Every finding on record at Onaga Operator, LLC

Based on record review, observations, and interviews, the facility failed to ensure Resident (R)2's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask, R3's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) masks and nasal cannula, and R32's nasal cannula were stored in a sanitary manner when not in use. The facility failed to ensure clean laundry was transported in a sanitary manner. The facility further failed to ensure staff performed adequate hand hygiene.Findings included:- On 04/27/26 at 07:40 AM, R2's CPAP mask lay on his bed and was not stored in a sanitary container.R3's nebulizer mask lay on her bedside table. R3's nasal cannula laid on her bed. They were not stored in sanitary containers.R32's oxygen nasal canula was wrapped around her oxygen canister and not stored in a sanitary containerOn 04/27/26 at 08:02 AM, Housekeeping V carried a grey comforter with white bedding down the hall in his arms next to his clothing. Housekeeping V did not transport the linens in a sanitary manner.On 04/28/26 at 09:51 AM, Laundry Supervisor U carried a gray long sleeve shirt down the hall on a hanger; the shirt was not covered.On 04/28/26 at 09:52 AM, R32's nasal cannula oxygen tubing was wrapped around the handle of her oxygen concentrator and was not stored in a sanitary container. On 04/28/26 at 09:55 AM, R2's CPAP mask laid on his bedside table, the CPAP was not stored in a sanitary container.On 04/28/26 11:25 AM, Laundry Supervisor V carried a gray short sleeve shirt down Hall 300 on a hanger. The shirt was not covered.On 04/30/26 at 08:11 AM, R2's CPAP lay on his bedside table and was not stored in a sanitary container.On 04/30/26 at 09:00 AM, R32's nasal cannula was wrapped around her oxygen canister, and a nasal cannula was wrapped around the handle of a portable oxygen tank in her room. R32's nasal cannulas were not stored in sanitary containers.On 04/30/26 at 09:59 AM, R14 transferred herself from a wheelchair to the toilet. R14 took her incontinent brief and slacks off, tossed the incontinent brief in the trash can, and placed her slacks on the floor. Certified Nurse's Aide (CNA) M instructed R14 to pull the call light chord when she was done and left the room. CMA R returned to R14's room and had R14 stand. CMA R locked the wheelchair brakes and asked R14 if she needed a new pair of slacks. R14 replied she did not know yet. R14 picked the slacks off the floor and placed them in her hands feeling all around them and then reported they were wet she would need a new pair of slacks. CNA M took the wet pair of slacks in her ungloved hands and placed them in the basket in the bathroom. CNA M then retrieved a pair of slacks from R14's dresser drawer. CNA M assisted R14 in putting on her slacks and shoes, touching both the slacks and shoes with her ungloved hands. CNA M applied a gait belt around R14's waist, assisted R14 in standing, and transferred to her wheelchair. CNA M touched R14's gait belt and the back of her shirt. CNA M then unlocked R14's wheelchair and R14 self-propelled out of the bathroom. R14 and CNA R did not wash their hands. On 04/30/26 at 10:15 AM, two shirts on hangers laid on top of a pink laundry bin outside the dirty utility room. The shirts were not transported in a sanitary manner. On 04/30/26 at 10:19 AM, CNA M verified she did not wash her hands, nor did she have R14 wash her hands. CNA M stated she should have washed her hands when entering the room after helping with incontinent cares and when leaving R14's room and stated she should have asked R14 if she wanted help with hand hygiene.On 04/30/26 at 11:00 AM, Administrative Nurse D stated staff should wash their hands before and after providing incontinent care and when touching contaminated materials. Administrative Nurse D stated the facility had containers for nebulizers to be stored in after nurses wash the nebulizer pieces. She stated that CPAP masks have a compartment in the CPAP machine that the masks are placed in after each use. She stated the nasal cannulas have bags dated that are connected either to the resident's chair, or to the residents' canisters. She stated laundry should be transported covered when it was taken to the residents' rooms. The facility's Handling of Clean Linen and Linen Distribution policy dated 06/26 documented clean laundry/bedding should be handled in a manner that prevents gross microbial contamination of the air and person handling the linen.The facility's Handwashing/Hand Hygiene dated 10/25 documented staff should be trained and regularly in-service on the importance of hand hygiene and preventing transmission of healthcare-associated infections. Staff should follow handwashing hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.The facility's Administering Medications through a Small Volume Nebulizer dated 11/25, documented staff should disassemble the parts and rinse them with hot water after each use. When the equipment is completely dry, store in a plastic bag the residents' name and date.The facility did not provide a CPAP or nasal cannula storage policy as requested on 04/30/26.

Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 28 residents who resided in the facility and received meals from the facility kitchen. Findings included:- On 04/28/26, the noon meal consisted of beef enchiladas, Spanish rice, and cheesecake. On 04/28/26 at 11:00 AM, observation revealed Dietary Staff (DS) BB was in the kitchen overseeing the preparation of the noon meal. On 04/27/26 at 07:35 AM, DS BB verified she was not a Certified Dietary Manager (CDM). DS BB stated she had enrolled and finished classes but had not taken the test. On 04/29/26 at 10:00 AM, Administrative Nurse D verified DS BB had no dietary manager certification but confirmed DS BB had enrolled in the dietary certification course though had not yet taken the test. Upon request, the facility did not provide a policy regarding a certified dietary manager.

Based on record review and interview, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ).Findings included:- The PBJ Staffing Data Report CASPER Report 1705D provided by the Centers for Medicaid and Medicare (CMS) for Fiscal Year (FY) 2026 Quarter (Q)1 documented excessively low weekend staffing.Review of the facility's actual working schedule sheets from 11/01/25 to 04/01/26 revealed the facility maintained and had the same number of staff scheduled and worked as during the week: One nurse for day shift, one nurse for evening and night shift; two to three nurse aides day shift, and two nurse aides on evening and night shift; and one medication aide on day and evening shift.The facility's Facility Assessment revised on 12/10/25, documented the specific needs of each resident in the community were identified and staffing was adjusted as needed. The facility assessment included staffing for each shift. The direct care staff was to have one licensed nurse for day shift, and one licensed nurse for evening; one medication aide on day and evenings; two to three nurse aides on day shift and two nurse aides on evening shift, and night shift; and one medication aide for day, and evening shift.On 04/21/26 at 08:06 AM, Administrative Staff A stated she was unsure why the facility showed extremely low weekend staffing on the PBJ. She stated she had worked on weekends as a nurse aide and had worked weekends as the charge nurse. Administrative Staff A stated she was not sure if her hours worked were reported in the PBJ data tracking. She also stated the facility had also had a nurse quit during the time the PBJ was showing extremely low weekend staffing.The facility's Payroll Based Journal dated 10/26 documented our community would submit payroll data in a uniform format to CMS, including staffing information for community, agency and contract staff. Direct Care Staff were defined as those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long-term care facility.

The facility identified a census of 32 residents, with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to prevent sexual abuse when Resident (R)2 used topical pain medication as lubrication and penetrated cognitively impaired resident R1 anally and vaginally. On 07/11/25 at 03:05 PM, cognitively impaired R1 reported to LN G she felt nauseated, and LN G noted R1 to be anxious. R1 stated R2 utilized topical pain medication (Voltaren) during a sexual encounter, as lubrication, R1 felt sick, and reported hurting and bleeding. LN G asked R1 to clarify if it was used in her vagina or rectum, and R1 stated vagina. R1 reported R2 had put it on himself, and then it went in. R1 was unable to provide a date or time when the incident with R2 occurred, but stated it was a couple of days ago. R1 was tearful, voiced embarrassment, reported feeling ashamed, and said she told R2 to stop, but R2 did not stop. The Social Services Staff X took R1 to the hospital, where R1 reported sexual activity and bleeding. R1 told the emergency room (ER) doctors she was penetrated anally by R2. The examination revealed a small internal hemorrhoid and excoriation of the rectal tissue. R1 stated when R2 touched her, she felt afraid, helpless, and scared. R1 continued to have uncontrolled anxiety and tearfulness, was found shaking uncontrollably in bed, and was very difficult to calm. This deficient practice placed R1 in immediate jeopardy, and other female residents at risk for sexual abuse.Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of stroke, hemiplegia (paralysis of one side of the body) affecting the left non-dominant side, hypertension (high blood pressure), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), aphasia (condition with disordered or absent language function), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of eight, which indicated moderately impaired cognition. The MDS documented R1 had no behaviors, required set-up/clean-up assistance with eating, required moderate staff assistance with bathing, and was independent with all other activities of daily living (ADL).The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/29/24, documented R1 was at risk for a decline in cognitive status. The staff oriented R1 frequently, R1 required extra time to respond to questions, and the staff were to ask simple, direct questions which were easier for R1 to answer.The Communication CAA, dated 10/29/25, documented R1 was at risk for decline in functional communication. The CAA documented R1 was able to answer simple, direct questions if given the time.The Functional Abilities CAA, dated 10/29/25, documented R1 as at risk for a decline in functional ability with ADLs. The CAA documented R1 was mostly independent with her ADLs.R1's Care Plan documented R1 had a BIMS of eight and directed staff to speak about one topic at a time and wait on her response for understanding (10/28/24). The care plan documented R1 had a diagnosis of depression and directed staff to engage R1 in conversation when she felt sad and provide emotional support (02/19/25). The care plan documented R1 had anxiety attacks and directed staff to reassure R1 when she had negative thoughts that brought her stress and anxiety (06/25/25).The Nurses Note, dated 07/10/25, documented R1 reported she had moderate (about a tablespoon) of bright red blood after having a soft stool this evening. R1 stated she strained a little bit, denied a history of bleeding or hemorrhoids, stated she did not know if the bleeding was rectal or vaginal, and denied pain or discomfort. R1 declined an emergency room visit for evaluation but agreed staff could contact her provider in the morning and schedule an office visit. R1 agreed she would notify staff of further episodes and not flush before the nurse visualized.The Social Services Note, dated 07/11/25 at 02:18 PM, documented Certified Nurse Aide (CNA) M came to Social Services Staff X's office at about 02:09 PM and reported R1 was very tearful. Social Services Staff X went to R1's room, and R1 wanted her door shut during the visit. R1 stated a male resident had her cream and told R1 she was not lubricated enough. R1 admitted to having sex with the male resident [R2]. R1 was tearful because she noticed blood coming from her rectum. The note documented R1 expressed embarrassment. Administrative Staff A asked R1 if the sexual activities were consensual or not, and R1 replied, No, I did not want to do it. R1 was calming down and weeping less and agreed to get examined by a doctor, in case her sexual activity had harmed her in any way, especially using arthritis cream [as lubrication]. Social Services Staff X transported R1 to the emergency room, where a Sexual Assault Nurse Examiner (SANE) saw R1. R1 provided the nurse with her story and claimed she was a bad girl. The SANE nurse asked R1 if the sex was consensual, and R1 replied, Yes. The SANE nurse stated the exam would not be necessary and any evidence collected would most likely not be found since the event occurred two days to a week ago. The SANE nurse stated that this may be the case due to R1 showering, changing clothes, and so on. The emergency room doctor arrived, asked R1 about her rectal bleeding, and R1 did not mention anything about her sexual activity or any possible penetration wounds. The doctor examined R1's rectal area and noted she had obvious internal hemorrhoids. The hospital treated R1with a suppository and released the resident.The Nurses Note, dated 07/11/25 at 02:40 PM, documented R1 reported she felt nauseated and like she was going to be sick. The note documented R1 appeared anxious and displayed evidence of picking at several lesions on her left hand and abdomen. R1 asked LN G to go to her art table and get that tube. LN G retrieved a tube of diclofenac 1% gel (topical pain medication). R1 asked LN G, What is that for? LN G told R1 it was a topical medication used for pain. LN G asked R1 where she got the medication, and R1 replied, [R2]. LN G told R1 the medication was usually kept on the nurse's cart. R1 stated she had felt sick ever since she used it. LN G asked R1 where she had applied the medication, and R1 was hesitant to discuss but stated, [R2] got it out of his drawer. I was in his room, and we were messing around, and I was having a problem. I am so embarrassed. LN G provided R1 emotional support. R1 told LN G, [R2] got it out of his drawer and said we can use this, indicating the diclofenac gel, for lubrication. LN G asked R1 to clarify if she meant the gel was used for lubrication. R1 answered, Yes. R1 stated, Ever since then, it has been hurting and I have been bleeding. LN G asked R1 to clarify if she meant in her rectum or her vagina, and R1 stated, vagina. R1 stated, [R2] put it on himself, and then it went in. LN G asked R1 when this occurred, and R1 said a couple of days ago. R1 was tearful and voiced embarrassment. LN G continued to provide emotional support. LN G asked R1 if she felt threatened or unsafe by R2, and R1 said, No. The emergency room Provider Note, dated 07/11/25, documented R1 presented to the emergency room with the complaint of rectal bleeding and sexual assault. R1 presented with bright red blood per the rectum and reported constipation over the last several days since consensual penile penetration to the rectum. The exam showed a small internal hemorrhoid and excoriation of the rectal tissue. The staff administered Anusol (topical steroid used to treat hemorrhoids or rectal irritation) 25 milligrams (mg) via suppository, gave discharge instructions with supportive care, and encouraged R1 to avoid further activity.The Nurses Note, dated 07/12/25, documented the nurse found R1 sobbing in her recliner. When asked what was wrong, R1 stated, I'm so upset with myself. When asked why R1 was upset with herself, R1 stated, It was something that happened with another resident. It wasn't his fault. It was mine. When asked if she was upset about her sexual encounter, R1 nodded her head. R1 stated, I am just so ashamed of myself. It should not have happened. R1 stated, I am such a weak person, and I should not have given him the opportunity.I did tell him to stop, but he didn't. Everyone thinks [R2] is pure as snow, but he is not.I can't stop my mind from running, it's going and going and going. The Nurses Note, dated 07/13/25, documented R1 continued to have uncontrolled anxiety and tearfulness regarding a sexual encounter with another resident. R1 was able to come out for the morning meal but remained tearful. R1 was found shaking uncontrollably in bed and was difficult to calm.On 07/28/25 at 09:30 AM, observation revealed R1 sat in her recliner staring out the window. The room was dark, and the TV was off. R1 was wringing her hands, breathing hard, and was tearful.On 07/28/25 at 09:30 AM, R1 stated she had been more depressed lately. R1 stated she did a bad thing and let R2 take advantage of her. R1 stated she did not want to talk about R2 or think about R2. She just wanted to forget anything ever happened. R1 stated she did not want R2 to do the things he did to her, but she was an old lady, and he was a man. She did not know what to do. R1 stated R2 was gone, and she did not have to worry about him coming into her room anymore. R1 stated she still wanted her door shut all the time because she was afraid someone else would come into her room. R1 stated when R2 touched her, she felt afraid, helpless, and scared.On 07/28/25 at 11:00 AM, Administrative Staff A stated she thought something happened between R1 and R2, but was unable to prove what happened. Administrative Staff A stated by the time the investigation started, R2 transferred to a higher-level of care hospital for heart issues, so he was unable to be interviewed by her, but the police interviewed him, and R2 denied knowing R1. Administrative Staff A stated the local police ran a background search on R2 and said if Administrative Staff A would have run that, she would not have accepted R2 into the facility because R2 had a history of abuse of women in another state. The police stated they could not charge R2 with anything because R1 told them it was consensual.On 07/28/25 at 12:15 PM, CNA M stated R1 called her into her room and asked to talk to her. R1 was crying and anxious and told her that [R2] had touched her, and she was not feeling well. CNA M stated she was not sure how to handle it, so she told the social worker. CNA M stated [R2] threw up red flags because he was able to leave the facility and get drunk, so you never knew what he was going to do.On 07/28/25 at 12:30 PM, Social Service Staff X stated she wished she had done a better job representing R1 at the emergency room. Social Services Staff X stated she did not tell the SANE nurse or the doctor R1 had cognitive deficits, and she was not sure R1 even knew what consensual meant. Social Services Staff X stated she did not know how much she should tell the SANE nurse or the doctor because she did not want to skew the findings or anything, and she is not R1's responsible party.The facility's Reporting Abuse to Facility Management, Including Sexual Consent F600 Policy, dated August 2024, documented it is the responsibility of the employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect, exploitation, or resident abuse. The community does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies, family members, legal guardians, sponsors, other residents, friends, or other individuals.On 07/28/25 at 03:15 PM, Administrative Staff A was provided the IJ template and notified of the facility's failure to ensure R1 was protected from sexual abuse, which placed R1 in immediate jeopardy.The facility identified and implemented immediate corrective actions, which were completed on 07/17/25 and included: R2 was placed on 1:1 on 07/11/25 at 03:00 PM and has since been discharged .All staff were re-educated on Abuse, Neglect, and Exploitation (ANE) after the incident, completed 07/17/25. The social worker will meet with R1 weekly for 4 weeks. The facility interviewed alert and oriented female residents regarding safety.Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at a J scope and severity.

The facility had a census of 25 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 25 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 10/01/24 at 10:30 AM, a review of the noon meal consisted of meatloaf, garlic mashed potatoes, dinner roll, lemon pudding, and California medley vegetables. On 10/01/24 at 11:30 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 09/30/24 at 08:39 AM, Dietary Staff BB verified he was not a certified dietary manager. Dietary Staff BB stated he had started taking the classes. On 10/02/24 at 11:00 PM, Administrative Nurse D verified Dietary Staff BB had no dietary manager certification. The facility's Food Service Staffing Policy, revised 10/23, documented a qualified dietitian would help oversee clinical nutritional services to the residents. If a destination was not full time the facility would employ another qualified nutritional professional to serve as the dietary manager. This person must meet one of the following qualifications: a. certified dietary manager b. certified food service manager cl had a similar certification in food service management from a national certifying body d. had an associate's or higher degree in food services management or hospitality if the course study included food service or restaurant management from an accredited institution of higher learning. E. had two or more years of experience in the position of dietary manager in a nursing facility setting and had completed a course of study in food safety and management topics integral to managing dietary operations including, but not limited to foodborne illness, sanitation procedures, and food purchasing, receiving and met the states established standards if applicable. The facility failed to employ a full-time certified dietary manager for 25 residents who resided in the facility and received meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.

The facility had a census of 25 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections when staff failed to implement laundry practices to eliminate infectious pathogens. This placed the residents at risk of obtaining an infection or communicable disease. Findings included: - On 10/02/24 at 10:27 AM, observation in the laundry room lacked evidence the staff monitored the washing machine water temperatures. On 10/02/24 at 10:27 AM, Housekeeping Staff (HS) U stated the facility had high-temperature washing machines, and the laundry staff did not check or record the hot water temperatures of the washing machines. She said maintenance was responsible for ensuring the hot water temperature for the washing machines was high enough. HS U stated residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) clothing and bedding were washed with the other residents' laundry as well. On 10/02/24 at 11:45 AM, Administrative Nurse D stated laundry or maintenance staff should be checking and recording the hot water temperatures for all laundry daily. On 10/02/24 at 10:30 AM, Maintenance Staff (MS) V stated he did not check the washing machine's hot water temperatures, he only checked hot water in areas in which he was monitoring for waterborne pathogens. The facility's Laundry and Bedding, Soiled Policy, revised 09/2023, instructed staff to handle all laundry as contaminated, and place and transport contaminated laundry in a bag or container at the location where it is used. The policy documented the recommendations for laundry cycles are per manufacturer guidelines and the following: hot water should be at 160 degrees Fahrenheit(F) for 25 minutes, low-temperature washing machines' hot water temperature should be 71-77 degrees F plus 125 parts per million (PPM) chlorine bleach rinse. The facility failed to provide a sanitary environment when staff failed to ensure washing machine temperatures were maintained in order to kill infectious pathogens. This placed the resident at risk of obtaining an infection or communicable disease.

