residents hand had a skin tear. I don't know where she got it (the skin tear) from. I didn't see how it happened. I only saw the blood."

Based on record review and interviews, the facility failed to maintain the highest practicable well being for 1 (#1) of 5 residents who was identified on the Incident/Accident Log provided by the facility on 02/17/11. R #1 had sustained a six and a half inch skin tear (of unknown origin) and experienced pain. Resident #1 also sustained an acute impacted [MEDICAL CONDITION] supracondylar femur with mild displacement (injury of unknown origin) and was also observed by staff to be experiencing pain. The findings are: A. On 02/03/11 at 10:37 am, the State Central Complaint Hotline received a complaint that while staff were trying to transfer Resident #1 she was screaming out in pain. Further review of the complaint revealed allegations that the resident had been crying out in pain and that she had ultimately sustained a fracture above the knee. B. On 02/17/11 review of the closed medical record for Resident #1 revealed the following: 1. The Face Sheet, dated 12/22/09, indicated [DIAGNOSES REDACTED]. 2. The Annual Minimum Data Set (MDS), dated [DATE], indicated the resident had moderately impaired cognitive skills for daily decision making. The MDS further indicated the resident needed extensive assistance with transferring and bed mobility. 3. Review of the Nursing Notes, Physician Telephone orders and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] a. Nurses Notes dated 01/14/11, at 1:00 am, "Resident new skin tear to left top hand. CNA (Certified Nursing Assistant) observed blood saturated gown and discovered resident was attempting to get out of bed." Late Entry at 1:00 am, stated, "Skin tear to left top hand measures 6 1/2 inches in length no depth...Resident complained of mild pain to the site." b. Nurses Notes dated 01/15/11, (no time indicated) "Yelled and cried several times this shift." c. Physician Recapitulation orders, dated January 2011, revealed the resident had an order for [REDACTED]. d. Administration Record, dated January 2011, revealed no documentation that Tylenol was administered to the resident on 01/14/11 or 1/15/11 when she was complaining of mild pain, yelling out and crying several times. e. Nurses Notes dated 01/17/11, at 5:00 am "Res (resident) complained of pain to L (left) knee. Mild redness and slightly swollen...Resident states painful. Shower done. Frequently requesting to go to bed." f. Nurses Notes dated 01/17/11, at 12:21 pm, "Resident c/o (complained of) pain to L (left) knee and femur. Yelling she is in pain. Notified nurse on duty of resident yelling and complaints of pain." g. Nurses Notes dated 01/17/11, at 12:50 pm "Wound nurse here reported resident complained of pain...Resident was yelling out and complaining of pain stated, '"I need orange juice."' After giving OJ (orange juice) continued to complain of pain when repositioned." h. Physician Telephone Orders, dated 01/17/11, revealed a telephone order for [MEDICATION NAME] (MS)[MEDICATION NAME] milligrams (mg) 1 tablet by mouth (po) twice a day (bid) for pain. Further review of the telephone orders, dated 01/17/11, revealed an order for [REDACTED]. i. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. j. Pharmacy Prescription Delivered Form, dated 01/17/11, revealed the medication [MEDICATION NAME] 15 mg tabs, and the [MEDICATION NAME] Solution "[MEDICATION NAME]" was delivered to the facility on [DATE]. k. MAR indicated [REDACTED]. l. Nurses Notes dated 01/18/11, (no time indicated) "Resident continued to call out... Resident yells out louder when left knee touched." m. Nurses Notes dated 01/18/11, at 4:20 pm, "Yelling out non-stop complaining (c/o) it's hurting. Yelling when repositioned. Screaming-yelled out non-stop. Yelling out is not a new behavior..." n. Pain Intervention Flowsheet, (no date indicated) revealed no documentation of interventions that were attempted to alleviate the residents pain she was experiencing on 01/14/11, 01/16/11 and on 01/17/11. o. On 01/18/11 at 6:50 pm, "X-ray results show she has an acute impacted fracture (Fx) with mild displacement." p. Hospice Nursing Notes, dated 01/18/11, indicated severe pain (about 4 days ago per family). q. Review of the Hospice Assessment, dated 01/18/11, revealed severe pain issues, screaming or crying out, facial frowning or wincing, fetal position, jumps when touched and bruising to left hand with [MEDICAL CONDITION]. C. On 02/17/11 at 3:24 pm, during an interview, the Director of Nursing (DON) stated that, she recalled the nurse (no name mentioned) had reported to her (no time or day indicated) that the resident was complaining of pain and that she was hollering out. The DON stated, "I asked the nurse what happened and she said she didn't know. I placed my hand on her left leg and she was hollering more and more... There was no possible way the resident could have fallen or gotten out of bed on her own... Nothing out of the ordinary happened to her. If there were obvious signs of abuse, our protocol is that we would immediately start an investigation and we would have reported it." D. On 02/17/11 at 4:00 pm, during an interview, Family member #1 of the resident stated, "My