The facility had a census of 25 residents. The sample included 13 residents, with four reviewed for hospitalization . Based on observation, record review, and interview, the facility failed to provide written notice for a facility-initiated transfer for Resident (R) 16, R24, R4, and R26 or their representatives when they were transferred to the hospital. The facility also failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities) of R16, R24, R4, and R26's discharge. This placed the residents at risk for uninformed care choices and impaired rights. Findings included: - R16's Electronic Medical Record (EMR) documented R16 had diagnoses of atrial fibrillation (rapid, irregular heartbeat), diastolic heart failure (the left heart ventricle doesn't relax properly between heartbeats), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and pleural effusion (abnormal accumulation of fluid in the lungs). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had moderately impaired cognition and was dependent upon staff for lower body dressing, toileting, and showers. R16 required substantial assistance with personal hygiene, upper body dressing, and transfers. R16 required supervision with ambulation. The Significant Change MDS, dated [DATE], documented R16 had moderately impaired cognition and required substantial assistance from staff for showers, lower body dressing, personal hygiene, transfers, and ambulation was not attempted. R16 required set-up assistance with eating. R16's Care Plan, dated 09/17/24 and initiated on 01/27/21, directed staff to administer medications as ordered, monitor for signs and symptoms of respiratory distress, monitor for edema (swelling), and administer oxygen continuously via nasal cannula (a medical device that provides supplemental oxygen) as ordered. R16's Progress Notes, dated 08/28/24 at 03:39 AM documented R16 was transferred to the hospital. R16's clinical record lacked evidence the resident or representative was provided written notice, or the ombudsman was notified of the hospital transfer. On 09/30/24 at 10:49 AM, observation revealed R16 sat in her recliner in her room. Her eyes were closed and she had her oxygen on. On 10/01/24 at 10:00 AM, Administrative Nurse D verified the LTCO had not been notified when R16 went to the hospital on the above date and verified no written notice was provided to R16 or her representative. Administrative Nurse D stated the social service designee was responsible for notifying the LTCO. On 10/02/24 at 01:41 PM, Social Service X verified she had not provided R16 or her representative with written notice when R16 was transferred to the hospital and stated she was unaware she was supposed to. The facility's Transfer and/or Discharge policy, dated 10/22, documented the resident and/or representative would be provided with a notice in writing, the reason for the transfer or discharge, and a copy would be sent to the State Long Term Care Ombudsman. The facility failed to provide R16 or her representative written notice regarding R16's facility-initiated transfer to the hospital and also failed to notify the LTCO. This placed R16 at risk of uninformed care choices and impaired rights. - R24's Electronic Medical Record (EMR) documented diagnoses of fracture (cracked or broken) of the patella (kneecap), unsteadiness on feet, fracture of the femur (the bone of the thigh or upper hind limb articulating at the hip and the knee). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R24 had severely impaired cognition. R24 required extensive assistance of one staff for dressing, and supervision with bed mobility, toileting, and transfers. R24 had no upper or lower extremity impairment. The Quarterly MDS, dated [DATE], documented R24 had severely impaired cognition. She required partial assistance with toileting and ambulation, and set-up assistance with eating, mobility, and personal hygiene. R24 had lower functional impairment on one side. R24's Care Plan, dated 09/24/24 and initiated on 01/09/23, documented R24 lacked safety awareness and had a history of falls. The update, dated 12/30/22, directed staff to educate the resident and family about safety reminders and what to do if a fall occurs. The plan directed staff to determine the possible root cause of the falls and alter or remove any potential causes of the falls if possible. R24's Progress Notes, dated 12/03/24 at 03:50 PM, documented R24 was transferred to the hospital. R24's clinical record lacked evidence the resident or representative was provided written notice, or the ombudsman was notified of the hospital transfer. On 10/01/24 at 11:18 AM, observation revealed Certified Nurse Aide (CNA) N placed a gait belt around the resident's waist. R24 stood up, pivoted, and sat down in the wheelchair. On 10/02/24 at 01:41 PM, Social Service X verified she had not provided R24 or her representative with written notice when R24 was transferred to the hospital and stated she was unaware she was supposed to. The facility's Transfer and/or Discharge policy, dated 10/22, documented the resident and/or representative would be provided with a notice in writing, the reason for the transfer or discharge, and a copy would be sent to the State Long Term Care Ombudsman. The facility failed to provide R24 or her representative written notice regarding R24's facility-initiated transfer to the hospital and failed to notify the LTCO. This placed R24 at risk of uninformed care choices and impaired rights. 32358 - R4's Electronic Medical Record (EMR) documented that R4 had diagnoses of chest pain and bradycardia (heart rate less than 60 beats per minute). R4's Quarterly Minimum Data Set (MDS), 06/23/24, documented R4 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented the resident had chest pain. R4's Care Plan, revised 09/24/24, documented R4 occasionally complained of chest pain. R4 had a loop recorder (a small device implanted underneath the skin of your chest that records your heart's rate and rhythm) in her mid-chest area. The care plan instructed staff to keep the area clean and dry until healed, observe for any signs or symptoms of infection, administer R4 oxygen as ordered by the physician, and impress upon the resident the importance of letting staff know when her chest pain first began, monitor vital signs during reported chest pain episodes (at least every five minutes), and monitor and document R4's lung fields; report to the physician any abnormal findings. The care plan instructed staff to document the description of R4's chest pain. The Progress Note, dated 01/18/24 at 11:35 AM documented R4 had been admitted to hospital on 01/17/24. The Progress Note, dated 02/01/2024 at 08:46 PM documented R4 had been admitted to the hospital. A review of R4's clinical record lacked evidence the resident or representative was provided written notice when she was transferred to the hospital or of notification to the LTCO of R4's discharge. On 09/30/24 at 02:58 PM, observation revealed R4 sat in a recliner in her room with her feet up on a footrest, reading a book. On 10/01/24 at 10:00 AM, Administrative Nurse D verified that the staff had not provided R4 or her representative with written notice of the transfer/discharge and did not notify the LTCO when R4 was admitted to the hospital. Administrative Nurse D stated Social Service X was responsible for the notifications. On 10/02/24 at 01:41 PM, Social Service X verified she had not provided R4 or her representative nor the LTCO with written notice when R4 was admitted to the hospital. Social Service X said she was unaware she was supposed to. The facility's Transfer and /or Discharge, Including Against Medical Advice (AMA) Policy, revised 10/22, documented that if a resident was transferred emergent to a hospital, the resident or representative would be provided, in writing and language they understood, the reason for the transfer or discharge and the facility would send a copy of the notice to the state LTCO. The facility failed to provide R4 or his representative written notice regarding R4's facility-initiated transfer to the hospital and further failed to notify the LTCO. This placed the resident and/or her representative at risk of uninformed care choices and impaired rights. - R26's Electronic Medical Record (EMR) documented that R26 had a diagnosis of constipation. R26's Medicare Five-Day Minimum Data Set (MDS), dated [DATE], documented that R26 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented that R26 was independent with most activities of daily living (ADLs). R26's Care Plan, revised 10/01/24, documented R26 required one staff assistance with toileting at times; when he was up in a wheelchair, he was continent of bowel and bladder, and when in bed he was incontinent at times. The Progress Note, dated 07/11/24 at 09:10 PM documented that R26 was admitted to the hospital. R26's clinical record lacked evidence the resident or representative was provided a written notice when he was transferred to the hospital or notification to the LTCO of R26's discharge. On 09/30/24 at 03:07 PM, observation revealed R26 sat on the edge of his bed with his eyes open. On 10/01/24 at 10:00 AM, Administrative Nurse D verified that the staff had not provided R26 or his representative nor the LTCO with written notice when R26 was admitted to the hospital. Administrative Nurse D stated Social Service X was responsible for notifying them. On 10/02/24 at 01:41 PM, Social Service X verified she had not provided R26 or her representative with written notice and had not notified the LTCO when R26 was admitted to the hospital. Social Service X stated she was unaware she was supposed to. The facility's Transfer and /or Discharge, Including Against Medical Advice (AMA) Policy, revised 10/22, documented that if a resident was transferred emergent to a hospital, the resident or representative would be provided, in writing and language they understood, the reason for the transfer or discharge and the facility would send a copy of the notice to the state LTCO. The facility failed to provide R26 or his representative written notice regarding R26's facility-initiated transfer to the hospital and further failed to notify the LTCO. This placed the resident and/or her representative at risk of uninformed care choices and impaired rights.

The facility had a census of 25 residents. The sample included 13 residents, with six reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate indication, or a documented physician rationale, which included unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of Resident (R) 19's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) and failed to ensure a 14-day stop date or specified duration for R19, R7 and R23s' ongoing as needed (PRN) antianxiety (a class of medications that calm an relax people with excessive anxiety, nervousness, or tension). This placed the residents at risk for unintended effects related to psychotropic (alters mood or thought) medications. Findings included: - R19's Electronic Medical Record (EMR) had diagnoses of dementia with other behavioral disturbances (a progressive mental disorder characterized by failing memory, confusion), anxiety (cognitive or emotional reaction characterized by apprehension uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). The Admission Minimum Data Set (MDS), dated [DATE], documented R19 had severely impaired cognition. R19 was dependent upon staff for eating, toileting, mobility, and transfers, and required substantial assistance for personal hygiene. R19 had inattention, disorganized thinking that fluctuates, verbal behaviors, and rejection of care daily. The MDS documented that R19 received antipsychotics, antidepressants (a class of medications used to treat mood disorders), and anti-anxiety medications. The Quarterly MDS, dated [DATE], documented R19 had severely impaired cognition and was dependent upon staff for toileting, mobility, showers, dressing, personal hygiene, and transfers. R19 had inattention, disorganized thinking that fluctuates, verbal behaviors, and rejection of care daily. The MDS documented that R19 received antipsychotic, antidepressant, antianxiety, and opioid (a class of controlled drugs used to treat pain) medication. R19's Care Plan, dated 08/25/24 and initiated on 04/01/24, directed staff to administer medications as ordered, monitor and document side effects, and monitor occurrences for target behaviors. The plan directed staff to ask one question at a time and wait for his response, contact his spouse for all medical changes, and minimize distractions while speaking to him. The Physician's Order, dated 03/28/24, directed staff to administer Seroquel (an antipsychotic medication), 125 milligrams (mg), once daily, for hallucinations. The Physician's Order, dated 06/01/24, directed staff to administer lorazepam (an antianxiety medication), 0.25 milliliters (ml), by mouth, every hour, as needed for anxiety. The order lacked a stop date. R19's EMR lacked a documented physical rationale which included unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued Seroquel. On 10/01/24 at 08:05 AM, observation revealed R19 sat at the dining table with staff present and he would periodically yell out Nurse, Nurse. On 10/01/24 at 09:45 AM, the Certified Nurse Aide (CNA) M stated R19 typically yelled out whether staff was with him or not and she notified the nurse when he did that. On 10/02/24 at 11:21 AM, Licensed Nurse (LN) G stated R19 did holler out and received PRN medication as well as he was offered whether to get up out of bed, a snack, or toileting. LN G further stated she was aware of the 14-day stop date for the PRN lorazepam but R19's physician would not put a stop date on the order. On 10/02/24 at 11:44 AM, Administrative Nurse D stated R19's physician would not put a stop date on the PRN lorazepam and was aware it was required but was unaware of the need for risk versus benefit or the indications for the use of an antipsychotic medication with a dementia diagnosis. Administrative Nurse D further stated the Consultant Pharmacist had not documented the lack of the stop date in the monthly reviews. The facility's Psychotropic Drug Use policy, dated 04/24, documented that residents would only receive antipsychotic and psychotropic medications when necessary to treat specific conditions for which they are indicated and effective and would not be used for discipline or convenience of the staff. Limit PRN orders for antidepressants hypnotics, and antianxiety medications to 14 days. This may be extended beyond the 14 days through documentation in the medical record by the practitioner as to why this should occur. The facility failed to ensure R19's lorazepam had a 14-day stop date or specified duration and failed to ensure R19 did not receive antipsychotic medication without an appropriate indication or required documentation for its use. This placed the resident at risk for adverse side effects. - The Electronic Medical Record (EMR) for R7's documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness), adjustment disorder with mixed anxiety (an extreme emotional or behavioral reaction within three months of a stressful or monumental life event), and pain. The Admission Minimum Data Set (MDS), dated [DATE], documented R7 had moderately impaired cognition and was dependent upon staff for eating, mobility, transfers, toileting, and showers. R7 had two to six days of depressed mood and received antidepressant (a class of medications used to treat mood disorders), opioid (a class of controlled drugs used to treat pain), antibiotic (a medicine that inhibits the growth of or destroys microorganisms), and anticoagulant (a class of medications sued to prevent the blood from clotting) medication for seven days. R7's Care Plan, dated 07/30/24 and initiated on 07/07/24, directed staff to allow R7 to voice her fears and concerns, administer medications as ordered, and monitor for side effects and behaviors. The Physician's Order, dated 07/19/24, directed staff to administer lorazepam (an antianxiety medication), 0.25 cubic centimeter (cc), every hour, prn, for anxiety and restlessness. The order lacked a stop date. On 10/01/24 at 08:30 AM, observation revealed R7 in her bed. She received her medication as ordered and without any issues. On 10/01/24 at 09:45 AM, Certified Nurse Aide (CNA) M stated R7 did not have any behaviors but used to; she mainly stayed in her room. On 10/02/24 at 11:21 AM, Licensed Nurse (LN) G stated R7 had periods of delusions (a false belief or judgment about external reality) but otherwise she had no behaviors. LN G further stated she was aware of the 14-day stop date for the PRN lorazepam but R7's physician would not put a stop date on the order. On 10/02/24 at 11:44 AM, Administrative Nurse D stated R7's physician would not put a stop date on the PRN lorazepam and was aware it was required. Administrative Nurse D further stated the Consultant Pharmacist had not documented the lack of the stop date in the monthly reviews. The facility's Psychotropic Drug Use policy, dated 04/24, documented that residents would only receive antipsychotic and psychotropic medications when necessary to treat specific conditions for which they are indicated and effective and would not be used for discipline or convenience of the staff. Limit prn orders for antidepressants hypnotics, and antianxiety medications to 14 days. This may be extended beyond the 14 days through documentation in the medical record by the practitioner as to why this should occur. The facility failed to ensure R7's lorazepam had a 14-day stop date or specified duration. This placed the resident at risk for adverse side effects. 32358 - R23's Electronic Medical Record (EMR) documented that R23 had a diagnosis of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R23's Significant Change Minimum Data Set (MDS), dated [DATE], documented R23 had short and long-term memory problems and severely impaired cognition. The MDS documented that R23 received an antianxiety (a class of medications that calm and relax people) medication during the observation period. R23's Care Plan, revised 09/23/24, instructed staff to provide physical and verbal cues to alleviate anxiety; give positive feedback, assist in verbalization of the source of agitation, and assist in setting goals for more pleasant behavior. The plan directed staff to encourage seeking out of staff members when agitated. The care plan instructed staff to intervene before R23's agitation escalated, guide him away from the source of distress, and engage R23 calmly in conversation or activity. The Physician Order, dated 02/04/23 at 09:57 PM instructed staff to administer Ativan (lorazepam-medication used to treat anxiety) oral concentrate two milligrams (mg)/milliliter (ml) give 0.25 ml orally every hour PRN or give 0.5 ml orally every hour PRN or give 0.75 ml orally every hour PRN or give one ml orally every hour as needed for anxiety with a stop date of indefinitely. On 07/10/24 at 10:00 AM, Administrative Nurse D verified the R23's PRN Ativan did not have a stop date and it should have one. Administrative Nurse D stated the facility staff were having a hard time getting the physician to place a stop date. The facility's Psychotropic Drug Use Policy, revised 04/24, documented the facility would limit PRN orders for antianxiety drugs to 14 days through documentation in the medical record by the practitioner as to why this should occur. The facility failed to ensure R23's physician order for PRN Ativan had a stop date. This placed the resident at risk for unnecessary psychotropic medications.

The facility had a census of 25 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to provide a nourishing, well-balanced diet for one resident who received a pureed diet. This placed the resident at risk for impaired nutrition. Findings included: - On 10/01/24 at 11:50 AM Dietary Staff (DS) CC reported the facility had one resident who received a pureed diet. DS CC placed one 4-ounce (oz) slice of meatloaf in a blender with 2.5 teaspoons (tsp.) of beef broth and blended to the consistency of mashed potatoes. DS CC transferred the meatloaf to a bowl using a spatula. DS CC retrieved a new small blender container and placed two 4-oz scoops of mixed vegetables into the blender, added 2.5 tsp. of liquid from the mixed vegetables, and blended to the consistency of mashed potatoes, then transferred the mixed vegetables into a small bowl. DS CC stated the resident would receive mashed potatoes and lemon pudding. When asked how the resident would receive his bread, DS CC stated she does not prepare pureed bread for the resident. On 10/01/24 at 12:30 PM, DS BB stated normally staff tried to fill in the pureed food item from the grain group with another item. DS CC went on to say it had been an active day, and staff thought that the resident would not eat the pureed bread due to it being soggy, so it was not prepared and offered. The facility's Therapeutic Diets Policy, revised 10/2023, documented those residents on therapeutic diets would not receive extra or reduced portions or modifications that are not part of the diet unless approved by the physician in conjunction with the clinical dietician. The facility failed to provide a nourishing, well-balanced diet to one resident who received a pureed diet. This placed the resident at risk for impaired nutrition.

The facility had a census of 25 residents. The sample included 13 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the inappropriate indication for Seroquel (an antipsychotic medication) for Resident (R)19 and failed to identify and report the lack of a stop date for R19, R7 and R23's as needed (PRN) lorazepam (an antianxiety medication). This placed the residents at risk for unnecessary psychotropic medication side effects. Findings included: - R19's Electronic Medical Record (EMR) had diagnoses of dementia with other behavioral disturbances (a progressive mental disorder characterized by failing memory, confusion), anxiety (cognitive or emotional reaction characterized by apprehension uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). The Admission Minimum Data Set (MDS), dated [DATE], documented R19 had severely impaired cognition. R19 was dependent upon staff for eating, toileting, mobility, and transfers, and required substantial assistance for personal hygiene. R19 had inattention, disorganized thinking that fluctuates, verbal behaviors, and rejection of care daily. The MDS documented that R19 received antipsychotics, antidepressants (a class of medications used to treat mood disorders), and anti-anxiety medications. The Quarterly MDS, dated [DATE], documented R19 had severely impaired cognition and was dependent upon staff for toileting, mobility, showers, dressing, personal hygiene, and transfers. R19 had inattention, disorganized thinking that fluctuates, verbal behaviors, and rejection of care daily. The MDS documented that R19 received antipsychotic, antidepressant, antianxiety, and opioid (a class of controlled drugs used to treat pain) medication. R19's Care Plan, dated 08/25/24 and initiated on 04/01/24, directed staff to administer medications as ordered, monitor and document side effects, and monitor occurrences for target behaviors. The plan directed staff to ask one question at a time and wait for his response, contact his spouse for all medical changes, and minimize distractions while speaking to him. The Physician's Order, dated 03/28/24, directed staff to administer Seroquel (an antipsychotic medication), 125 milligrams (mg), once daily, for hallucinations. The Physician's Order, dated 06/01/24, directed staff to administer lorazepam (an antianxiety medication), 0.25 milliliters (ml), by mouth, every hour, as needed for anxiety. The order lacked a stop date. R19's EMR lacked a documented physical rationale which included unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued Seroquel. The Drug Regimen Review, dated 5/06/24, 07/04/24, 08/06/24, and 09/10/24 failed to address the as-needed lorazepam. The drug regimen review for 06/06/24 documented R19 was on as-needed lorazepam and had no stop date with a response from the physician that R19 was on hospice care services (medical care for people with an anticipated life expectancy of 6 months or less). The EMR lacked further documentation regarding a stop date for R19's as-needed lorazepam. On 10/01/24 at 08:05 AM, observation revealed R19 sat at the dining table with staff present and he would periodically yell out Nurse, Nurse. On 10/01/24 at 09:45 AM, the Certified Nurse Aide (CNA) stated R19 typically yelled out whether staff was with him or not and she notified the nurse when he did that. On 10/02/24 at 11:21 AM, Licensed Nurse (LN) G stated R19 did holler out and received PRN medication as well as he was offered whether to get up out of bed, a snack, or toileting. LN G further stated she was aware of the 14-day stop date for the PRN lorazepam but R19's physician would not put a stop date on the order. On 10/02/24 at 11:44 AM, Administrative Nurse D stated R19's physician would not put a stop date on the PRN lorazepam and was aware it was required but was unaware of the need for risk versus benefit or the indications for the use of an antipsychotic medication with a dementia diagnosis. Administrative Nurse D further stated the Consultant Pharmacist had not documented the lack of the stop date in the monthly reviews. Upon request a policy for Drug Regimen Review was not provided by the facility, The facility failed to ensure the Consultant Pharmacist identified and reported the lack of a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of antipsychotic medication and failed to identify and report the continued use of as needed lorazepam without a stop-date. This placed the resident at risk for unnecessary psychotropic medication side effects. - The Electronic Medical Record (EMR) for R7's documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness), adjustment disorder with mixed anxiety (an extreme emotional or behavioral reaction within three months of a stressful or monumental life event), and pain. The Admission Minimum Data Set (MDS), dated [DATE], documented R7 had moderately impaired cognition and was dependent upon staff for eating, mobility, transfers, toileting, and showers. R7 had two to six days of depressed mood and received antidepressant (a class of medications used to treat mood disorders), opioid (a class of controlled drugs used to treat pain), antibiotic (a medicine that inhibits the growth of or destroys microorganisms), and anticoagulant (a class of medications sued to prevent the blood from clotting) medication for seven days. R7's Care Plan, dated 07/30/24 and initiated on 07/07/24, directed staff to allow R7 to voice her fears and concerns, administer medications as ordered, and monitor for side effects and behaviors. The Physician's Order, dated 07/19/24, directed staff to administer lorazepam (an antianxiety medication), 0.25 cubic centimeter (cc), every hour PRN for anxiety and restlessness. The order lacked a stop date. The Drug Regimen Review, dated 07/04/24, 08/06/24, and 09/10/24 failed to address the PRN lorazepam. On 10/01/24 at 08:30 AM, observation revealed R7 in her bed. She received her medication as ordered and without any issues. On 10/01/24 at 09:45 AM, Certified Nurse Aide (CNA) M stated R7 did not have any behaviors but used to; she mainly stayed in her room. On 10/02/24 at 11:21 AM, Licensed Nurse (LN) G stated R7 had periods of delusions (a false belief or judgment about external reality) but otherwise she had no behaviors. LN G further stated she was aware of the 14-day stop date for the PRN lorazepam but R7's physician would not put a stop date on the order. On 10/02/24 at 11:44 AM, Administrative Nurse D stated R7's physician would not put a stop date on the PRN lorazepam and was aware it was required. Administrative Nurse D further stated the Consultant Pharmacist had not documented the lack of the stop date in the monthly reviews. Upon request a policy for Drug Regimen Review was not provided by the facility, The facility failed to ensure the Consultant Pharmacist identified and reported the lack of a stop date for R7's PRN lorazepam. This placed the resident at risk for inappropriate use of as-needed antianxiety medication. 32358 - R23's Electronic Medical Record (EMR) documented R23 had a diagnosis of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R23's Significant Change Minimum Data Set (MDS), dated [DATE], documented R23 had short and long-term memory problems and severely impaired cognition. The MDS documented that R23 received an antianxiety (a class of medications that calm and relax people) medication during the observation period. R23's Care Plan, revised 09/23/24, instructed staff to provide physical and verbal cues to alleviate anxiety; give positive feedback, assist in verbalization of the source of agitation, and assist in setting goals for more pleasant behavior. The plan directed staff to encourage seeking out of staff members when agitated. The care plan instructed staff to intervene before R23's agitation escalated, guide him away from the source of distress, and engage R23 calmly in conversation or activity. The Physician Order, dated 02/04/23 at 09:57 PM instructed staff to administer Ativan (lorazepam-medication used to treat anxiety) oral concentrate two milligrams (mg)/milliliter (ml) give 0.25 ml orally every hour PRN or give 0.5 ml orally every hour PRN or give 0.75 ml orally every hour PRN or give one ml orally every hour as needed for anxiety with a stop date of indefinitely. The Consultant Pharmacist (CP) Regimen Review from 05/01/24 to 09/30/24 lacked evidence the CP identified and reported that R23's PRN Ativan order lacked a stop date or specified duration with a documented physician rationale for the extended use. On 07/10/24 at 10:00 AM, Administrative Nurse D verified the CP had not alerted the facility of the lack of a stop date for R23's PRN Ativan. Upon request, the facility did not provide a policy regarding CP regimen review. The facility failed to ensure the CP identified and reported R23's PRN Ativan lacked a stop date or specified duration. This placed the resident at risk for unnecessary medication side effects.

The facility had a census of 25 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with instruction to staff on providing interventions for the prevention of constipation (difficulty passing stools) for one resident, Resident (R) 26, who had a history of constipation and had been admitted to hospital for constipation. This placed R26 at risk for impaired care due to uncommunicated care needs. Findings included: - R26's Electronic Medical Record (EMR) documented that R26 had a diagnosis of constipation. R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R26 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented the resident was independent with most activities of daily living (ADLs). The MDS documented R26 was frequently incontinent of bowel. R26's Care Plan, revised 10/01/24, documented that R26 required one staff assistance with toileting at times; when he was up in a wheelchair, he was continent of bowel and bladder, and when in bed he was incontinent at times. The care plan lacked a section regarding interventions to avoid constipation. The Progress Note, dated 07/06/24 at 09:34 AM, documented that R26 had difficulty having a bowel movement (BM) and had a long history of constipation. The note documented R26 requested he be administered Colace (stool softener). The Progress Note, dated 07/11/24 at 02:45 PM, documented R26 did not participate in therapy that day because he had severe constipation. The note documented R26 endorsed extreme straining when attempting to have a BM and had small bright blood from the rectum. Staff administered a Fleets enema (procedure of inserting liquid directly into the rectum to induce a BM). The Progress Note, dated 07/13/2024 at 11:55 AM, documented R26 was admitted to the hospital for constipation and hypotension (low blood pressure). On 09/30/24 at 03:07 PM, observation revealed R26 sat on the edge of the bed with eyes open. On 10/02/24 at 10:18 AM, Administrative Nurse E verified R26's Care Plan lacked information with interventions for staff to implement for R26 to help him avoid constipation. On 10/02/24 at 11:45 AM, Administrative Nurse D verified R26's Care Plan lacked information with interventions for staff to implement for R26 to help him avoid constipation. The facility's Comprehensive Care Plans Policy, revised 08/24, documented the facility would provide a comprehensive centered care plan that included measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural, and psychological (the most basic things that everyone needs to survive) needs would be developed for each resident. The facility failed to develop a comprehensive care plan for R26 with instructions to staff on interventions to provide him to avoid constipation. This placed R26 at risk for impaired care due to uncommunicated care needs.

The facility identified a census of 31 residents with three residents reviewed for medication errors. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free of significant medication errors. On 02/12/24 R1 returned to the facility from a cardiology appointment with a new order for metolazone, a diuretic (medication to promote the formation and excretion of urine), 2.5 milligrams (mg) that day, and another dose on 02/14/24. Licensed Nurse (LN) G incorrectly read the order as 25 mg and instructed LN H to administer five of R1's 5 mg metolazone from his PRN (as needed) stock. When the pharmacy delivered the medication to the facility a few hours later, LN G saw the dose was 2.5 mg. LN G called R1's cardiologist and received orders to monitor R1 for depleted fluid volume and to obtain a basic metabolic panel (BMP-laboratory blood test) the next day. On 02/13/24, R1's BMP showed R1's potassium level was critically low at 2.6 millimoles per liter (mmol/L) (normal range is 3.5 to 5.2 mmol/L). R1 admitted to the hospital and received intravenous fluids and potassium. R1's potassium remained critically low through 02/14/24 and low through 02/19/24 when he returned to the facility on oral potassium supplements. The facility's failure to ensure R1 remained free from significant medication errors resulted in R1 receiving ten times the ordered dose of metolazone which placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and chronic kidney disease. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of fourteen which indicated intact cognition. The MDS documented R1 had shortness of breath at rest, with exertion, and while lying flat. The MDS documented R1 was on oxygen. The MDS documented R1 required substantial or maximal assistance with toileting, and partial or moderate assistance with bathing and lower body dressing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/16/23, documented R1 was at risk for cognitive loss and had disorganized thinking. Staff frequently oriented R1 to the date, time, and events. The CAA documented R1's head of bed was elevated due to difficulty breathing when lying flat. The Activities of Daily Living (ADL) Functional Rehabilitation Potential CAA, dated 06/16/23, documented R1 was at risk for decline in his functional ability with ADL. The CAA documented R1 required one staff assistance with most of his ADL, R1 was able to make his needs known, and he used the call light for assistance. R1's Care Plan, dated 06/12/23, directed staff to administer R1's medications as ordered. The plan directed staff to elevate R1's head of the bed to prevent shortness of breath while lying flat. The plan directed staff to administer R1 oxygen as ordered by his physician. Staff were directed to monitor R1 for difficulty breathing, signs and symptoms of respiratory insufficiency, and anxiety. The Progress Note, dated 02/12/24 at 11:25 AM, documented R1 had an appointment with his cardiologist and new orders were received for metolazone 25 mg on Monday 02/12/24 and Wednesday 02/14/24. The facility was ordered to check R1's labs and call the cardiologist with the results on Thursday or Friday. R1's February 2024 Medication Administration Record (MAR) documented R1 received 25 mg of metolazone on 02/12/24. R1's Laboratory Report, dated 02/12/24, documented R1's potassium level was 3.9 mmol/L. The Progress Note, dated 02/12/24 at 12:45 PM, documented the facility received R1's metolazone from the pharmacy. The pharmacy sent metolazone 2.5 mg, but R1 had already received metolazone 25 mg. LN G called R1's cardiologist's nurse and left a message about the 25 mg dose staff administered to R1. The Progress Note, dated 02/12/24 at 12:52 PM, documented R1's cardiologist nurse called the facility with orders from R1's cardiologist to watch R1. R1 should have some urine output getting the fluid off. The office nurse directed if R1 started showing signs of depleted fluid volume the facility staff should contact R1's primary care physician. R1's cardiologist ordered a BMP to be drawn on Tuesday 02/13/24, and Wednesday 02/15/24. The facility was ordered not to give R1 2.5 mg of metolazone on Wednesday. The Progress Note, dated 02/13/24 at 11:08 AM, documented a BMP was obtained from R1 and sent to the lab. The Progress Note, dated 02/13/24 at 12:14 PM, documented the medication error occurred as a result of poor penmanship by the provider and staff not seeing the warning when entering the order into the EMR. The Progress Note, dated 02/13/24 at 02:04 PM, documented R1's primary care physician requested the facility send R1 to the emergency department due to R1's critically low potassium at 2.6 mmol/L. LN G's 02/14/24 Witness Statement documented on Monday, 02/12/24, R1 had a cardiologist appointment at 09:00 AM. R1 returned from his appointment with an orange piece of paper with handwritten orders. LN G read the order as metolazone 25 mg on Monday and Wednesday and to check labs and call the cardiologist's office with the results on Thursday or Friday morning. LN G called R1's responsible party to notify her of the new order. R1's responsible party stated she talked with R1's cardiologist and knew R1 would be getting extra water pills because R1 had lots of extra fluid he needed to get rid of. LN G then showed LN H the orders and LN H commented on the large dose. LN G told LN H R1's responsible party said R1 had a lot of fluid to get rid of. LN G then put the order into the computer EMR to be administered now and again on Wednesday. LN G asked LN H to pull five pills of R1's PRN 5 mg metolazone to equal 25 mg. R1 received the 25 mg of metolazone before noon. LN G stated at about 12:30 PM, the pharmacy delivered a bubble pack of metolazone 2.5 mg with directions to give 2.5 mg on Monday and Wednesday. LN G showed LN H the directions on the bubble pack and proceeded to call R1's cardiologist. R1's cardiologist's nurse answered, and LN G notified her the wrong dose was administered to R1. The cardiologist's nurse told LN G to monitor R1 and if he started showing signs of low fluid volume then R1 would need to go to the emergency department for fluids and to call R1's primary care physician with any other concerns over the next few days. Within two minutes R1's cardiologist's nurse called LN G with orders to not give R1 the metolazone 2.5 mg on Wednesday, and to draw a BMP on Tuesday and Wednesday. The cardiologist's nurse told LN G to monitor R1 for intolerance as the fluid may come off too quickly and if R1 had problems, he would have to go to the emergency department for fluids to replenish his electrolytes. LN G called R1's responsible party and told her the facility would monitor R1 for low fluid volume or signs he was not handling it well. LN H's Witness Statement, dated 02/14/24, documented on Monday, 02/12/24, R1 went to an appointment and upon return, LN G showed LN H the new orders. Upon reading the orders, LN H told LN G the dose was high, and said the physician must be trying to get that fluid off. LN G told LN H R1 had a lot of fluid. LN H told LN G she would have to wait until the pharmacy delivered the medication. LN G told LN H that R1 had PRN metolazone 5 mg. LN G said she would put in the orders and then LN H could get R1 his medication and not have to wait. LN G put the order in the EMR. LN H pulled up the MAR and it directed to give R1 five tablets of 5 mg metolazone. LN H gave R1 the medication as ordered. Later towards the end of LN H's shift, the pharmacy delivered R1's medication. LN G received the medication and the orders read to give R1 2.5 mg of metolazone. The updated Root Cause Analysis, documented the problem was R1 received the wrong dose of medication. The reason for the wrong dose administration was LN G read the order incorrectly, LN G did not use the template in the EMR to enter the order and did not pay attention to the alert from the EMR. LN H, who gave the medication, did not see the alert indicating a dose warning. LN G and LN H did not realize the dose was greater than what was acceptable, and LN G and LN H pulled the medication from R1's PRN dose instead of waiting for the medication to come from the pharmacy. The Progress Note, dated 02/16/24 at 06:45 PM, documented R1 readmitted to the facility post-hospitalization for low potassium. The Hospital Discharge Summary, dated 02/16/24, documented R1 admitted to the hospital for low potassium on 02/13/24 after nursing staff accidentally gave R1 metolazone 25 mg after his cardiologist ordered metolazone 2.5 mg. R1's BMP on 02/13/24 showed a potassium level of 2.6 mmol/L. R1 admitted to the hospital and received two liters of normal saline with 20 milliequivalents (mEq) of potassium. On 02/14/24 R1's potassium level was 2.4 mmol/L after administration of 40 mEq of potassium intravenously (IV-administered directly into the bloodstream via a vein) and 40 mEq of potassium by mouth. On 02/15/24, R1's potassium level was 3.0 mmol/L despite continued potassium replacement. R1 received an additional 40 mEq of potassium IV in addition to his oral dosing. On 02/16/24, R1's potassium level was 3.1 mmol/L. R1 received a total of 80 mEq of potassium orally and 40 mEq of potassium by IV. A potassium level check in the afternoon showed R1 had a potassium level of 5.0 mmol/L, a normalized potassium level, and discharged back to the nursing home. The Facility Incident Report, dated 02/19/24, documented at approximately 11:42 AM LN H gave R1 25 mg of metolazone instead of 2.5 mg. R1 returned from a cardiology visit and had a new handwritten order for 2.5 mg of metolazone. LN G and LN H interpreted the order as 25 mg. LN G entered the order as 25 mg metolazone and LN H gave the medication dose that was entered into the MAR. LN H gave the medication from R1's PRN card. When the local pharmacy delivered the prescription at approximately 12:40 PM, LN G noticed the pharmacy sent a dose of 2.5 mg of metolazone. LN G immediately called the cardiologist and requested to speak to his nurse. LN G told the nurse what happened. The nurse instructed LN G to monitor R1 for any signs of low fluid volume because R1 would need to go to the emergency department and call R1's primary care physician with any concerns. Approximately two minutes later, R1's cardiologist's nurse called LN G back and ordered LN G to monitor for signs and symptoms of hypovolemic (abnormally low circulating blood volume) shock (an acute medical condition associated with a fall in blood pressure), in which case R1 would need to go to the emergency department, and not to give R1 the 2.5 mg of metolazone on Wednesday, and to draw a BMP on Tuesday, 02/13/24, and Wednesday, 02/14/24. R1 was monitored for low fluid volume. A BMP was drawn as ordered and showed a potassium level of 2.6 mmol/L. The clinic staff notified the facility of the critical lab value and gave the order to transport R1 to the emergency department. On 03/13/24 at 10:30 AM, R1 laid in bed with his oxygen on watching TV. R1 wore pajama pants and slippers. On 03/13/24 at 10:30 AM, R1 stated when he found out he had received the wrong dose of medication, he was scared. R1 stated he was still uneasy about his medication being wrong. On 03/13/24 at 09:45 AM, Administrative Staff A stated the medication error should never have happened because if the nurse putting in the medication had paid attention to the alerts in the EMR, instead of clicking through them, the medication would not have been given. Administrative Staff A stated all the nurses had been trained to pay attention to the alerts and adhere to the alerts. On 03/13/24 at 01:00 PM, LN H stated she thought the dose of metolazone was high and she questioned LN G about it. LN G told her R1 had a lot of fluid that needed to come off and LN G was going to put the order in for now, for 25 mg of metolazone. LN H stated she listened to her charge nurse and administered 25 mg of metolazone. On 03/13/24 at 01:15 PM, LN G stated when she received the order for metolazone she thought the order read 25 mg. LN G stated she knew R1 had as needed metolazone 5 mg tablets, so she put the order in for five 5 mg tablets (metolazone) to be given now. LN G stated she did not wait for the pharmacy to deliver the medication because metolazone was a diuretic and she did not want R1 to be up all-night urinating. LN G denied that she had clicked through the alerts in the EMR when she input the order. The Physician Medication Orders, and Documentation of Medication Administration Policy, revised September 2023, documented medications shall be administered only upon written order of a person duly licensed and authorized to subscribe medications. The facility shall maintain a medication administration record to document all medications administered. The facility's failure to ensure R1 remained free from significant medication errors resulted in R1 receiving ten times the ordered dose of metolazone which placed R1 in immediate jeopardy. On 02/13/24 the facility completed education which included The Rights of Medication Administration, Face to Face Order Entry (using EMR template - if dose is not available get a double check), Pay Attention to Alerts (medication allergy/maximum dose exceeded), and Transcribing Orders and Order Entry into PCC. All corrective actions were completed prior to the onsite survey therefore the deficient practice was deemed past noncompliance. The scope and severity remained at a J.

The facility identified a census of 32 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff identified an and reported immediately to the administrator an episode of abuse when staff manually restrained Resident (R)1 to administer medications. On 11/10/23 at around 06:30 PM Certified Medication Aid (CMA) R asked Certified Nurse Aide (CNA) M and CNA N to help administer eye ointment to R1. CMA R, CNA M, and CNA N went into R1's room and CMA R climbed on top of R1, straddled him, and pinned his arms under the blankets while R1 attempted to resist. CNA M told CMA R the actions were inappropriate, but CMA R ignored CNA M. Neither CNA M nor CNA N reported the incident at that time. At 06:18 AM, CNA M texted Administrative Nurse D and at 07:45 AM Administrative Nurse D called CNA M back and CNA M told Administrative Nurse D of the incident with CMA R and R1. On the afternoon of 11/14/23, almost four days after the incident, Administrative Nurse D spoke with CMA R about the incident and stated it could never happen again but did not report to Administrative Staff A until 11/15/23. The facility staff failed to identify and report an episode of abuse to Administrative Staff A immediately as required. This placed R1 and the 31 other residents in the facility in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The MDS documented R1 had impairment to one side of his upper and lower extremities. The MDS further documented R1 required the use of a wheelchair, was totally dependent on staff for transfer, bed mobility, oral hygiene, toileting, bathing, and dressing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/23, documented R1 had short-term and long-term memory loss and exhibited behaviors of inattention, disorganized thinking, and altered level of consciousness. The Communication CAA, dated 07/07/23, documented R1 as at risk for social isolation due to only being able to answer mostly yes and no questions; it usually took R1 a little bit of time for him to answer questions. Staff were directed to anticipate R1's needs. The Activities of Daily Living Function/Rehabilitation Potential CAA, dated 07/07/23, documented R1 required assistance of two staff for all activities of daily living and required the use of a sit-to-stand lift for transfers and toileting. R1's Care Plan, revised 04/29/21, directed staff R1 often said no when he meant yes (for example immediately questioning staff why they were leaving and not doing something after R1 had just declined cares). Staff were directed to encourage R1 to allow cares such as incontinence care, going to meals, taking medications, and going to bed per R1's routine. Staff were to provide education to R1 to assure he would understand what he was saying no to. The care plan directed staff to re-approach R1 after refusal of care and take the time to explain cares, medications, and procedures. If R1 refused medications, staff were to provide clear, concise education on the use of each medication. R1 usually took the medications if staff told him what the medication was for. The Progress Note, dated 10/24/23, documented R1 continued to have purulent (producing or containing pus) drainage from both eyes. R1 did not tolerate the gentamycin (antibiotic) eye drops and stated that [expletive] burns. As a result, staff was only able to get one or two drops in once or twice daily. The note recorded the inquiry to the physician asking if erythromycin (antibiotic) ophthalmic (relating to the eyes) ointment, given in the evening or night while R1 was sleeping, would be more effective. The October 2023 Treatment Administration Record (TAR), documented a new order for erythromycin ophthalmic ointment. Instill one centimeter (cm) in both eyes one time a day for conjunctivitis (eye infection). Give when the resident was sleeping soundly. The Progress Note, dated 10/25/23, documented nursing attempted to apply erythromycin ointment to R1's eyes and R1 refused and became very aggressive and combative with both the CMA and charge nurse. R1 said no and started pinching and hitting staff. Staff were unable to instill the ointment. The Progress Note, dated 10/27/23, documented R1 continued to be on erythromycin ointment to both eyes. R1 would not allow the medication to be placed in his eyes and administration must be done when R1 was asleep. The nurse was able to get the ointment on R1's eyes and R1 rubbed his eyes as the ointment was applied. The facility's Incident Report, documented CNA M sent Administrative Nurse D a text message on 11/11/23 at 06:18 AM asking Administrative Nurse D to give her a call. Administrative Nurse D called CNA M at 07:45 AM and CNA M asked Administrative Nurse D if she spoke to CMA R because CMA R had done it again. Administrative Nurse D asked CNA M Did what again? and CNA M replied that CMA R administered eye ointment to R1 in a way that she held his eyes open while R1 resisted. Administrative Nurse D told CNA M that she would talk to CMA R about the situation. Administrative Nurse D spoke to CMA R on the afternoon of 11/14/23 and told her that residents had the right to refuse medication and treatments and the action CMA R took to administer R1's eye ointment could not happen again. On the morning of 11/15/23, Administrative Nurse D reported the incident to Administrative Staff A and an investigation was started. CMA R was suspended. During the investigation, the facility noted CNA M's witness statement said she reached out to Administrative Nurse D because of recurrence. CNA M was asked when the other occurrence happened, and CNA M reported she was unsure. When Administrative Staff A asked CNA M if she reported it the first time, CNA M stated, I think I told [Administrative Nurse D] but I can't remember if it was in text or phone message. Administrative Nurse D stated she did not get a text or message about it. CNA M explained she witnessed (twice) CMA R crawled in the bed and straddled R1 to hold him down in order to get his eye ointment in. CMA R admitted this happened on 11/10/23. Both CNA M and CNA N admit the incident happened on 11/10/23 and from the camera footage, the facility believed the incident happened at approximately 06:30 PM. CNA M reported she had alerted Administrative Nurse D after the event of 11/10/23 because she knew of the need to report. CNA N did not report the event on 11/10/23 because she believed CNA M notified Administrative Nurse D. The root cause analysis documented a failure of staff to ensure management was notified immediately to the events and failure of management staff to get enough information to decide how to proceed. The Social Services Note, dated 11/15/23, documented the facility social worker notified R1's responsible party and explained the incident when CMA R forced R1 to accept his eye ointment. The facility social worker explained to R1's responsible party the method was unacceptable and was considered abuse. CMA R was suspended for the time. Police were called and the facility filed a report. According to administration and other staff, R1 had no injuries. R1's responsible party verbalized understanding and stated he did not plan to press any formal charges. CNA N's Witness Statement, dated 11/16/23, documented CNA N heard CMA R ask CNA M if she was ready to help her give R1 his eye drops. CNA M and CNA N followed CMA R into R1's room. CNA M stood next to R1's head as he laid in bed and CMA R was next to CNA M by the bed. CNA N stated she stood back and was there just in case CNA M and CMA R needed help. CMA R proceeded to climb on top of R1, straddle him like she was sitting on a saddle, with the covers pulled tightly over R1's arms. CNA M told CMA R that she was not supposed to do that. CNA M stated it numerous times, but CMA R said that is what she always did with her kids. R1 tried to move his arms in a motion of trying to fight. CNA N did not hear R1 say anything. Once CMA R had they eye drops in R1's eyes, she climbed off of R1 and CNA N heard CNA M tell CMA R she was going to contact Administrative Nurse D about the incident. CMA R kept telling CNA N that was how she always did her kids and that it always worked. CNA N stated CMA R went back to her medication cart to continue giving medications to the other residents. CNA N stated she did not report the incident to Administrative Nurse D because she knew CNA M was going to. CMA R's Witness Statement, dated 11/17/23, documented CMA R was trying to give R1 his eye ointment and he was resisting so CMA R asked the aides to help. CMA R stated she decided to straddle R1 in the bed in order to get the ointment in his eyes. CNA M's Witness Statement, dated 11/22/23, documented CNA M was unsure of the date, but one evening CMA R asked CNA N and her to help her administer R1's eye ointment. CMA R kept asking CNA N and her if they wanted to see how she did eye medications on her kids. CNA M stated she politely declined and stated R1 was not a child, he was a resident. CMA R then proceeded to crawl on top of R1 and straddle him. CMA R attempted to pull his arms down under her legs to which R1 fought and would not allow. CMA R struggled for a minute with R1 before getting the eye ointment in his eyes. CMA R, CNA M, and CNA N exited the room and went about their shift. CNA M stated she thought she contacted Administrative Nurse D but could not remember how she contacted her. The next shift CNA M worked with CMA R, on 11/10/23, CMA R again asked CNA M and CNA N to help her with R1's eye ointment. CNA M told CMA R that he had been refusing a lot and other medication aides had a much gentler approach. CMA R proceeded to state, This is how I do my kids, and climbed on top of R1 and straddled him again. CNA M stated she told CMA R she should not be doing that, and CMA R ignored her. CNA M stated she stayed until CMA R was finished to ensure no harm to either CMA R or R1 occurred. CNA M stated that she then immediately contacted Administrative Nurse D to inform her of the re-occurrence of the incident via text message. Administrative Nurse D's Witness Statement, dated 11/22/23, documented Administrative Nurse D was alerted via text message to call CMA M on 11/11/23 at 06:18 AM. Administrative Nurse D returned CNA M's call at approximately 07:54 AM. CNA M stated that CMA R had administered eye ointment to R1 in a way that CMA R held R1's eyelids open and R1 was resisting administration. Administrative Nurse D told CNA M she would talk with CMA R. On 11/14/23 in the afternoon, Administrative Nurse D talked to CMA R and told her that every resident had the right to refuse medications and treatments and this action could not ever happen again. Administrative Nurse D stated on 11/15/23, during the morning stand up meeting, she notified Administrative Staff A of what happened. Administrative Staff A immediately educated Administrative Nurse D of the abuse reporting policies and the investigation began immediately. LN G's Witness Statement, dated 11/22/23, documented Licensed Nurse (LN) G stated on 11/10/23, at the end of the shift at 10:00 PM, CMA R told her that she was able to administer R1's eye drops by straddling his leg. On 12/07/23 at 09:30 AM, observation revealed R1 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) at the breakfast table and ate breakfast. R1 was slow to acknowledge verbal greeting. On 12/07/23 at 10:30 AM, Administrative Staff A stated as soon as she heard about the incident in the morning meeting on 11/15/23, she told staff this was an abuse allegation, and an investigation was needed. Administrative Staff A stated she started an investigation and called CMA R in order to suspend her and get her witness statement. Administrative Staff A stated she did not understand why CMA R thought that what she did was appropriate. CMA R was terminated on 11/21/23. Administrative Staff A stated that abuse and neglect and reporting policy education was started for all staff on 11/15/23 and finished on 11/16/23 and a QAPI meeting was held on 12/15/23 with the medical director. On 12/07/23 at 11:00 AM, Administrative Nurse D stated the incident never should have happened and when CNA M reported it to her, she did not think it was as bad as it turned out to be. Administrative Nurse D said she should have done some more investigating and asked questions about the incident to ensure R1's safety. On 12/07/23 at 11:30 AM, CNA M stated this was the second time she saw CMA R crawl up on top of R1 to administer eye ointment. CNA M stated she knew she had told Administrative Nurse D about it, but maybe she did not. CNA M stated R1 struggled and fought both times CMA R gave him eye ointment. CNA M confirmed she did not text Administrative Nurse D until the following morning. The facility Abuse and Neglect Policy, revised August of 2022, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation, and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition. Upon hire and annually, covered individuals will be notified of their obligations to report suspicion of abuse and neglect. The facility through the Administrator or their designee will report alleged violations related to mistreatment, exploitation, neglect, or abuse including injuries of unknown origin and misappropriation of resident property the results of all investigations to the proper authorities in appropriate time frames. The facility staff failed to identify abuse and report to Administrative Staff A immediately as required. This placed R1 and the 31 other residents in the facility in immediate jeopardy. On 11/16/23 the facility completed the following corrective actions: The facility had a Quality Assurance and Performance Improvement (QAPI) meeting with the facility medical director. Staff completed an assessment of R1 on 11/15/23. All employees were educated on abuse, neglect, restraints, and reporting policies which was completed on 11/16/23. CMA R was suspended on 11/15/23 and then terminated on 11/21/23. All corrective actions were completed prior to the onsite survey therefore the citation was issued as past noncompliance at the scope and severity of L.