concerns were that the facility did not tell us how she (the resident) fractured her leg. She also had a very big bruise on her hand that went all the way from her thumb and all the way across her hand from her knuckles to her wrist and it was black and blue." The family member stated, "When we went to visit she was in excruciating pain. She was just screaming. I told the nurse that she was having pain and she kept saying she has dementia and there is nothing wrong with her. When we touched her anywhere on that left side she would just scream. Nothing was ever told to us by the facility as to what happened. Nothing was ever explained to us. We were very upset. I'm saying no-one told us and she got hurt." E. On 02/17/11 at 4:34 pm, during an interview, Family member #2/Power of Attorney to resident #1 stated, "When we stopped by, we could hear hear her screaming from the nurses station. Her door was shut as we stood outside. At this time, a nurse came out storming mad saying, 'She didn't let me get her up.'" As we went in her room she said her leg was killing her... Every time they moved her she was in pain. There was no way she could have fallen out of bed... The nurse kept saying she was just having low calcium." F. On 02/17/11 at 5:23 pm, during an interview, Registered Nurse (RN #1) stated, "Everyone knew she had a broken leg. I thought it was a hairline fracture not a significant fracture." G. On 02/17/11 at 5:42 pm, during an interview, Licensed Practical Nurse (LPN #1) confirmed the resident had a large skin tear. The LPN then stated, "If you have an injury, then I would have called the family." H. On 02/18/11 at 9:00 am, during an interview, LPN #2 confirmed the resident had a bad skin tear on her hand. She stated, "Her whole hand was black. A couple of days went by. The family was concerned. About 2-3 hours later, the DON came to me saying we need an x-ray." At shift change, LPN #2 verified the x-ray report came back identifying a fracture. She stated, "I informed the DON that an unwitnessed fracture is a sentinel event and you better call someone to report it." I. On 02/18/11 at 9:15 am, during an interview, the resident's Physician confirmed that he assessed the resident on 01/17/11, the pain was diffuse and more localized. The Physician further confirmed the resident was bed ridden and to his knowledge she had not fallen out of bed. J. On 02/18/11 at 9:28 am, during an interview, CNA #1 stated that on Tuesday 01/18/11 when she saw the resident, "Her knee was discolored and greenish yellow in color. There was a huge skin tear on her hand." K. On 02/18/11 at 9:57 am, during an interview, CNA #2 stated, "When I came on shift Monday morning 1/17/11 she was complaining of a lot of pain when we tried to get her dressed... As I was turning her towards me, she was screaming out in pain... She would say where it hurts and she would scream when I touched her leg... I called the nurse (identified as LPN #2) who walked into the residents room with me and another CNA (identified as CNA #1) and I asked "Do you see the discoloration? The day went on and she continued to complain of pain... I also told the wound nurse (identified as LPN #4) that she was complaining of a lot of pain." The CNA stated, "The next day (Tuesday 01/18/11) when I came on shift, she was still in a lot of pain. She complained and did not want to get up... She stayed in bed the whole day on Tuesday... I know she had a skin tear on her hand. That is when I started thinking something happened." L. On 02/18/11 at 10:15 am, during an interview referring to the night of Sunday 01/16/11, CNA #3 stated, "I was doing rounds at 8:15 pm. When I turned her on her left side she made a yelp which alarmed me, was worse than usual and I told the nurse... She was crying more than usual... I remember because of her screaming... She would say 'my leg' but when I touched her hip and around her knee area she screamed." The CNA indicated that on the early morning of Monday 01/17/11 at 5:00 am she and a nurse (identified as LPN #5) transferred the resident into a shower chair... (LPN #5) showered her, she was crying and screaming... After the shower we transferred her and she was yelping... the nurse did say she is crying more than usual. M. On 02/18/11 at 11:50 am, during an interview, LPN #4 stated, "Her knee looked swollen, red and she was in pain. She yelled out when we tried to turn her." N. On 02/18/11 at 12:10 pm, during an interview, referring to the early morning of Monday 01/17/11, LPN #5 stated, "The resident was complaining of pain to her knee when I showered her." O. On 02/18/11 at 9:00 am, during a telephone interview, the Complaints Manager with the State of N.M. Department of Health stated that the facility should have reported the Injury of unknown origin. P. On 02/18/11 at 1:45 pm, during an interview, the Administrator stated, "As far as reporting goes, in my mind it should have been reported... A follow-up investigation should have been completed by the facility." Q. On 02/22/11 at 11:00 am, during a telephone interview, CNA #5 stated, "I checked and saw the back of the residents hand had a skin tear. I don't know where she got it (the skin tear) from... I didn't see how it happened... I only saw the blood."