The facility identified a census of 32 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure residents remained free from abuse including physical restraint when staff manually restrained Resident (R) 1 to administer medications. On 11/10/23 at around 06:30 PM, Certified Medication Aide (CMA) R asked Certified Nurse Aide (CNA) M and CNA N to help administer eye ointment to R1. CMA R, CNA M, and CNA N went into R1's room and CMA R climbed on top of R1, straddled him, and pinned his arms under the blankets while R1 attempted to resist. CNA M told CMA R the actions were inappropriate, but CMA R ignored CNA M. The facility staff failed to ensure R1 remained free from abuse when staff physically restrained him. This placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The MDS documented R1 had impairment to one side of his upper and lower extremities. The MDS further documented R1 required the use of a wheelchair, was totally dependent on staff for transfer, bed mobility, oral hygiene, toileting, bathing, and dressing. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/23, documented R1 had short-term and long-term memory loss and exhibited behaviors of inattention, disorganized thinking, and altered level of consciousness. The Communication CAA, dated 07/07/23, documented R1 as at risk for social isolation due to only being able to answer mostly yes and no questions; it usually took R1 a little bit of time for him to answer questions. Staff were directed to anticipate R1's needs. The Activities of Daily Living Function/Rehabilitation Potential CAA, dated 07/07/23, documented R1 required assistance of two staff for all activities of daily living and required the use of a sit-to-stand lift for transfers and toileting. R1's Care Plan, revised 04/29/21, directed staff R1 often said no when he meant yes (for example immediately questioning staff why they were leaving and not doing something after R1 had just declined cares). Staff were directed to encourage R1 to allow cares such as incontinence care, going to meals, taking medications, and going to bed per R1's routine. Staff were to provide education to R1 to assure he would understand what he was saying no to. The care plan directed staff to re-approach R1 after refusal of care and take the time to explain cares, medications, and procedures. If R1 refused medications, staff were to provide clear, concise education on the use of each medication. R1 usually took the medications if staff told him what the medication was for. The Progress Note, dated 10/24/23, documented R1 continued to have purulent (producing or containing pus) drainage from both eyes. R1 did not tolerate the gentamycin (antibiotic) eye drops and stated that [expletive] burns. As a result, staff was only able to get one or two drops in once or twice daily. The note recorded the inquiry to the physician asking if erythromycin (antibiotic) ophthalmic (relating to the eyes) ointment, given in the evening or night while R1 was sleeping, would be more effective. The October 2023 Treatment Administration Record (TAR), documented a new order for erythromycin ophthalmic ointment. Instill one centimeter (cm) in both eyes one time a day for conjunctivitis (eye infection). Give when the resident was sleeping soundly. The Progress Note, dated 10/25/23, documented nursing attempted to apply erythromycin ointment to R1's eyes and R1 refused and became very aggressive and combative with both the CMA and charge nurse. R1 said no and started pinching and hitting staff. Staff were unable to instill the ointment. The Progress Note, dated 10/27/23, documented R1 continued to be on erythromycin ointment to both eyes. R1 would not allow the medication to be placed in his eyes and administration must be done when R1 was asleep. The nurse was able to get the ointment on R1's eyes and R1 rubbed his eyes as the ointment was applied. The facility's Incident Report, documented CNA M sent Administrative Nurse D a text message on 11/11/23 at 06:18 AM asking Administrative Nurse D to give her a call. Administrative Nurse D called CNA M at 07:45 AM and CNA M asked Administrative Nurse D if she spoke to CMA R because CMA R had done it again. Administrative Nurse D asked CNA M Did what again? and CNA M replied that CMA R administered eye ointment to R1 in a way that she held his eyes open while R1 resisted. Administrative Nurse D told CNA M that she would talk to CMA R about the situation. Administrative Nurse D spoke to CMA R on the afternoon of 11/14/23 and told her that residents had the right to refuse medication and treatments and the action CMA R took to administer R1's eye ointment could not happen again. On the morning of 11/15/23, Administrative Nurse D reported the incident to Administrative Staff A and an investigation was started. CMA R was suspended. During the investigation, the facility noted CNA M's witness statement said she reached out to Administrative Nurse D because of recurrence. CNA M was asked when the other occurrence happened, and CNA M reported she was unsure. When Administrative Staff A asked CNA M if she reported it the first time, CNA M stated, I think I told [Administrative Nurse D] but I can't remember if it was in text or phone message. Administrative Nurse D stated she did not get a text or message about it. CNA M explained she witnessed (twice) CMA R crawled in the bed and straddled R1 to hold him down in order to get his eye ointment in. CMA R admitted this happened on 11/10/23. Both CNA M and CNA N admit the incident happened on 11/10/23 and from the camera footage, the facility believed the incident happened at approximately 06:30 PM. CNA M reported she had alerted Administrative Nurse D after the event of 11/10/23 because she knew of the need to report. CNA N did not report the event on 11/10/23 because she believed CNA M notified Administrative Nurse D. The root cause analysis documented a failure of staff to ensure management was notified immediately to the events and failure of management staff to get enough information to decide how to proceed. The Social Services Note, dated 11/15/23, documented the facility social worker notified R1's responsible party and explained the incident when CMA R forced R1 to accept his eye ointment. The facility social worker explained to R1's responsible party the method was unacceptable and was considered abuse. CMA R was suspended for the time. Police were called and the facility filed a report. According to administration and other staff, R1 had no injuries. R1's responsible party verbalized understanding and stated he did not plan to press any formal charges. CNA N's Witness Statement, dated 11/16/23, documented CNA N heard CMA R ask CNA M if she was ready to help her give R1 his eye drops. CNA M and CNA N followed CMA R into R1's room. CNA M stood next to R1's head as he laid in bed and CMA R was next to CNA M by the bed. CNA N stated she stood back and was there just in case CNA M and CMA R needed help. CMA R proceeded to climb on top of R1, straddle him like she was sitting on a saddle, with the covers pulled tightly over R1's arms. CNA M told CMA R that she was not supposed to do that. CNA M stated it numerous times, but CMA R said that is what she always did with her kids. R1 tried to move his arms in a motion of trying to fight. CNA N did not hear R1 say anything. Once CMA R had they eye drops in R1's eyes, she climbed off of R1 and CNA N heard CNA M tell CMA R she was going to contact Administrative Nurse D about the incident. CMA R kept telling CNA N that was how she always did her kids and that it always worked. CNA N stated CMA R went back to her medication cart to continue giving medications to the other residents. CNA N stated she did not report the incident to Administrative Nurse D because she knew CNA M was going to. CMA R's Witness Statement, dated 11/17/23, documented CMA R was trying to give R1 his eye ointment and he was resisting so CMA R asked the aides to help. CMA R stated she decided to straddle R1 in the bed in order to get the ointment in his eyes. CNA M's Witness Statement, dated 11/22/23, documented CNA M was unsure of the date, but one evening CMA R asked CNA N and her to help her administer R1's eye ointment. CMA R kept asking CNA N and her if they wanted to see how she did eye medications on her kids. CNA M stated she politely declined and stated R1 was not a child, he was a resident. CMA R then proceeded to crawl on top of R1 and straddle him. CMA R attempted to pull his arms down under her legs to which R1 fought and would not allow. CMA R struggled for a minute with R1 before getting the eye ointment in his eyes. CMA R, CNA M, and CNA N exited the room and went about their shift. CNA M stated she thought she contacted Administrative Nurse D but could not remember how she contacted her. The next shift CNA M worked with CMA R, on 11/10/23, CMA R again asked CNA M and CNA N to help her with R1's eye ointment. CNA M told CMA R that he had been refusing a lot and other medication aides had a much gentler approach. CMA R proceeded to state, This is how I do my kids, and climbed on top of R1 and straddled him again. CNA M stated she told CMA R she should not be doing that, and CMA R ignored her. CNA M stated she stayed until CMA R was finished to ensure no harm to either CMA R or R1 occurred. CNA M stated that she then immediately contacted Administrative Nurse D to inform her of the re-occurrence of the incident via text message. Administrative Nurse D's Witness Statement, dated 11/22/23, documented Administrative Nurse D was alerted via text message to call CMA M on 11/11/23 at 06:18 AM. Administrative Nurse D returned CNA M's call at approximately 07:54 AM. CNA M stated that CMA R had administered eye ointment to R1 in a way that CMA R held R1's eyelids open and R1 was resisting administration. Administrative Nurse D told CNA M she would talk with CMA R. On 11/14/23 in the afternoon, Administrative Nurse D talked to CMA R and told her that every resident had the right to refuse medications and treatments and this action could not ever happen again. Administrative Nurse D stated on 11/15/23, during the morning stand up meeting, she notified Administrative Staff A of what happened. Administrative Staff A immediately educated Administrative Nurse D of the abuse reporting policies and the investigation began immediately. LN G's Witness Statement, dated 11/22/23, documented Licensed Nurse (LN) G stated on 11/10/23, at the end of the shift at 10:00 PM, CMA R told her that she was able to administer R1's eye drops by straddling his leg. On 12/07/23 at 09:30 AM, observation revealed R1 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) at the breakfast table and ate breakfast. R1 was slow to acknowledge verbal greeting. On 12/07/23 at 10:30 AM, Administrative Staff A stated as soon as she heard about the incident in the morning meeting on 11/15/23, she told staff this was an abuse allegation and an investigation was needed. Administrative Staff A stated she started an investigation and called CMA R in order to suspend her and get her witness statement. Administrative Staff A stated she did not understand why CMA R thought that what she did was appropriate. CMA R was terminated on 11/21/23. Administrative Staff A stated that abuse and neglect and reporting policy education was started for all staff on 11/15/23 and finished on 11/16/23 and a QAPI meeting was held on 12/15/23 with the medical director. On 12/07/23 at 11:00 AM, Administrative Nurse D stated the incident never should have happened and when CNA M reported it to her, she did not think it was as bad as it turned out to be. Administrative Nurse D said she should have done some more investigating and asked questions about the incident to ensure R1's safety. On 12/07/23 at 11:30 AM, CNA M stated this was the second time she saw CMA R crawl up on top of R1 to administer eye ointment. CNA M stated she knew she had told Administrative Nurse D about it, but maybe she did not. CNA M stated R1 struggled and fought both times CMA R gave him eye ointment. CNA M confirmed she did not text Administrative Nurse D until the following morning. The facility Abuse and Neglect Policy, revised August of 2022, documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation, and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition. Upon hire and annually, covered individuals will be notified of their obligations to report suspicion of abuse and neglect. The facility through the Administrator or their designee will report alleged violations related to mistreatment, exploitation, neglect, or abuse including injuries of unknown origin and misappropriation of resident property the results of all investigations to the proper authorities in appropriate time frames. The facility staff failed to ensure R1 remained free from abuse when staff physically restrained him. This placed R1 in immediate jeopardy. On 11/16/23 the facility completed the following corrective actions: The facility had a Quality Assurance and Performance Improvement (QAPI) meeting with the facility medical director. Staff completed an assessment of R1 on 11/15/23. All employees were educated on abuse, neglect, restraints, and reporting policies which was completed on 11/16/23. CMA R was suspended on 11/15/23 and then terminated on 11/21/23. All corrective actions were completed prior to the onsite survey therefore the citation was issued as past noncompliance at the scope and severity of J.

The facility identified a census of 30 residents. The sample included five residents. Based on record review and interviews, the facility failed to notify the physician when two urinalysis (UA- examination of urine) samples were not collected and/or tested as ordered for Resident (R) 1. This deficient practice had the risk for miscommunication between the resident, the physician, and the facility and unwarranted physical complications for R1. Findings included: - R1 admitted to the facility on [DATE] and discharged to the hospital on 03/29/23. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented a diagnosis of urinary tract infection. The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R1 required extensive physical assistance with two staff for bed mobility, transfers, locomotion, dressing, and toileting; extensive physical assistance with one staff for personal hygiene; and supervision with setup help only for eating. R1 was frequently incontinent of bowel movements and urine; he was not on a toileting program. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 03/29/23, documented R1 was at a risk for a potential decline in his ADLs and was noted to not want assistance with his ADLs. The Urinary Incontinence and Indwelling Catheter (tube placed in the bladder to drain urine into a collection bag) CAA dated 03/29/23, documented R1 was at risk for a potential increase in his incontinence of bowel and bladder. The Care Plan did not address ADLs or bowel and bladder. The Orders tab of R1's EMR documented an order with a start date of 03/13/23 for urinalysis (UA- examination of urine) in the morning (AM); an order with a start date of 03/16/23 to obtain a UA; and an order with a start date of 03/27/23 to perform straight catherization (intermittent catheterization using a thin tube inserted through the urethra into the bladder to empty the bladder of urine) and repeat UA. R1's medical record revealed the following: A Nursing Note on 03/13/23 at 12:31 AM documented the facility received referral back for Tylenol (pain medication) and ibuprofen (pain medication) as directed for temperature with UA in the morning. R1's medical record lacked evidence the UA was obtained and performed as ordered on 03/13/23 and lacked evidence the physician was notified. A Nursing Note on 03/15/23 at 03:25 PM documented when the nurse was in R1's room, he complained about having cloudy urine and burning with urination. R1 requested that staff collected his urine. The nurse told him they needed an order to obtain a UA and Consultant GG was faxed with the above information. A Nursing Note on 03/16/23 at 07:00 PM documented the facility received an order from Consultant GG to obtain UA. A Skilled Note on 03/19/23 at 02:14 PM documented a clean catch urine specimen was obtained for pending UA with culture and sensitivity (test performed on urine to determine what bacterial organisms were present in the urine and what antibiotic (medication used to treat bacterial infections) medications they were sensitive to) if indicated. R1's medical record lacked evidence the UA ordered on 03/16/23 and collected on 03/19/23 was performed and lacked evidence the physician was notified. On 05/22/23 at 03:04 PM, Licensed Nurse (LN) G stated if there was an order for a UA, staff tried to collect it within 24 hours and sometimes had to request a straight catherization to obtain it. She stated if the UA was collected, it was documented in the nurses notes and it depended on who was working whether it was followed up on or not. LN G stated the UAs were collected within 24 hours and sometimes 48 hours. She stated the provider was notified if a UA was not collected as ordered. R1's UA on 03/19/23 was collected but was not taken to the hospital within the 24-hour window so it could not get performed. She stated three days was a long time to wait to obtain a UA if a resident was symptomatic. LN G stated the UA that was collected in theER on [DATE] came back contaminated so another one was obtained on 03/29/23 which came back cultured as fungal, but he had already transferred out to the hospital. On 05/22/23 at 03:28 PM, Administrative Nurse D stated they needed an order for a UA and should have been collected within the first six to eight hours after ordered. She stated she preferred the UA to be collected at shift change so the off-going shift could take it to the hospital to be performed. She stated the provider should have been notified if a UA was not collected because an order for a straight catherization may need to be obtained. Administrative Nurse D stated the UA ordered on 03/16/23 should have been collected before 03/19/23 and that sample had sat in the medication room too long and was not able to be processed. She stated samples were not placed in a cooler at the nurse's station. The facility's Laboratory Services policy, last revised November 2017, directed clinical laboratory services to meet the needs of the residents were provided by the community. The policy directed labs were obtained under an order by the practitioner. The facility's Change in a Resident's Condition or Status policy, last revised November 2017, directed the facility staff promptly notified the resident, their attending physician, and resident representative of changes in the resident's medical/mental and or status. The policy directed except in a medical emergency, notifications were made within 24-hours of a change occurring in the resident's medical/mental condition or status. The facility failed to notify the physician when two UA samples were not collected and/or tested as ordered for R1. This deficient practice had the risk for miscommunication between the resident, the physician, and the facility and unwarranted physical complications for R1.

The facility identified a census of 30 residents. The sample included five residents. Based on record review and interviews, the facility failed to follow a physician's order to obtain a urinalysis for Resident (R) 1, who had a history of a urinary tract infection (UTI) and had complained of signs and symptoms of a UTI in the facility. This deficient practice had the risk for delayed treatment and unwarranted physical complications for R1. Findings included: - R1 admitted to the facility on [DATE] and discharged to the hospital on 03/29/23. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented a diagnosis of urinary tract infection. The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R1 required extensive physical assistance with two staff for bed mobility, transfers, locomotion, dressing, and toileting; extensive physical assistance with one staff for personal hygiene; and supervision with setup help only for eating. R1 was frequently incontinent of bowel movements and urine; he was not on a toileting program. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 03/29/23, documented R1 was at a risk for a potential decline in his ADLs and was noted to not want assistance with his ADLs. The Urinary Incontinence and Indwelling Catheter (tube placed in the bladder to drain urine into a collection bag) CAA dated 03/29/23, documented R1 was at risk for a potential increase in his incontinence of bowel and bladder. The Care Plan did not address ADLs or bowel and bladder. The Orders tab of R1's EMR documented an order with a start date of 03/13/23 for urinalysis (UA- examination of urine) in the morning (AM); an order with a start date of 03/16/23 to obtain a UA; and an order with a start date of 03/27/23 to perform straight catherization (intermittent catheterization using a thin tube inserted through the urethra into the bladder to empty the bladder of urine) and repeat UA. R1's medical record revealed the following: A Nursing Note on 03/13/23 at 12:31 AM documented the facility received referral back for Tylenol (pain medication) and ibuprofen (pain medication) as directed for temperature with UA in the morning. A Nursing Note on 03/15/23 at 03:25 PM documented when the nurse was in R1's room, he complained about having cloudy urine and burning with urination. R1 requested that staff collected his urine. The nurse told him they needed an order to obtain a UA and Consultant GG was faxed with the above information. R1's medical record lacked evidence the UA was obtained and performed as ordered on 03/13/23. A Nursing Note on 03/16/23 at 07:00 PM documented the facility received an order from Consultant GG to obtain UA. A Skilled Note on 03/19/23 at 02:14 PM documented a clean catch urine specimen was obtained for pending UA with culture and sensitivity (test performed on urine to determine what bacterial organisms were present in the urine and what antibiotic (medication used to treat bacterial infections) medications they were sensitive to) if indicated. R1's medical record lacked evidence the UA ordered on 03/16/23 and collected on 03/19/23 was performed. A Nursing Note on 03/21/23 at 05:13 AM documented R1 began yelling help at 11:30 PM and stated he needed to go to the hospital for his heart ticking backwards. At 03:15 AM, R1 was able to reach the sheriff's office and they sent emergency medical services (EMS) to the facility to transport him to the local hospital. R1 left the facility at 03:30 AM with EMS. A Nursing Clinical Evaluation Note on 03/21/23 at 08:58 AM documented R1 was at the emergency department (ED) after calling 911 to have himself taken to the ED for evaluation of his heart. The only finding in the ED was R1 had a UTI. An ED Note on 03/21/23 documented R1's UA indicated a UTI and he was given a dose of Rocephin (antibiotic) and was to complete a seven-day course of Macrobid (antibiotic) twice daily. R1 was transported back to the nursing home per the facility van. A Nursing Note on 03/25/23 at 04:49 AM documented R1 was confused at that time and thought he was outside instead of lying-in bed. A Skilled Note on 03/26/23 at 05:25 PM documented R1 firmly believed different things throughout the day such as his recliner was not his and firmly believing delusions that were not true. A Nursing Note on 03/27/23 at 11:11 AM documented the last UA culture obtained in the emergency room (ER) grew back contaminated. R1's urine was still cloudy, dark, and had a foul odor. Nursing requested order to straight catharize R1 due to no improvement in urine. R1 was more confused and not acting like himself. A Nursing Note on 03/27/23 at 05:19 PM documented the facility received communication back from Consultant HH stating it was okay to straight catharize R1 and repeat the UA. A Nursing Note on 03/28/23 at 12:57 PM documented the UA was obtained via straight catherization. R1's urine was cloudy and orangish in color, the UA was taken to the hospital to be completed. A Nursing Note on 03/28/23 at 02:44 PM documented the UA results were back with culture indicated. UA results were cloudy with moderate blood, protein, bacteria, and white blood cells. The results were faxed to Consultant HH. R1's culture results from the UA obtained on 03/28/23 revealed his urine cultured candida glabrata (fungal or yeast infection). A Nursing Note on 03/29/23 at 10:37 AM documented the facility received a fax back from Consultant HH who wanted to wait until the culture came back before treating since R1 was already on antibiotics. A Nursing Note on 03/29/23 at 03:54 PM documented R1 had been more lethargic that day and required assistance with eating and drinking. He had very little output that day and his family was concerned. Staff felt that with R1's decline in condition, decrease in fluid intake, and continued UTI, he could have become septic. A fax was sent to Consultant HH for further orders or changes in orders. A Nursing Note on 03/29/23 at 04:53 PM documented the facility received communication back from Consultant HH that R1 needed to be seen by provider and sent to the ER if need. R1's family member wanted him transferred to the ER. An ED Note on 03/29/23 documented R1 arrived to the ED for lethargy and poor oral intake. R1 was diagnosed with sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infections which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock) due to UTI and was given intravenous (through a vein) fluids. R1 was increasingly responsive with fluid resuscitation but despite fluid resuscitation, he remained hypotensive (low blood pressure). R1 was transferred to a larger hospital for further treatment. A Nursing Note on 03/29/23 at 09:46 PM documented the nurse spoke to the local hospital staff who notified the nurse R1 was being transferred to a larger hospital for very cloudy urine and low blood pressure. A Hospitalist Admission Note on 03/29/23 documented R1 presented with altered mental status, he was diagnosed with a UTI earlier that month and treated with Macrobid but still had symptoms, so another UA was done which was in process. R1 developed altered mental status earlier that day and was taken to the local ER where he was found to be hypotensive, and his urine appeared infected. He was awake and alert although, slow to respond. R1 was admitted to the intensive care unit (ICU) for septic shock/UTI/acute renal failure (when the kidneys suddenly become unable to filter waste products from the blood). Per request, the facility was unable to provide UA results for the UAs ordered on 03/13/23 and 03/16/23. On 05/22/23 at 03:04 PM, Licensed Nurse (LN) G stated if there was an order for a UA, staff tried to collect it within 24 hours and sometimes had to request a straight catherization to obtain it. She stated if the UA was collected, it was documented in the nurses notes and it depended on who was working whether it was followed up on or not. LN G stated the UAs were collected within 24 hours and sometimes 48 hours. She stated the provider was notified if a UA was not collected as ordered. R1's UA on 03/19/23 was collected but was not taken to the hospital within the 24-hour window so it could not get performed. She stated three days was a long time to wait to obtain a UA if a resident was symptomatic. LN G stated the UA that was collected in theER on [DATE] came back contaminated so another one was obtained on 03/29/23 which came back cultured as fungal, but he had already transferred out to the hospital. On 05/22/23 at 03:28 PM, Administrative Nurse D stated they needed an order for a UA and should have been collected within the first six to eight hours after ordered. She stated she preferred the UA to be collected at shift change so the off-going shift could take it to the hospital to be performed. She stated the provider should have been notified if a UA was not collected because an order for a straight catherization may need to be obtained. Administrative Nurse D stated the UA ordered on 03/16/23 should have been collected before 03/19/23 and that sample had sat in the medication room too long and was not able to be processed. She stated samples were not placed in a cooler at the nurse's station. The facility's Laboratory Services policy, last revised November 2017, directed clinical laboratory services to meet the needs of the residents were provided by the community. The policy directed labs were obtained under an order by the practitioner. The facility's Change in a Resident's Condition or Status policy, last revised November 2017, directed the facility staff promptly notified the resident, their attending physician, and resident representative of changes in the resident's medical/mental and or status. The policy directed except in a medical emergency, notifications were made within 24-hours of a change occurring in the resident's medical/mental condition or status. The facility failed to follow the physician's order to obtain a urinalysis for R1, who had a history of a UTI and had complained of signs and symptoms of a UTI in the facility. This deficient practice had the risk for delayed treatment and unwarranted physical complications for R1.

The facility identified a census of 30 residents. The sample included five residents with three residents reviewed for bowel and bladder. Based on record review and interviews, the facility failed to provide an individualized toileting program for bowel and bladder as indicated on assessment for Resident (R) 1. This deficient practice had the risk for an increase in incontinence (lack of voluntary control over urination or defecation), a decline in psychosocial well-being, and a loss of dignity for R1. Findings included: - R1 admitted to the facility on [DATE] and discharged to the hospital on 03/29/23. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented a diagnosis of urinary tract infection. The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R1 required extensive physical assistance with two staff for bed mobility, transfers, locomotion, dressing, and toileting; extensive physical assistance with one staff for personal hygiene; and supervision with setup help only for eating. R1 was frequently incontinent of bowel movements and urine; he was not on a toileting program. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 03/29/23, documented R1 was at a risk for a potential decline in his ADLs and was noted to not want assistance with his ADLs. The Urinary Incontinence and Indwelling Catheter (tube placed in the bladder to drain urine into a collection bag) CAA dated 03/29/23, documented R1 was at risk for a potential increase in his incontinence of bowel and bladder. The Care Plan did not address ADLs, bowel and bladder incontinence, or a toileting program. The Assessments tab of R1's EMR revealed the following: A Nursing: Bladder Incontinence Evaluation on 03/11/23 documented R1's bladder incontinence was irreversible but there was potential for continence to be maintained or improved by reducing incontinent episodes through a bladder program. A Nursing: Bowel Incontinence Evaluation on 03/13/23 documented R1 had bowel incontinence present and R1 was to be scheduled at certain times to sit on commode as a routine toilet schedule. A Nursing: Three Day Voiding/Bowel Movement Evaluation on 03/13/23 documented R1 was not continent and based on the voiding diary, R1 was a candidate for habit training and/or scheduled voiding. R1's medical record lacked evidence of a toileting program or scheduled voiding as indicated in the assessments after admission. On 05/22/23 at 02:20 PM, Certified Nurse Aide (CNA) M stated she knew how to care for residents by reading the care plan. She stated the care plan documented how a resident toileted and residents were toileted after waking, before and after each meal, and before bedtime. CNA M stated the care plan documented if a resident was on a toileting program along with ADL assistance needed. On 05/22/23 at 03:04 PM, Licensed Nurse (LN) G stated staff knew how to care for residents by looking at the care plan which included ADLs and incontinence care. She stated residents were toileted before and after meals and every two hours. There was a three-day voiding sheet when the residents first admitted , giving an idea of incontinence. LN G stated a toileting program were placed on the care plan along with toileting preferences during the night. On 05/22/23 at 03:28 PM, Administrative Nurse D stated staff knew how to care for residents through the care plans, communication sheets, and shift report. She stated some residents required a toileting program or two-hour check and changes which were directed on the care plan. Administrative Nurse D stated if the bowel and bladder evaluations indicated a toileting program or schedule then a toileting program or scheduled was initiated and it was placed on the care plan. The facility's Fecal Incontinence- Assessment and Management policy, last revised November 2017, directed residents were evaluated upon admission and quarterly for bowel continence and the care plan addressed the type of fecal incontinence if known and the interventions utilized. The facility's Urinary Continence and Incontinence- Assessment and Management policy, last revised November 2017, directed as part of the initial and ongoing assessments, the nursing staff screened for information related to urinary continence. If after the transient causes of incontinence were treated and the resident remained incontinent, staff initiated a toileting plan. As appropriate, based on assessing the category and type of incontinence, the staff provided scheduled toileting, prompted voiding, or other interventions to try to manage incontinence. The facility failed to provide an individualized toileting program for bowel and bladder as indicated on assessment for R1. This deficient practice had the risk for an increase in incontinence, a decline in psychosocial well-being, and a loss of dignity for R1.

The facility had a census of 30 residents with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide two of three sampled residents, Resident (R)17 and R26 (or their representative) the completed (SNF ABN) Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form 10055. Findings included: - The Medicare form 10055 informed the beneficiary that Medicare may not pay for skilled therapy services and provides a cost estimate for continued services. I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. A provider must issue advance written notice to enrollees before termination of services in a Skilled Nursing Facility (SNF), Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF). If an enrollee files an appeal, then the plan must deliver a detailed explanation of why services should end. The facility lacked documentation staff provided Resident R17, or his representative, form 10055 which included the estimated cost documentation for the services to be able to make an informed choice whether the resident wanted to receive the items or services, knowing he may have to pay out of pocket. The resident's skilled services ended on 11/07/22. The facility lacked documentation staff provided R26, or his representative, form 1055 which included the estimated cost documentation for the services to be able to make an informed choice whether the resident wanted to receive the items or services, knowing he may have to pay out of pocket. The resident's skilled services ended on 10/24/22. On 04/05/23 at 08:40 AM, Social Services X verified she had not provided the 10055 form to R17 or R26. On 4/05/23 at 09:20AM, Administrative Staff A verified the facility had not provided the 10055 form to R17 and R26. The facility's Beneficiary Notice policy, dated March 2023 indicated the facility would ensure that Medicare resident be able to make the decision to determine if skilled services would be covered by Medicare and indicated the facility would ensure that Medicare residents are informed of their right to appeal and request demand billing of services when it is determined that a resident will no longer qualify for Medicare coverage services, as evidenced by the policy. The denial letter would contain CMS Form 10055. The letters would explain the appeal process, with contact addresses and phone number. The resident or the DPOA must choose to continue or not continue services. The facility failed to provide R17 and R26, or their representatives, CMS form 10055, when discharged from skilled care, which placed them at risk to make uninformed decisions about continuation of their skilled care

The facility had a census of 30 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide an environment free of accident hazards for Resident (R) 25 who smoked cigarettes. This placed R25 at risk for avoidable injuries and fire related hazards. Findings included: - R25's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented the resident was independent with activities of daily living (ADLs) and required staff supervision in the facility. R25's Smoking Care Plan directed the staff R25 had a smoking schedule, and she required her cigarettes and lighter kept in a locked box on the medication cart. The care plan further stated the smoking assessment allowed the resident to light her own cigarettes and safely extinguish them, but R25 needed to return her lighter to staff when she came back inside after smoking. The facility's Smoking Acknowledgement signed by the resident on 11/01/22, states R25 agreed with specific smoking times, and agreed smoking materials were to be kept locked up and not kept in the resident's personal possession. On 03/30/23 at 11:45 AM, observation revealed R25 sat on a chair in the dining room. Further observation revealed R25 stood up from her chair and ambulated out the dining room patio door, took a cigarette out of the front pocket of her hoodie and took out a lighter and lit a cigarette. On 03/30/23 at 12:10PM, observation revealed R25 re-entered the dining room and sat back down on a dining chair. At 12:30PM, observation revealed R25 stood up from her chair and ambulated out the dining room patio door, took a cigarette out of the front pocket of her hoodie and took out a lighter and lit a cigarette. On 03/30/23 at 12:40PM, observation revealed R25 re-entered the dining room and sat back down on a dining chair. On 04/03/23 at 08:50AM, observation revealed R25 sat on a chair in the dining room. R25 stood up, and took a lighter and cigarette out of her front hooded sweatshirt pocket. Further observation revealed R25 ambulated out the dining room patio door, and lit a cigarette. On 04/03/23 at 09:15AM, Certified Medication Aide (CMA) R stated resident's smoking materials were to be kept in a locked box on the medication cart and given to resident's at scheduled smoking times. On 04/03/23 at 09:20AM, observation of the locked box which contained resident cigarettes did not contain R25's lighter. On 04/04/23 at 11:50AM, observation revealed R25 stood by the medication cart and stated, I just keep my lighter in my pocket. On 04/04/23 at 03:00PM, Administrative Nurse F verified the care plan directed the staff to lock up R25's cigarettes and lighter and to provide them to her at scheduled smoking times. On 04/05/23 at 09:10AM, Administrative Nurse D verified the facility's expected staff to place R25's cigarettes and lighter in a locked box in the medication cart. The Smoking Policy dated 03/2020, states the facility will establish and maintain safe resident smoking practices, smoking restrictions will be strictly enforced as to protect the safety of resident's who do not smoke. Smoking materials for residents shall be secured at all times. The facility failed to provide a safe environment for R25 which placed the resident at risk for avoidable injuries and fire related hazards.

The facility had a census of 30 resident and the sample included twelve. Based on observation, record review, and interview, the facility failed to prevent an incident of staff neglect for Resident (R) 7, when R7 slid out of bed on 03/11/23 and Administrative Nurse E failed to document and report the fall to other care staff so staff could provide follow up fall care. On 03/28/23, R7 was diagnosed with a right femur (thigh bone) fracture (broken bone), which was originally classified as an injury of unknown origin until the investigation revealed the resident had a fall which a staff member was aware of but neglected to document, notify the physician and family, and provide after fall care until after the injury was apparent. Findings included: - R7's Electronic Medical Record (EMR) recorded diagnoses which included anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), mild cognitive impairment (early stage of memory loss or other cognitive ability loss such as language or visual perception), cerebral infarction (stroke-death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), and weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R7 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The MDS further documented R7 had unsteady balance, functional impairment on one lower extremity, and had one non-injury fall during the look-back period. The Fall Care Area assessment dated [DATE], documented the resident had slow and unsteady balance, ambulated with a walker in her room, and did not always remember to use her call light to call for assistance with mobilization. The Fall Risk Assessments, dated 12/21/22, 01/22/23, and 03/13/23 documented the resident was a high fall risk. The Fall Care Plan, dated 01/07/23, directed staff to ensure R7 had a safe environment with the floors free from spills or clutter, a reachable call light, non-slip shoes or socks, bed in the lowest position at night, and personal items withing reach. The fall care plan documented the resident had a history of vertigo (sensation of spinning, dizziness), which could cause her to fall, and directed staff to remind her to call for assistance if she was dizzy. R7's EMR lacked evidence of the fall which occurred on 03/11/23 and lacked evidence of post fall assessments and investigation related to an unwitnessed fall from bed. A Progress Note in R7's EMR documented on 03/28/23 a Certified Occupational Therapy Assistant (COTA) evaluated R7 and alerted staff that R7 had increased swelling of her right thigh. Nursing staff evaluated the thigh and confirmed it was a change from the previous day. The physician and family were notified, and the resident was transported the hospital. The X-Ray of the right femur revealed an acute fracture of the distal femur (thigh bone). The EMR documented the resident was transferred to a higher level of care on 03/28/23 and had surgical repair of the fractured femur on 03/30/23. On 03/29/23 in Facility Reported Incident KS00179204 the facility reported R7 had an injury of unknown origin. The facility reported R7 had a history of chronic knee pain which had worsened since 03/11/23, when the residnet tested positive for covid (highly contagious potentially fatal respiratory virus). R7 was hospitalized [DATE] and returned to facility 03/13/23 and, due to knee pain and weakness, staff began using the sit to stand lift for transfers. On 03/19/23 some right knee swelling, and shadowing were noted to the right knee. On 03/20/23, R7's physician evaluated R7 and R7 denied any uncontrolled pain. R7 continued to have complaints of right knee pain, right leg pain, back pain, as well as pain all over. Staff administered R7's pain medications as ordered and applied Bio Freeze (topical pain relief gel) applied as ordered. On 03/28/23, R7 had increased bruising around the knee and swelling above the knee, and R7 was sent to the hospital and diagnosed with a femur fracture. The facility's Fall Investigation, dated 04/03/23, documented on 03/11/23 at 07:35 AM, Certified Nurse Aide (CNA) R delivered R7 her room tray and noted the resident had been incontinent and slid off her bed and onto the floor with her back up against the bed; R7 was in a squat position with knees bent and the left knee on the floor. CNA R and Administrative Nurse E assisted R7 to stand and get into the bed. Administrative Nurse E assessed R7 and Administrative Nurse E did not find any injuries and R7's range of motion was per her usual. Staff assessed the resident, provided cares then transferred her from the bed to the recliner per sit to stand lift Family came in later that day and requested the resident go to the hospital for evaluation. The fall investigation further documented the resident was admitted to the hospital for weakness, urinary tract infection (UTI), and Covid (a highly contagious respiratory disease). The resident returned to the facility 03/13/23. On 04/04/22 at 01:00 PM, observation revealed R25 sat in a recliner in the living room. Further observation revealed the resident the resident had her eyes closed and her footrest was elevated. On 04/03/23 at 04:00 PM, Administrative Nurse E verified R7 slid off the bed on 03/11/23 but Administrative Nurse E did not classify that as a fall and do the post-fall protocols and assessments because R7's buttocks did not make contact with the floor so Administrative Nurse E did not think it counted as a fall, therefore she did not report it or do fall protocol. On 04/04/22 at 09:00 AM, Administrative Staff A verified R7 had a fall on 03/11/23 which resulted in a fracture right femur and Administrative Nurse E failed to report the fall to administration until 04/03/23 which did not allow the facility to adequately assess, investigate a report the fall with injury. The facility's Abuse Prevention policy, dated June 2022, documented residents have the right to be free from, abuse, neglect misappropriation of property, corporal punishment, exploitation and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical director. The facility staff administration and employees are committed to protecting resident from abuse by anyone included, but not necessary limited to facility staff, other residents, consultants volunteers, and staff from other agencies providing services to our resident's, consultants, volunteers, and staff from other agencies providing services to our resident's, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. The facility failed to prevent an incident of staff neglect for R7, when R7 slid out of bed and staff failed to document and report the fall to other care staff so staff could provide follow up fall cares and assessment for R7. This failure placed R7 at risk for unidentified injuries and ongoing neglect and/or abuse.

The facility identified a census of 30 residents. The sample included three residents reviewed for medication errors. Based on observations, record review, and interviews, the facility failed to prevent a significant medication error for Resident (R) 1 when facility staff prepared and wrongly administered R2's medications, including psychotropic (any drug that affects brain activities associated with mental processes and behavior) and antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications, to R1 on 11/16/22. Certified Medication Aide (CMA) R prepared R1's medications, then realized R1 was in the shower. CMA R labeled the medication cup with R1's name, placed the cup back in the cart, and began to prepare R2's medications. CMA R then observed R1 in the dining room and gave R1 the medications she had prepared for R2. As a result, R1 had a significant change in condition which required transfer to the local hospital where she was intubated (tube inserted down the throat to secure the airway) and transferred to a larger hospital for intensive care. CMA R failed to implement the standards of practice regarding medication administration when she failed to verify the right medication for the right resident, prior to administration, which placed R1 in Immediate Jeopardy. Findings included: - R1 admitted to facility on 09/06/18. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling) of right lower limb, generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder), orthostatic hypotension (blood pressure dropping with change of position), and mild intermittent asthma (disorder of narrowed airways that caused wheezing and shortness of breath). The Annual Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 was independent with activities of daily living (ADL) and required setup help only with eating. R1 received antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), anticoagulant (medication used to prevent blood from thickening or clotting), and diuretic (medication to promote the formation and excretion of urine) medications seven days in the seven-day lookback period. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of 15, which indicated intact cognition. R1 was independent with ADLs and required setup help only with eating. R1 received antidepressant, anticoagulant, antibiotic (medication that inhibits or destroys microorganism that cause infections), and diuretic medications seven days in the seven-day lookback period. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 04/19/22, documented R1 was at risk for decreased functional ability to perform ADLs. R1 was dependent with most ADLs with assist of staff as needed. The Psychotropic Drug Use CAA dated 04/19/22, documented R1 was at risk of adverse side effects for antidepressant medication use and nursing monitored R1 for adverse side effects of antidepressant medication daily. The Care Plan, initiated 01/08/21 and revised 02/04/22, documented R1 was at risk for adverse effects of medications because she took medications that had a Black Box Warning (BBW- warnings required by the Food and Drug Administration for certain medications that carry serious safety risks), psychotropic medications, and had medication allergies. The Care Plan documented an intervention, initiated 05/01/21, that directed nursing monitored for adverse effects and side effects of all medications and reported changes in condition to provider in timely manner. The Care Plan documented interventions, initiated 02/04/22, that directed R1 received citalopram and nursing monitored for side effects/adverse effects and efficacy of treatment; and nurse monitored all new prescription for drug interactions and potential allergies. The Care Plan, initiated 01/08/21, documented R1 was at risk for respiratory distress related to asthma and directed staff gave medications as ordered and monitored/documented side effects and effectiveness. The Orders tab of R1's EMR documented an order with a start date of 11/12/22 for Zyvox (antibiotic) 600 milligram (mg) two times a day for wound infection/cellulitis for 10 days. The facility's Investigation, not dated, documented on 11/16/22 at approximately 09:45 AM, CMA R was passing medications and had placed R1's medications into a medication cup. She then realized R1 was in the shower. CMA R labeled the medication cup and placed it in the top drawer of the medication cart then proceeded to prepare R2's medications. CMA R finished preparing R2's medications when R1 walked out of the shower. CMA R handed R1 the cup of pills that she had just prepared. When CMA R went to give R2 her medications, she realized she gave R1 the wrong medications and immediately notified LN G. LN G notified the clinic at 09:55 AM and sent a fax detailing the medications R1 received at 09:58 AM. LN G advised the clinic nurse that there was some urgency because R1 was taking Zyvox and had ingested psychiatric medications as well as an antiparkinsonian agent. R1 went to the dining room at approximately 10:00 AM, ate breakfast, then joined group activities. At 10:25 AM, the activity director notified staff that R1 nodded off which was not unusual for her. LN G asked staff to check R1's vital signs and staff reported R1 was not acting normal. LN G assessed R1 and noted a decreased level of consciousness, muttering speech, was stuporous (a state of near-unconsciousness or insensibility), but responded to verbal and tactile cues. R1 was pale and declined as LN G assessed her. LN G called the clinic and was put on hold, at that time she hung up and called 911 instead. Emergency Medical Services (EMS) arrived at the facility at 10:35 AM. R1's oxygen saturation was 90% on room air, she was placed on supplemental oxygen at 2 liters per minute (lpm). A peripheral intravenous (IV- infusion administration of fluids into a vein by means of a steel needle or plastic catheter) catheter was placed in R1's right forearm and normal saline (saline water solution) infusion was started. R1's blood glucose was checked and was 44 mg per deciliters (mg/dL). The Emergency Medical Technician (EMT) pushed Dextrose 5% in water (D5W- IV solution used to replace lost fluids and limited carbohydrates in the body) via IV. R1 left the facility with EMS at approximately 10:55 AM. LN G gave report to the emergency department (ED) provider and notified R1's family. Consultant GG was in the facility for the Quality Assurance (QA) meeting and informed staff that R1 was intubated and was being transferred to a larger hospital. The root cause analysis of the event was determined to be CMA R did not inquire if R1 was ready for her pills before preparing medications. CMA R was working a task that was not her routine assignment. A Nursing Note on 11/16/22 at 10:01 AM documented CMA R reported to LN G that around 09:30 AM, she gave R1, R2's medications. The medications ingested were: Carbidopa-levodopa (medication used to treat Parkinson's [slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness] disease or Parkinson's like symptoms) 50 mg/200 mg two tablets, cephalexin (antibiotic medication) 500 mg, cholecalciferol (vitamin supplement) 1000 mg, clozapine (antipsychotic medication)100 mg, famotidine (medication used to treat acid reflux and stomach ulcers) 20 mg, magnesium oxide (mineral supplement) 400 mg, venlafaxine extended release (antidepressant) 150 mg, and vitamin B12 (vitamin supplement) 1000 mg. R1 had not had her usual morning medications yet and was currently on Zyvox for treatment of a wound infection. Zyvox had several drug interactions. R1's Medical Record revealed a Hospitalist History and Physical on 11/16/22 that documented R1 was accidentally given medications that belonged to another patient that included carbidopa-levodopa, clozapine, and venlafaxine. R1 was taken to an outlying hospital where she was noted to have acute encephalopathy with a low Glasgow Coma Scale (GCS- a tool used to assess and calculate a patient's level of consciousness) of around seven (patients with a GCS score of seven or less were considered comatose) and was intubated to protect her airway. R1's hypoglycemia was treated with dextrose and her hypotension responded to IV fluids. R1 was transferred to a larger hospital for further care. The Intensive Care Unit (ICU) team was consulted and R1 was likely to be extubated (standard procedure to remove a tube that was placed in a patient's airway) the next day if she was doing well. In a Witness Statement on 11/18/22, CMA R stated she prepared R1's medications, unaware she was in the shower at the time. CMA R labeled the medication cup and put them in the top drawer of the med cart. CMA R was working on R2's medications when R1 came out of the shower. She finished R2's medications and handed the wrong cup to R1. CMA R realized what happened and went to R1 to see if she had taken the medication. R1 had just taken them. CMA R went straight to the charge nurse to report what happened. On 11/21/22 at 10:59 AM, R1 sat in her chair in her room and played a game on her phone. She stated on 11/16/22, she had taken her medications before breakfast and had somehow received the wrong medications. On 11/21/22 at 11:45 AM, CMA R stated she did not know that R1 was in the shower before she prepared her medications. CMA R labeled the med cup and placed in med cart then moved on to R2. R1 came out of shower and went to the dining room. CMA R stated she did not know how she did not manage to grab the cup out of the cart, but she gave R1 the medications she had just prepared for R2. CMA R stated she went down the hall to obtain R2's blood pressure when she realized she gave R1 the wrong medications and ran back to the dining room to see if R1 had taken the medications yet. CMA R stated R1 had just taken the medications, so she reported the medication error to the nurse. CMA R stated to prevent med errors, she was to follow the rights of medication administration, which included right resident, medication, dose, route, and time and was to make sure the resident was directly in front of her when preparing medications. On 11/21/22 at 11:54 AM, LN G stated she was charting around 09:40 AM to 09:45 AM when CMA R told her she made a mistake and had given R1, R2's medications. She stated CMA R held R1's pills in the drawer after realizing she was in the shower and continued to pass medications. CMA R was pulling R2's meds and accidently gave R1 the medications. At that point, because R2 had a lot of psychotropic medications and R1 was receiving Zyvox, which had a lot of drug interactions, she pulled both residents' Medication Administration Records (MAR) and printed them out. She stated she went through R2's med list with CMA R to determine what meds she gave to R1. LN G stated she called the doctor at 09:50 AM and faxed a list of medications R1 received at 09:58 AM. She told all staff to watch R1, because if she anything was to happen, it would be around 10:30 AM. R1 finished breakfast and joined exercise group around 10:10 AM and fell asleep, which was not uncommon for her. At 10:25 AM, CMA was sent to check vitals and came back later saying LN G needed to look at R1 as she was not herself and was acting weird. LN G went to dining room, R1's oxygen saturation was 89% on room air, which was not uncommon due to her respiratory status as an asthmatic. LN G had Administrative Nurse D take a peek at R1, because LN G wanted to send her to the emergency room . LN G called the provider and spoke to the receptionist, but hung up and decided to call 911. EMS arrived and they checked R1's blood sugar, which measured 44 mg/dL. D5W was given through right forearm, oxygen had been applied at 2 lpm, and R1 was stable for transport to the hospital. LN G stated she gave report to the ER provider and later the hospital's pharmacist had called for a report on what medications R1 received. She stated she prevented medication errors by following the five rights of administration, checking the MAR against the medication card, recognizing what medications were placed in the cup, and not pulling medications ahead of time. She stated staff stayed with the residents to make sure medications were taken and nobody left pills with R1. On 11/21/22 at 12:00 PM Administrative Nurse D stated she was informed by LN G there was a medication error on the floor. She stated CMA R had popped R1's pills and went to give them to her, but R1 was in the shower. CMA R then labeled the medication cup and placed it in the medication cart drawer then moved on to next resident. R1 came out of the shower and in CMA R's mind, she had R1's pills and handed her the medications that were in her hand. LN G contacted primary care to see how to proceed, informed him of R1's allergies and what medications she took. They were instructed to monitor R1, which they did. Administrative Nurse D stated because R1 was on Zyvox and it had a lot of drug interactions, staff were concerned. She stated R1 had a noticeable change in condition about an hour after ingestion and was transferred to the ER via EMS. Administrative Nurse D stated education was conducted on the policy of administering oral medications. The facility's Administering Oral Medications policy, last revised [DATE], directed staff checked the label on medication and confirmed medication name and dose with the MAR, confirmed the identity of the resident, allowed resident to swallow oral tablets at his/her own pace, remained with the resident until all medications had been taken. The facility's Identifying and Managing Medication Errors and Adverse Consequences policy, last revised April 2017, directed staff followed relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. The facility failed to prevent a significant medication error when facility staff wrongly administered R2's medications, including psychotropic and antipsychotic medications, to R1 on 11/16/22. R1 had a significant change in condition which required transfer to the local hospital where she was intubated and transferred to a larger hospital for care. CMA R failed to implement the standard of practice regarding medication administration when she failed to verify the right medication was given to the right resident. This placed R1 in Immediate Jeopardy. The facility completed the following corrections by 11/18/22: The medication error was reviewed in Quality Assurance and Performance Improvement (QAPI) on 11/16/22 and immediate corrective actions were put into place. A medication drop lock box was ordered on 11/16/22 for discontinued narcotics All CMA and nurses were trained on the facility medication policy, five medication rights, and timely medication dispensing on 11/16/22 to 11/17/22 The facility replaced R2's medications on 11/17/22 Medication administration audits were completed by Administrative Nurse D on 11/17/22 Both medication carts and medication room were audited by Administrative Nurse D on 11/18/22. The deficient practice was cited as past non-compliance.

The facility had a census of 33 residents. The sample included three residents reviewed for neglect. Based on observation, record review, and interview, the facility failed to prevent an incident of neglect for Resident (R) 1, when Certified Nurse Aide (CNA) M walked away from the resident while R1 sat in a whirlpool chair that was raised approximately four feet in the air. R1 fell from the whirlpool chair which resulted in a fractured (broken) C2 vertebrae (cervical break in a bone in your neck), six fractured ribs (slender curved bones protecting the chest cavity and its organs), a punctured lung, brain bleed, and a laceration (a deep cut) to the left side of her head. This deficient practice placed R1 in immediate jeopardy and had the potential to affect the other 24 residents in the facility. Findings included: - R1's Physician order [REDACTED].), and pain. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition, inattention, disorganized thinking, and an altered level of consciousness. The MDS documented the resident required extensive assistance of two staff for transfers, ambulation, dressing, and dependent on one staff for bathing. The Fall Care Area Assessment (CAA), dated 07/08/19, documented the resident at risk for falls and had impaired balance with transitions from one place to another. The Activities of Daily Living (ADL) Care Plan, dated 12/03/19, documented the resident anxious, used her Broda chair (positioning chair) when unable to walk and liked whirlpools twice a week. The Fall Risk Assessments, dated 01/02/2020 and 02/06/2020, documented the resident had a score of 10 indicating high risk for falls. The Occupational Therapy Evaluation, dated 01/02/2020, documented the resident had poor posturing alignment (position of the body), leaned to the right and left, and migrated (moved) to the edge of her seat, which posed a high risk for falls. The Nurse's Note, dated 02/09/2020 at 12:53 PM, documented Certified Nurse Aide (CNA) M alerted Licensed Nurse (LN) G to the whirlpool room and found the resident lying on the floor, on her left side with her head against the north wall, and actively convulsing (uncontrolled actions of the body). The note documented CNA M stated the resident fell from the whirlpool lift chair headfirst. LN G and LN H moved the resident to assess an actively bleeding laceration on the resident's head. LN H called EMS (Emergency Medical Services) and the resident transferred to the hospital. The Radiology Report, dated 02/09/2020, documented the resident had multiple left lateral (side) rib fractures, a left pneumothorax (a punctured lung), C2 hairline fracture (tiny cracks on a bone in the neck), and a small subarachnoid hemorrhage (bleeding in the brain) in the posterior right temporal lobe (area of the brain behind the ears). On 02/17/2020 at 10:51 AM, observation revealed the whirlpool lift chair in the hallway by the maintenance room with a lockout tagout (a tag affixed to the locked device that cautions others not to attempt to use it) on the lift. Further observation revealed a 17- inch gap from the seat to the safety bar that was on the chair. On 02/17/2020 at 08:00 AM, Administrative Staff A stated staff educated and removed CNA M from work on 02/09/2020 and suspended her on 02/10/2020 Administrative Staff A stated the whirlpool room and chair had not been used since the incident, staff were immediately educated on mechanical lifts and safety straps were ordered for the chair. Administrative Staff A stated all resident care plans were updated and lift transfer assessments were completed for all resident's on 02/10/2020. On 02/17/2020 at 10:25 AM, LN G stated she heard CNA M call for help from the Whirlpool room. LN G entered the room, observed the resident lying on the floor convulsing, and sent CNA M to get another nurse to assist her with the resident. LN G stated a second nurse, LN H, entered the room, they assessed the resident's vital signs, which were within normal limits, and called EMS. LN G stated staff covered the resident with a bath blanket and assisted EMS with lifting the resident onto the gurney (a wheeled stretcher used for transporting hospital patients). On 02/17/2020 at 11:10 AM, CNA M stated after she gave R1 a whirlpool bath, the resident remained seated in the whirlpool chair, raised approximately four feet in the air, as CNA M clipped the resident's toenails. CNA M stated she turned on the call light to have another staff member get the resident a clean shirt. CNA N responded but did not turn off the call light. CNA M stated she made sure the resident was not leaning forward in the whirlpool chair and pulled the chair closer to her as she reached out to turn off the call light, approximately two feet away. CNA M stated after she turned off the call light, she turned to walk back to the resident. CNA M stated R1 curled up in a ball and slipped out of the whirlpool chair under the chair's safety bar. CNA M stated there were no safety straps on the chair. CNA M called for the nurse because the resident started to convulse. LN G entered the room, placed a towel on the resident's bleeding head wound, and CNA M went to get another nurse to assist. CNA M stated staff called EMS who transferred the resident to the hospital. On 02/17/2020 at 12:00 PM, Administrative Nurse D stated the resident had a history of [REDACTED]. On 02/17/2020 at 01:10 PM, LN H stated staff called her to the Whirlpool room and observed R1 lying on her left side having a [MEDICAL CONDITION]. LN H stated she and another nurse assessed the resident's vital signs, made sure the resident's airway was clear, and LN H called EMS. EMS quickly arrived and transferred the resident to the hospital. LN H stated CNA M told her she had the resident in the whirlpool chair raised up approximately four feet and the resident fell out of the chair The facility's Recognizing Signs and Symptoms of Abuse/Neglect policy, dated (MONTH) 2006, documented community staff would not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or the Director of Nursing immediately. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Signs of neglect are leaving someone unattended who needs supervision. The facility failed to adequately secure and monitor cognitively impaired R1 while she sat in the raised whirlpool chair. R1 fell from the chair and sustained a fractured C2 vertebrae, six fractured ribs, punctured lung, brain bleed, and a laceration to the left side of her head. This deficient practice placed the resident in immediate jeopardy. The deficient practice was identified as past non-compliance and was corrected on 02/10/2020 when staff removed the whirlpool chair from use, implemented in-service education and competencies for all staff on mechanical lifts, added safety straps to the whirlpool chair, and completed new resident assessments for the whirlpool chair.

The facility reported a census of 32 residents with 5 residents identified at risk for elopement (when a resident leaves the premises or safe area without staff knowledge). The sample included 3 residents reviewed for elopement. Based on observation, record review, and interview, the facility failed to ensure 1 resident (#1), identified as moderate risk for elopement, received adequate supervision and appropriate interventions to prevent elopement after staff left an exit door alarm disabled for approximately 3 hours. Resident #1 exited the facility without staff knowledge, walked approximately 0.4 miles, and was found by a member of the community approximately 1 block away from the facility. This deficient practice placed resident #1, and 5 other residents identified at risk for elopement, in immediate jeopardy during the time the door alarm was disabled. Findings included: - The physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED].(elation or fell ing down)). The Admission Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident with severely impaired cognition, poor safety awareness, and rejection of cares with physical behaviors. He/she walked without assistance and received anti-psychotic and anti-depressant mediations. The quarterly MDS dated [DATE] documented no changes to the resident's admission assessment. He/she had memory impairment and severely impaired decision making skills. The Care Area Assessment (CAA) dated 10/18/16 for cognition recorded the resident had short and long term memory impairment, inattention, disorganized thinking and wandered daily. The elopement risk assessment dated [DATE] documented the resident had a score of 16, which identified him/her at moderate risk for elopement. The care plan dated 4/17/17 documented the resident wandered and was at risk for elopement, wore a wanderguard (a wrist or ankle worn device that alarms near the door) and directed staff to provide one on one (1:1) monitoring when the resident experienced periods of restlessness and agitation. The nurse's note dated 6/24/17 at 9:52 P.M. documented on 6/24/17 at 4:30 P.M. the facility received a call from local citizen G who inquired about the resident's presence in the facility. He/she observed the resident walking east, on a main street, at a stop sign by his/her house. The nurse's note indicated staff last observed the resident in his/her room at 1:15 P.M (2 hours and 25 minutes earlier). On 6/24/17 at 4:35 P.M. Staff member M drove his/her car to the location reported by citizen G, found the resident, and returned him/her to the facility at 4:40 P.M. Staff assessed the resident and no injuries noted. The resident wore a long sleeve top, pants, and socks (no shoes). According to Google maps, the resident walked 300 feet or 0.4 miles from the facility, approximately 1 block. According to wunderground.com, the outside temperature on 6/24/17 between 3:52 P.M. and 4:52 P.M. was 80 to 81 degrees. The winds were light and the sky was clear. The facility investigation revealed on 6/24/17 at approximately 3:30 P.M. direct care staff member O manually turned off the door alarm to the 400 hall door on the facility's west side so a cognitively alert resident could enter and exit to do some gardening (the facility plan of correction, dated 6/28/17 documented staff turned off the alarm at 1:40 PM). Review of the facility closed circuit camera revealed resident #1 exited through this same door at 4:16 P.M. The investigation revealed staff responded to the wanderguard alarm, did not observe the resident at that time and silenced the wanderguard alarm. The investigation further documented the actual result was resident #1 left the building and the potential was high for this resident to have gotten hurt, lost in a wooded area, or be hit by a vehicle or train. On 6/28/17 at 3:38 P.M. the resident activated a motion sensor alarm at the door to his/her room and staff immediately responded to the resident. On 6/28/17 at 3:45 PM, observation of the route the resident walked at the time of the elpopement revealed the resident exited out the back of building, walked south on a gravel alley drive, walked east along a paved road to a stop sign and then turned back west on the street. The street the resident walked along had 25 miles per hour traffic, lacked a sidewalk and had deep culverts on both sides of the street. On 6/28/17 at 4:59 P.M. the resident exited his/her room, activated the motion sensor alarm, walked to the end of the 200 hall, and exited the facility, sounding the door and wanderguard alarms. Dietary staff M and an unidentified staff member followed a few seconds behind the resident and escorted the resident back inside the facility. On 6/28/17 at 2:46 P.M. dietary staff M stated on 6/24/16 at 4:30 P.M. he/she received a call from citizen G advising the whereabouts of the resident, and he/she went to pick up the resident in his/her personal car. Dietary staff M asked the resident if he/she would like a ride back to the facility and he/she said, No Dietary staff M then said, Well, I cannot park my car here, and the resident said, Oh, okay, and (with a sigh) the resident got into the car and returned to the facility. On 6/28/17 at 2:22 P.M. administrative staff A stated on 6/24/17 between 1:30 and 3:30 P.M. direct care staff O (who was unavailable for interview as he/she no longer worked at the facility at the time of the investigation) shut off the door alarm to the 400 hall to let someone out. The staff member had every intention of turning the alarm back on but got called away and forgot. Resident #1 (per the camera) exited through that door at 4:16 P.M The resident's wanderguard alarm sounded and two staff responded, but did not perform a thorough search outside for the resident and did not do a head count when they re-entered the facility and deactivated the wanderguard alarm. The facility's policy Elopement revised 2/8/17 documented if a door alarm sounded, the alarm cannot be shut off until you have physically opened the door and gone outside to see if you can see anyone. If no one was seen, a complete head count must be done immediately. If a resident was missing you must follow the elopement policy. All new hires will be educated on the door alarms and the wander alarms to assure they understand the process of alarms/elopements. The facility failed to ensure this resident received adequate supervision and appropriate interventions to prevent an elopement, after staff identified the resident as an elopement risk, when this cognitively impaired resident exited the facility on 4/24/17 after staff left an exit door alarm disabled for approximately 3 hours. Resident #1 exited the facility without staff knowledge through that door, walked approximately 0.4 miles, and was found by a member of the community approximately 1 block away from the facility. This deficient practice placed resident #1, and 5 other residents identified at risk for elopement, in immediate jeopardy during the time the door alarm was disabled. This deficient practice was found to be past non-compliance when the facility implemented and completed the following by 6/25/17 at 5:30 P.M.: All staff in-serviced by 6/25/17 at 5:30 PM on door alarms and the elopement process; the resident was immediately placed 1:1 with staff until 10:47 PM on 6/24/17 when the manual door alarm shut off was disabled by maintenance; monitoring of the education on door alarms and elopement process will be conducted twice daily by administrative and administrative nursing staff.

The facility reported a census of 35 residents. The sample included 3 residents reviewed for elopement. Based on observation, record review, and interview, the facility failed to ensure 1 resident (#1) received adequate supervision and appropriate interventions to prevent elopement after staff identified the resident at moderate risk for elopement. Resident #1 exited the facility without staff knowledge, walked approximately 0.61 miles, and was found by the facility's Consultant Staff X approximately 6 blocks away from the facility. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The physician's orders [REDACTED].#1 included a [DIAGNOSES REDACTED]. feeling down). The Admission Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident with severely impaired cognition, poor safety awareness, and rejection of cares with physical behaviors. He/she walked without assistance and received anti-psychotic and anti-depressant medications (medications for mental illness and feeling down). The Care Area Assessment (CAA) dated 10/18/16 for cognition recorded the resident had short and long term memory impairment, inattention, disorganized thinking, and wandered daily. The elopement risk assessment dated [DATE] documented the resident had a score of 16, which indicated a moderate risk for elopement. The care plan dated 10/22/16 documented the resident wandered and was at risk for elopement, and directed staff to provide one on one (1:1) monitoring when the resident experienced periods of restlessness and agitation. The nurse's note dated 2/4/17 at 2:38 P.M. documented the facility received a call from Consultant Staff X who inquired about the resident's presence in the facility, as he/she observed the resident walking on a main street in the city. The nurse's note indicated staff last observed the resident in his/her room at 2:32 P.M During a search of the facility and facility grounds, staff failed to locate the resident and at 2:48 P.M. (10 minutes later), Consultant Staff X returned the resident to the facility. According to Google maps, the resident walked 0.61 miles from the facility, approximately 6 blocks. According to wunderground.com, the outside temperature on 2/4/17 at 2:52 P.M. was 55.9 degrees Fahrenheit. On 2/8/17 at 4:00 P.M., the resident sat in a recliner in the front common area. Licensed nursing staff F performed a check of the resident's alarm guard bracelet (a wrist or ankle device which alarmed near the door). The monitor indicated the alarm functioned properly. On 2/14/17 from 11:14 A.M. to 11:50 A.M., the resident sat in the dining room with a staff member, but did not eat his/her lunch. He/she got up and went to the facility's common area, and walked hand in hand with direct care staff K. The resident broke free of direct care staff K's hand and walked swiftly to a couch and sat down. Direct care staff K left the resident on the couch, went to the dining room, retrieved the resident's lunch tray, and both sat momentarily at a table in the common area. The resident suddenly stood up, and, in less than 10 seconds, exited through the front door of the facility. The door alarm and the resident's bracelet sounded. Direct care staff K responded quickly and escorted the resident back inside the facility. On 2/8/17 at 1:55 P.M., direct care staff H stated he/she worked on 2/4/17, and both the front door and the quiet room door (which led outside the facility) alarmed at the same time. Direct care staff H stated it was very windy on 2/4/17, and the wind blew the doors open, which sounded the alarm. Direct care staff H stated he/she asked another staff member to check the doors when they alarmed, and reset them from a centrally located reset button. Direct care staff H further stated when he/she pushed the reset button, it reset all of the doors. On 2/8/16 at 5:00 P.M. administrative staff A stated staff received education when a door alarmed, the door must be reset at the door. The facility's policy Elopement revised October 2012 lacked documentation related to how and when to deactivate and/or silence door alarms and wander guard devices. The facility failed to ensure this resident received adequate supervision and appropriate interventions to prevent an elopement, after staff identified the resident as an elopement risk, and when this cognitively impaired resident exited the facility without staff's knowledge on 2/4/17. This deficient practice placed resident #1 in immediate jeopardy. The facility implemented the following corrective measures on 2/5/17: A review of the policy and procedure on elopement. If a door alarm is sounding, the alarm cannot be shut off until staff have physically opened the door and went outside to see if they can see anyone. If no one is seen, a complete head count must be done immediately. If a resident is missing, staff must follow the elopement policy. All newly hired staff will be educated on the door alarms and the wander alarms to assure they understand the process of alarms/elopements, door alarms, how to respond, answer, check and headcount. Wander system - how to check if working - to be checked every shift - sign off and on. If door alarm is going off before it is manually reset, staff must notify the supervisor immediately. If staff notice a door has loose hardware, please notify maintenance/administrator. If the wind is blowing the door can be locked; however, they can still be opened from the inside. Everyone needs to respond to the door alarms immediately - whatever door is sounding must be answered. Especially if the front door and Hall 3 door are alarming at the same time - both have to be checked. We are getting a new system and education that we will walk thru the process with staff. When (resident) is out with family, increased frequency of monitoring as a trigger for him/her wanting to leave. Radios/telephones must be kept on staff in case you need to relay help is needed.

The facility had a census of 34 residents. The sample included 18. Based on observation, interview, and record review the facility failed to provide appropriate interventions to prevent the development of a facility acquired pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (#8) Resident #8 had a history of [REDACTED]. Findings included: - Resident #8's physician order [REDACTED]. glucose, there's not enough insulin made or the body can't respond to the insulin), and pressure ulcer stage 2 (superficial open sore in the upper layer of skin) The quarterly (MDS) Minimum Data Set 3.0 assessment, dated 3/19/14, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 3 and exhibited inattention, disorganized thinking behaviors, and verbal behaviors towards others. The MDS further indicated the resident required extensive assistance from 2 staff for dressing and transfers, required extensive assistance from 1 staff for personal hygiene, and he/she was frequently incontinent of urine. The MDS indicated the resident weighed 169 pounds, had a stage 1 pressure ulcer with moisture related skin damage, and the facility provided nutritional/hydration pressure ulcer care interventions. The 2/3/14 care plan instructed the staff to follow the facility's Pressure Ulcer protocol, reposition the resident every 2 hours, report redness or loss of skin integrity to the charge nurse, provide a licensed nurse skin assessment every week, and apply pressure boots to the resident's feet at night. The 3/6/14 care plan update instructed the staff to apply A&D ointment (ointment with Vitamin A & D) to the resident's feet daily and to apply pressure relief boots when he/she was in bed. The 5/6/14 care plan update instructed the staff apply pressure relief boots at all times, and to notify the physician with any change in status, signs or symptoms of infection, redness, foul odor, or pain. The care plan directed the staff to consult physical therapy, and occupational therapy, and the registered dietician as needed. The 6/23/14 care plan instructed the staff to apply a pressure relieving mattress to the resident's bed, pressure relieving cushion to the resident ' s chair, to consult the dietician as needed, apply boots to his/her feet at all times, provide treatment to the affected areas per the physician's order [REDACTED]. The 2/3/14 Braden skin assessment score of 19 indicated the resident was not at risk for skin break down. Review of the medical record revealed the resident had stage 2 pressure ulcers on his/her heels and gluteal cleft (center of buttocks) when admitted to the facility on [DATE]. The 2/4/14 physician's order [REDACTED].<http://labtestsonline.org/understanding/conditions/malnutrition>), [MEDICATION NAME] (evaluation of overall health status) and a total protein (amount of total protein in the blood) blood laboratory test if not done in the past month. The 2/17/14 (RD) Registered Dietician's initial assessment indicated the resident received Med Pass with meals and he/she had a stage 2 pressure ulcer. The RD assessment indicated the resident appeared quite frail, and would be followed closely, and he/she may recommend a daily multi vitamin in addition to other supplements. The 3/6/14 physician's orders [REDACTED]. The 3/20/14 at 3:14 PM nurse's note indicated the resident's gluteal cleft stage 2 pressure ulcer was closed with a 0.5 cm area of moisture related maturation (the process of ripening or developing something or of making it more mature) and staff continued to treat the area. The nurse's notes revealed no mention of when the resident's heels closed. The 3/27/14 laboratory report indicated the resident had a low [MEDICATION NAME] result of 2.8 (normal 3.5 to 5.0), a total protein of 6.0 (normal 6.5 to 8.1), and a low pre [MEDICATION NAME] of 12.2 (normal 20.0 to 40.0). (lab obtained 52 days after the physician ordered) The 4/30/14 registered dietician's quarterly review indicated the RD recommended the facility use power pudding (an edible mixture to induce bowel movements) for the resident's chronic constipation and he/she would follow up on the success of the pudding. The RD note further indicated the resident independently moved about the facility in his/her wheelchair and weighed 167.2 pounds (5.8 pound weight loss). The RD note revealed no documentation related to the resident's low pre-[MEDICATION NAME] and total protein levels obtained on 3/27/14. The 5/5/14 at 11:30 AM nurse's note indicated the staff observed the resident had slightly reddened dry skin on his/her heels. The 5/6/14 at 8:07 AM nurse's note indicated the resident's left heel had a 4.5 (cm) centimeter by 4.5 cm roofed (closed) blister with white skin covering the blister with surrounding redness, and no drainage. The 5/6/14 physician's visit indicated the resident had a [DIAGNOSES REDACTED]. The note indicated the physician suspected this was due to accidental shearing and the staff reported no known trauma to the resident's heels. The note continued to indicate the resident was more mobile in his/her wheelchair, than when first admitted to the facility, and the resident had chronic, recurring ulcerations to his/her feet. The note indicated the staff would update the resident ' s pressure reduction boots, use skin prep (is a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) to the heels, a pad with foam over the ulcerations, and secure with gauze, daily. Review of the 5/8/14 weekly skin integrity tool indicated the resident received gluteal cleft and heel treatment and had pressure reducing boots. (The skin assessment did not include a description of the wound or measurements.) The 5/16/14 at 7:20 AM nurse's note indicated the resident had an unstageable blister on his/her left heel which measured 4.9 cm by 5 cm. The note indicated the superior medial left heel (a second area on the left) had a roofed (closed) clear full blister with no surrounding redness which measured 2.7 cm by 3.1 cm. The 5/27/14 at 1:49 PM nurse's note indicated the resident had a right heel blister that measured 2.7 cm by 3.1 cm with a small closed area on the side of the blister which measured 1.4 cm by 0.6 cm and the facility notified the physician. The 5/27/14 physician's orders [REDACTED]. The 5/29/14 at 4:19 PM nurse's note indicated the resident's right heel had an open area that measured 2.7 cm by 3.0 cm with a clear intact blister present and his/her peri (genital) wound was intact and unstageable at this time. The note further indicated the resident's right heel had a 0.9 cm by 0.9 cm firm pink area that was present on admission. The note further indicated the resident's left heel had a 5 cm by 4 cm red firm area which was an intact blister and unstageable at this time. The note continued to indicate the resident's left heel also had a 3.6 cm by 5.0 cm by 0.3 cm in depth intact blister with loose skin, which felt firm to the touch. The 6/2/14 at 7:28 AM nurse's note indicated the resident's right heel had a 2.5 cm by 2.2 cm with 0.2 cm in depth clear intact blister present with a 0.8 cm by 0.8 cm hardened pink area next to the blister. The note further indicated the resident's left heel had a 4 cm by 3.3 cm by 0.2 cm in depth red intact blister on the medial side of the left heel and the bottom of the resident's left heel had a 4.2 cm by 4.7 cm hardened red area and was unstageable. The 6/3/14 at 3:01 PM nurse's note indicated the resident's physician debrided (the process of removing nonliving tissue) the hardened left heel area of the unroofed blister and indicated the area a stage 2 pressure ulcer. The note further described the wound bed as pink with 2 red areas present. The note indicated the resident's left heel a smaller red blister which was debrided and had a congealed (firm) blood clot under the skin and the wound bed was dark pink to red in color. The note indicated the resident's right heel was unstageable and unable to be debrided. The 6/3/14 physician's orders [REDACTED]. (The previous physician's orders [REDACTED]. The 6/12/14 at 2:18 PM nurse's note indicated the resident's physician debrided both of the resident's right and left heel pressure ulcers. The left heel had an area 1.6 cm by 1.4 cm with red tissue and an area 1.3 x 1.4 of red tissue and an area 1.0 by 1.0 cm of red tissue with a total area of 3.6 by 5 cm with healthy skin. The note indicated the resident's right heel measured 2.5 cm by 3.5 cm and was unroofed and debrided. Review of the June 21, 2014 weekly skin integrity tool indicated the resident received gluteal cleft and heel treatment and had pressure reduction boots at all times. (The skin assessment did not indicate a description of the wound or measurements documented by the staff) The 7/5/14 at 2:54 PM nurse's note indicated the resident's left heel had increased redness, had a black and blue spot in the middle, and the staff would monitor for softness, worsening, and notify the wound nurse of the changes. The 7/10/14 referral form revealed the physician instructed the facility to continue the current treatment, for the resident to wear pressure reduction boots at all times, obtain a pre-[MEDICATION NAME], total protein, and [MEDICATION NAME] with monthly 7/14/14 lab draw, and to confirm the dietician was following the resident as a high risk. The 7/10/14 physician's visit indicated the status of the resident's heels appeared to be traumatic and it was unclear how the resident was shearing his/her heels. The note indicated the physician suspected the shearing to be acquired by independent mobilization of his/her wheelchair. The physician recommended the staff assist the resident with mobilization over the next two weeks as the facility worked to heal the area, and directed the staff to continue the current treatment. Review of the medical record revealed no documentation by the RD since 5/6/14 when the pressure ulcers developed although the resident's protein levels on 3/27/14 were below normal and the RD made no reference to the abnormal lab values on his/her last review of the resident on 4/30/14. On 7/10/14 at 2:45 PM, observation revealed the resident asleep in his/her bed tilted to the left with pillows and Nurse A at the bedside to do a dressing change on the resident's heels. Nurse A removed the resident's pressure relieving boots, and his/her dressings applied to the resident's feet with scissors. The resident's right heel has a 4 cm by 2 cm area of pinkness with no open area and the resident's left heel had bloody drainage from the wound which measured 3 cm by 2.5 cm area that was black around the edges and dark red in the center. Nurse A cleansed the resident's heels with wound cleanser and applied [MEDICATION NAME] ointment, covered with foam and wrapped with gauze. On 7/9/14 at 9:55 AM, Nurse D verified the RD had not been involved in the resident's pressure ulcer treatment since the resident's heels reopened on 5/6/14. On 7/9/14 at 10:39 AM, Nurse G verified he/she had a concern the resident's heel felt mushier and the resident had been hurting more. Nurse D further verified in the 4 days he/she had been working with the resident he/she felt the physician needed to evaluate the wounds, because they had gotten worse and were almost black. On 7/9/14 at 10:45 AM, Nurse D verified he/she was the wound care nurse and was not notified the resident's heel was getting worse and the physician was not notified of the progression and should have been notified if there was a change. Nurse D further verified the facility failed to document at least weekly measurements and description of the resident's wounds. On 7/9/14 at 1:48 PM, Nurse G stated the resident's left heel was purple, blackish and mushy and the resident had complained of pain when it was cleaned and dressed the wound. Nurse G further verified staff had notified him/her in report the resident's heel was getting better and he/she was not notified of the 7/5/14 documentation. On 7/9/14 at 1:45 PM, Dietary Manager H verified he/she was not notified the RD the resident's heels reopened in May. On 7/9/14 at 2:09 PM, Registered Dietician I verified he/she was not notified the resident had a pressure area during his/her last visit to the facility on [DATE]. (30 days after the resident developed the stage 2 pressure ulcers on his/her heels) On 7/10/14 at 3:30 PM, Administrative Staff F verified the facility had weekly skin and weight meetings during which the wound nurse and dietary made recommendations of the resident needs. Administrative Staff F further stated the facility involved the RD if a resident had a skin or weight loss issue. On 7/16/14 at 10:45 AM, Physician Staff J verified the facility's system for dietary measures were not implemented to assist in wound healing. On 7/10/14 at 1:54 PM, Dietary Manager H verified the RD was last in the facility on 6/6/14. The facility's 10/2012 Pressure Sore Monitoring Assessment and Documentation policy instructed the staff when a pressure ulcer is identified the weekly pressure sore record is used for the initial baseline assessment tool as well as causative factors is completed. The policy further indicated the outcome of wound care interventions are assessed weekly by an interdisciplinary team consisting of the dietician, physical therapist, nurse manager, staff nurse, and nursing assistants. The policy instructed the staff to document the resident's dietary status and stated all residents with a wound should be screened for nutritional deficit by obtaining an [MEDICATION NAME] level and/or a weight variance. Dietary interventions are suggested based on [MEDICATION NAME]/weight variance. The policy instructed the staff the outcome of the interventions by dietary are to be monitored weekly by the wound team. The policy further instructed the staff to document what interventions are in place to manage pressure and to check for pressure relief between all bones and under heels. The facility failed to implement preventative measure for Resident #8 who re-developed unstageable pressure ulcers, and failed to accurately assess and seek timely physician intervention to prevent further progression of the wound.

The facility had a census of 45 residents. The sample included 25 residents. Based on observation, record review and interview, the facility failed to ensure the psychosocial needs of the resident were met and the resident did not display a pattern of decreased social interaction and/or increased withdrawal, anger, or depressive behaviors or lead to behaviors of alcohol consumption for 1 of 25 residents. (#43) - The 3/19/14 Psychotherapy Progress note revealed Resident #43 had a history of [REDACTED]. The quarterly (MDS) Minimum Data Set 3.0 assessment, dated 3/17/14, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 12 which indicated moderately impaired cognition. The assessment revealed the resident was independent with bed mobility, transfers, toileting, eating, and walking in his/her room, and extensive assistance of 1 staff member for dressing. The assessment further revealed the resident required supervision with no staff assistance for walking in corridor, locomotion on and off the unit, had unsteady balance when walking and had no falls since admission. The assessment indicated the resident felt depressed and hopeless daily. The quarterly MDS, dated [DATE], and the admission MDS, dated [DATE], both indicated the resident displayed no behaviors. The 11/7/13 (CAA) Care Area Assessment for behaviors indicated the resident was short tempered and easily annoyed daily. The CAA further stated the resident experienced delusions and displayed verbal behaviors toward others. The 11/22/13 Care Plan Conference Report indicated the resident refused to attend the meeting. The report indicated the resident was blind in one eye and required supervision so he/she would not run into other residents. The report further indicated the resident was often [MEDICAL CONDITION] his/her emotions and was paranoid at times. The care plan update on 1/11/14, indicated at 2:15 PM, the resident shoved another resident and stated he/she was on a tapering dose of [MEDICATION NAME](severe pain medication) and refused to take many of his/her medications. The care plan directed the staff to redirect the resident, provide activities, and to visit 1:1 with the resident. The care plan did not provide interventions specific to the resident's behaviors. The 2/19/14 care plan for behaviors stated the resident had socially inappropriate and disruptive behaviors and directed the staff to intervene if necessary, to assess whether the behavior endangered the resident or others, and to maintain a calm environment. The care plan lacked specific target behaviors with specific instructions to staff on ways to intervene and provide psychosocial support. The 2/19/14 care plan stated the resident walked to the liquor store, and purchased and consumed alcohol against physician orders [REDACTED]. The care plan lacked specific education to use or who to contact to inquire about alcohol anonymous meetings. The 11/1/13 facility Elopement Risk Assessment indicated the staff assessed the resident as an elopement risk due to his/her moderate cognitive impairment. The assessment directed the staff to redirect the resident, and involve social services and activities. The November and December 2013, January, February, and March 2014 Behavior Monitoring Sheets revealed the resident yelled and cursed several days. The sheets lacked documentation of the resident ' s behaviors on the following days: The 10/31/13 physician order [REDACTED]. The 10/31/13 physician order [REDACTED]. 1) For the use of an antipsychotic medication: 11/11, 11/12, 11/13, - Day shift 3/19, 3/24, 3/25, 3/29, 3/30 - Day shift 3/19, 3/24, 3/25, 3/29, 3/30- Evening shift 2) For the use of mood stabilizer medication: 1/10, 1/28 - Day shift 1/4, 1/5, 1/6, 1/7, 1/8, 1/9 - Evening shift 3/24, 3/25, 3/29, 3/30- Dayshift 3/24, 3/25, 3/29, 3/30- Evening shift The 11/23/13 at 8:41 AM, nurse's note stated the resident demanded his/her wander guard (a wrist or ankle band tracking application designed to prevent persons at risk, from leaving a facility unless they are accompanied) be removed or he/she would slash the staff ' s tires. The note further stated staff removed the wander guard. The notes had no documentation of attempted education or intervention prior to removing the wander guard. The 12/3/13 at 3:07 PM, nurse's note stated the resident knocked over residents' walkers and threw things in the 200 Hall. The nurse's note further stated the staff notified the Director of Nursing and the local law enforcement. The notes had no documentation of specific intervention by staff during the resident's behavior. The 12/30/13 physician's orders [REDACTED]. The 1/15/14 at 3:43 PM, nurse's note stated Resident #43 had an altercation with another resident in the facility. The note further stated Resident #43 took off his/her belt, pounded on doors, looking for the other resident to continue the fight, and the staff called the local law enforcement and requested they come to the facility. The note stated the staff notified the hospital, Director of Nursing and the Administrator. The notes had no documentation of specific interventions by staff during the resident ' s behavior. The 1/2/14 at 2:12 PM, social service note stated the Resident #43 was in the social service office and requested change. The note further stated another resident stated Resident #43 was disrespectful for interrupting his/her visit with the social service designee. Resident #43 stated he/she would like to knock the resident out of the chair but walked away. The 2/20/14 at 3:30 PM, nurse's note stated the Director of Nursing and another staff member took the resident to the liquor store where the resident purchased 3 small bottles of whiskey and returned the resident to the facility to consume the liquor. The 2/22/14 at 7:46 PM, nurse's note stated the hospitality aide followed the resident out of the facility. The note stated after a long period of time, a nurse went to look for the resident and the hospitality aide. The note stated the nurse wanted no altercation with the resident, so the nurse took the resident to the liquor store. The note further stated the resident purchased a pint of rum and requested staff leave the resident 1 block away from the facility. The note stated 2 staff members later assisted the resident into a wheelchair after he/she had fallen asleep on a bench in front of the facility. The note had no documentation of attempted interventions or psychosocial support other than to assist the resident to obtain liquor. The 2/26/14 at 3:56 PM, social services note stated a local citizen notified the facility the resident was laying in a private driveway 1 block south of the facility. The note further stated the (SSD) Social Service Designee and 1 staff member found the resident unsteady on his/her feet, and dirt on the back of his/her pants and coat. The note had no documentation of intervention after the incident. The 2/28/14 at 12:08 PM, nurse's note stated the facility issued a 30 day involuntary discharge notice to the resident due to not following the facility rules regarding his/her behavior of leaving the facility and consuming alcohol. (Although the facility staff assisted the resident in purchasing the alcohol). The note further stated the facility would cancel the 30 day notice if the resident's behavior regarding the alcohol stopped. The 3/15/14 at 1:52 PM, nurse's note stated the resident had refused all of his/her medications as of the end of February 2014 and the staff notified the physician. The 3/21/14 at 9:23 PM, nurse's note stated the SSD found the resident asleep on a bench on Main Street with one empty 1/2 pint bottle of vodka. The note further stated earlier in the day, the resident had purchased a pint size bottle of whiskey and drank it while seated in front of the facility. The note had no documentation of monitoring the resident prior to or intervention after the incident. The 3/24/14 at 3:19 PM, nurse's note stated the police came to the facility and searched the resident's room and found a 1/2 pint bottle of vodka. The note further state the police strongly encouraged the resident not to purchase any more alcohol. The 3/25/14 at 5:37 PM, nurse's note stated the resident fell at the end of the facility parking lot. The note further stated the resident, was very unsteady on his/her feet, and stated he/she was drunk. The resident required the assistance of 4 staff members to stand up. The note had no documentation of monitoring the resident prior to or intervention after the incident. The 3/27/14 at 10:47 AM, social service note stated a representative from a inpatient treatment facility would come to the facility to visit with the resident on 4/7/14. The 4/7/14 at 5:43 PM, nurse's note stated the resident passed out on his/her bed with a liquor bottle still in his/her hand. The nurse ' s note had no documentation of specific interventions by the staff. The 4/8/14 at 8:16 AM, social service note stated the resident stood in front of a house by the facility, drank vodka, and threw the empty bottle in the driver's seat of an employee's vehicle. The nurse ' s note had no documentation of specific interventions by the staff. The 4/8/14 at 3:09 PM, nurse's note stated the city police found the resident by the liquor store drinking and placed the resident in the front seat of the police car and transported his/her back to the facility. The nurse ' s note had no documentation of specific interventions by the staff. The 4/16/14 at 1:44 PM, nurse's note stated the facility canceled the 30 day notice and planned to try different approaches and treatment for [REDACTED]. (As of 4/24/14 at 7:43 AM, the progress notes had no documentation the facility transferred the resident to the inpatient facility). The 4/17/14 at 8:29 PM, nurse's note stated the resident was drunk the entire shift after being passed out downtown. The note further stated the resident was agitated and had a confrontation with another resident. The nurse's note had no documentation of specific interventions by the staff during the resident' s behavior. The 4/21/14 at 8:35 AM, nurse's note stated the resident had tremors and stated he/she had drank 3 1/2 pints of alcohol on Saturday and 2 pints of alcohol on Sunday morning. The note further stated the staff notified the physician and the physician directed the staff to administer [MEDICATION NAME] (an antianxiety medication), 0.5 (mg) milligrams, every 4-6 hours as needed, and to monitor vital signs. The note had no documentation of monitoring the resident or attempted intervention. On 4/16/14 at 2:00 PM, observation revealed the resident standing in front of the facility talking with another resident. On 4/15/14 at 10:00 AM, Administration Staff Y stated he/she thought the resident was scared when he/she first came to the facility and needed to adjust to the facility. On 4/16/14 at 10:00 AM, Nurse Aide L stated the resident walked downtown daily and the resident had behaviors that are not easily redirected by the staff. On 4/16/14 at 3:15 PM, Nurse K stated the resident went downtown to the liquor store and drank a lot. Nurse K further stated he/she went with the resident when he/she bought alcohol. Nurse K stated staff was not sure of how to take care of the resident who had a [DIAGNOSES REDACTED]. On 4/21/14 at 10:21 AM, Social Service Staff A stated the resident does not respond to redirection or 1:1. Social Service Staff A stated he/she had attempted to get the resident into AA (alcoholics anonymous) meetings. He/she further stated the resident would attend some of the meetings but then change his/her mind. The resident had expressed desires to move but would change his/her mind and wanted to stay at the facility and receive treatment. On 4/21/14 at 11:30 AM, Administrative Staff E stated the resident was not to drink in the facility and verified the staff was unable to effectively monitor and redirect the resident ' s behaviors. The January 2011 facility Unmanageable Resident policy stated the staff would provide a safe place for the resident to live. The policy directed the staff that if a resident's behavior became abusive, hostile, assaultive or unmanageable in a way that jeopardized his/her safety or the safety of others, the nurse must provide safety for all concerned, notify the Director of Nursing and the physician. The policy further directed staff to contact the local law enforcement should a resident pose an immediate danger, or became violent. The policy stated the facility would implement discharge proceedings as instructed by the attending physician or medical director. The 6/13 Facility House Rules stated the use of alcohol or illegal substances were prohibited. The house rules further stated failure to comply with the policy may result in discharge from the facility. The facility failed to provide treatment and services for psychosocial adjustment without the increase of decreased social interaction, aggressive behavior and alcohol consumption for Resident #43.

The facility had a census of 34 residents. The sample included 18. Based on observation, interview, and record review the facility failed to provide appropriate interventions to prevent the development of a facility acquired pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (#8) Resident #8 had a history of [REDACTED]. Findings included: - Resident #8's physician order [REDACTED]. glucose, there's not enough insulin made or the body can't respond to the insulin), and pressure ulcer stage 2 (superficial open sore in the upper layer of skin) The quarterly (MDS) Minimum Data Set 3.0 assessment, dated 3/19/14, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 3 and exhibited inattention, disorganized thinking behaviors, and verbal behaviors towards others. The MDS further indicated the resident required extensive assistance from 2 staff for dressing and transfers, required extensive assistance from 1 staff for personal hygiene, and he/she was frequently incontinent of urine. The MDS indicated the resident weighed 169 pounds, had a stage 1 pressure ulcer with moisture related skin damage, and the facility provided nutritional/hydration pressure ulcer care interventions. The 2/3/14 care plan instructed the staff to follow the facility's Pressure Ulcer protocol, reposition the resident every 2 hours, report redness or loss of skin integrity to the charge nurse, provide a licensed nurse skin assessment every week, and apply pressure boots to the resident's feet at night. The 3/6/14 care plan update instructed the staff to apply A&D ointment (ointment with Vitamin A & D) to the resident's feet daily and to apply pressure relief boots when he/she was in bed. The 5/6/14 care plan update instructed the staff apply pressure relief boots at all times, and to notify the physician with any change in status, signs or symptoms of infection, redness, foul odor, or pain. The care plan directed the staff to consult physical therapy, and occupational therapy, and the registered dietician as needed. The 6/23/14 care plan instructed the staff to apply a pressure relieving mattress to the resident's bed, pressure relieving cushion to the resident ' s chair, to consult the dietician as needed, apply boots to his/her feet at all times, provide treatment to the affected areas per the physician's order [REDACTED]. The 2/3/14 Braden skin assessment score of 19 indicated the resident was not at risk for skin break down. Review of the medical record revealed the resident had stage 2 pressure ulcers on his/her heels and gluteal cleft (center of buttocks) when admitted to the facility on [DATE]. The 2/4/14 physician's order [REDACTED].<http://labtestsonline.org/understanding/conditions/malnutrition>), [MEDICATION NAME] (evaluation of overall health status) and a total protein (amount of total protein in the blood) blood laboratory test if not done in the past month. The 2/17/14 (RD) Registered Dietician's initial assessment indicated the resident received Med Pass with meals and he/she had a stage 2 pressure ulcer. The RD assessment indicated the resident appeared quite frail, and would be followed closely, and he/she may recommend a daily multi vitamin in addition to other supplements. The 3/6/14 physician's orders [REDACTED]. The 3/20/14 at 3:14 PM nurse's note indicated the resident's gluteal cleft stage 2 pressure ulcer was closed with a 0.5 cm area of moisture related maturation (the process of ripening or developing something or of making it more mature) and staff continued to treat the area. The nurse's notes revealed no mention of when the resident's heels closed. The 3/27/14 laboratory report indicated the resident had a low [MEDICATION NAME] result of 2.8 (normal 3.5 to 5.0), a total protein of 6.0 (normal 6.5 to 8.1), and a low pre [MEDICATION NAME] of 12.2 (normal 20.0 to 40.0). (lab obtained 52 days after the physician ordered) The 4/30/14 registered dietician's quarterly review indicated the RD recommended the facility use power pudding (an edible mixture to induce bowel movements) for the resident's chronic constipation and he/she would follow up on the success of the pudding. The RD note further indicated the resident independently moved about the facility in his/her wheelchair and weighed 167.2 pounds (5.8 pound weight loss). The RD note revealed no documentation related to the resident's low pre-[MEDICATION NAME] and total protein levels obtained on 3/27/14. The 5/5/14 at 11:30 AM nurse's note indicated the staff observed the resident had slightly reddened dry skin on his/her heels. The 5/6/14 at 8:07 AM nurse's note indicated the resident's left heel had a 4.5 (cm) centimeter by 4.5 cm roofed (closed) blister with white skin covering the blister with surrounding redness, and no drainage. The 5/6/14 physician's visit indicated the resident had a [DIAGNOSES REDACTED]. The note indicated the physician suspected this was due to accidental shearing and the staff reported no known trauma to the resident's heels. The note continued to indicate the resident was more mobile in his/her wheelchair, than when first admitted to the facility, and the resident had chronic, recurring ulcerations to his/her feet. The note indicated the staff would update the resident ' s pressure reduction boots, use skin prep (is a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) to the heels, a pad with foam over the ulcerations, and secure with gauze, daily. Review of the 5/8/14 weekly skin integrity tool indicated the resident received gluteal cleft and heel treatment and had pressure reducing boots. (The skin assessment did not include a description of the wound or measurements.) The 5/16/14 at 7:20 AM nurse's note indicated the resident had an unstageable blister on his/her left heel which measured 4.9 cm by 5 cm. The note indicated the superior medial left heel (a second area on the left) had a roofed (closed) clear full blister with no surrounding redness which measured 2.7 cm by 3.1 cm. The 5/27/14 at 1:49 PM nurse's note indicated the resident had a right heel blister that measured 2.7 cm by 3.1 cm with a small closed area on the side of the blister which measured 1.4 cm by 0.6 cm and the facility notified the physician. The 5/27/14 physician's orders [REDACTED]. The 5/29/14 at 4:19 PM nurse's note indicated the resident's right heel had an open area that measured 2.7 cm by 3.0 cm with a clear intact blister present and his/her peri (genital) wound was intact and unstageable at this time. The note further indicated the resident's right heel had a 0.9 cm by 0.9 cm firm pink area that was present on admission. The note further indicated the resident's left heel had a 5 cm by 4 cm red firm area which was an intact blister and unstageable at this time. The note continued to indicate the resident's left heel also had a 3.6 cm by 5.0 cm by 0.3 cm in depth intact blister with loose skin, which felt firm to the touch. The 6/2/14 at 7:28 AM nurse's note indicated the resident's right heel had a 2.5 cm by 2.2 cm with 0.2 cm in depth clear intact blister present with a 0.8 cm by 0.8 cm hardened pink area next to the blister. The note further indicated the resident's left heel had a 4 cm by 3.3 cm by 0.2 cm in depth red intact blister on the medial side of the left heel and the bottom of the resident's left heel had a 4.2 cm by 4.7 cm hardened red area and was unstageable. The 6/3/14 at 3:01 PM nurse's note indicated the resident's physician debrided (the process of removing nonliving tissue) the hardened left heel area of the unroofed blister and indicated the area a stage 2 pressure ulcer. The note further described the wound bed as pink with 2 red areas present. The note indicated the resident's left heel a smaller red blister which was debrided and had a congealed (firm) blood clot under the skin and the wound bed was dark pink to red in color. The note indicated the resident's right heel was unstageable and unable to be debrided. The 6/3/14 physician's orders [REDACTED]. (The previous physician's orders [REDACTED]. The 6/12/14 at 2:18 PM nurse's note indicated the resident's physician debrided both of the resident's right and left heel pressure ulcers. The left heel had an area 1.6 cm by 1.4 cm with red tissue and an area 1.3 x 1.4 of red tissue and an area 1.0 by 1.0 cm of red tissue with a total area of 3.6 by 5 cm with healthy skin. The note indicated the resident's right heel measured 2.5 cm by 3.5 cm and was unroofed and debrided. Review of the June 21, 2014 weekly skin integrity tool indicated the resident received gluteal cleft and heel treatment and had pressure reduction boots at all times. (The skin assessment did not indicate a description of the wound or measurements documented by the staff) The 7/5/14 at 2:54 PM nurse's note indicated the resident's left heel had increased redness, had a black and blue spot in the middle, and the staff would monitor for softness, worsening, and notify the wound nurse of the changes. The 7/10/14 referral form revealed the physician instructed the facility to continue the current treatment, for the resident to wear pressure reduction boots at all times, obtain a pre-[MEDICATION NAME], total protein, and [MEDICATION NAME] with monthly 7/14/14 lab draw, and to confirm the dietician was following the resident as a high risk. The 7/10/14 physician's visit indicated the status of the resident's heels appeared to be traumatic and it was unclear how the resident was shearing his/her heels. The note indicated the physician suspected the shearing to be acquired by independent mobilization of his/her wheelchair. The physician recommended the staff assist the resident with mobilization over the next two weeks as the facility worked to heal the area, and directed the staff to continue the current treatment. Review of the medical record revealed no documentation by the RD since 5/6/14 when the pressure ulcers developed although the resident's protein levels on 3/27/14 were below normal and the RD made no reference to the abnormal lab values on his/her last review of the resident on 4/30/14. On 7/10/14 at 2:45 PM, observation revealed the resident asleep in his/her bed tilted to the left with pillows and Nurse A at the bedside to do a dressing change on the resident's heels. Nurse A removed the resident's pressure relieving boots, and his/her dressings applied to the resident's feet with scissors. The resident's right heel has a 4 cm by 2 cm area of pinkness with no open area and the resident's left heel had bloody drainage from the wound which measured 3 cm by 2.5 cm area that was black around the edges and dark red in the center. Nurse A cleansed the resident's heels with wound cleanser and applied [MEDICATION NAME] ointment, covered with foam and wrapped with gauze. On 7/9/14 at 9:55 AM, Nurse D verified the RD had not been involved in the resident's pressure ulcer treatment since the resident's heels reopened on 5/6/14. On 7/9/14 at 10:39 AM, Nurse G verified he/she had a concern the resident's heel felt mushier and the resident had been hurting more. Nurse D further verified in the 4 days he/she had been working with the resident he/she felt the physician needed to evaluate the wounds, because they had gotten worse and were almost black. On 7/9/14 at 10:45 AM, Nurse D verified he/she was the wound care nurse and was not notified the resident's heel was getting worse and the physician was not notified of the progression and should have been notified if there was a change. Nurse D further verified the facility failed to document at least weekly measurements and description of the resident's wounds. On 7/9/14 at 1:48 PM, Nurse G stated the resident's left heel was purple, blackish and mushy and the resident had complained of pain when it was cleaned and dressed the wound. Nurse G further verified staff had notified him/her in report the resident's heel was getting better and he/she was not notified of the 7/5/14 documentation. On 7/9/14 at 1:45 PM, Dietary Manager H verified he/she was not notified the RD the resident's heels reopened in May. On 7/9/14 at 2:09 PM, Registered Dietician I verified he/she was not notified the resident had a pressure area during his/her last visit to the facility on [DATE]. (30 days after the resident developed the stage 2 pressure ulcers on his/her heels) On 7/10/14 at 3:30 PM, Administrative Staff F verified the facility had weekly skin and weight meetings during which the wound nurse and dietary made recommendations of the resident needs. Administrative Staff F further stated the facility involved the RD if a resident had a skin or weight loss issue. On 7/16/14 at 10:45 AM, Physician Staff J verified the facility's system for dietary measures were not implemented to assist in wound healing. On 7/10/14 at 1:54 PM, Dietary Manager H verified the RD was last in the facility on 6/6/14. The facility's 10/2012 Pressure Sore Monitoring Assessment and Documentation policy instructed the staff when a pressure ulcer is identified the weekly pressure sore record is used for the initial baseline assessment tool as well as causative factors is completed. The policy further indicated the outcome of wound care interventions are assessed weekly by an interdisciplinary team consisting of the dietician, physical therapist, nurse manager, staff nurse, and nursing assistants. The policy instructed the staff to document the resident's dietary status and stated all residents with a wound should be screened for nutritional deficit by obtaining an [MEDICATION NAME] level and/or a weight variance. Dietary interventions are suggested based on [MEDICATION NAME]/weight variance. The policy instructed the staff the outcome of the interventions by dietary are to be monitored weekly by the wound team. The policy further instructed the staff to document what interventions are in place to manage pressure and to check for pressure relief between all bones and under heels. The facility failed to implement preventative measure for Resident #8 who re-developed unstageable pressure ulcers, and failed to accurately assess and seek timely physician intervention to prevent further progression of the wound.

The facility had a census of 45 residents. The sample included 25 residents. Based on observation, interview and record review the facility failed to provide care and services to 5 of 25 sampled residents for physician ordered interventions for a resident with inflamed hemorrhoids who experienced pain with fecal impaction (is a solid, immobile bulk of human feces that can develop in the rectum as a result of chronic constipation) (#8), to manage pain for a resident who received hospice services (#49), to monitor and provide individualized interventions for residents who exhibited purging behaviors (#41) to monitor bowel elimination and provide intervention (#45), and to monitor extensive bruising (#21) Findings included: - Resident #8's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 3/19/14, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 3, disorganized thinking, inattention, and verbal behavior towards others. The MDS further indicated the resident required total assistance from 2 staff for bed mobility, and extensive assistance of 2 staff for transfers and toileting, he/she had occasional bowel incontinence and frequent urine incontinence. The 2/3/14 care plan directed the staff to check and change the resident for incontinence every 2 hours and as needed, administer as needed medications to the resident, and provide comfort for the resident. The care plan further directed the staff to provide pharmacological and non pharmacological measures, monitor, and document if the pain relieved. The care plan continued to direct the staff to establish causative factors and ways to alleviate pain. The 2/5/14 physician's standing order directed the staff to administer the following to the resident: [MEDICATION NAME] (a laxative), 1 suppository rectally, daily, as needed for constipation Milk of Magnesia (a laxative), 30 (ml) milliliters, daily, as needed for constipation The 2/25/14 physician's orders [REDACTED]. The bowel monitoring documentation for March 2014 revealed the resident had no bowel movements on the following: 3/1/14 to 3/10/14 (10 consecutive days) 3/18/14 to 3/22/14 (5 consecutive days) the staff documented administration of [MEDICATION NAME] (a pain medication), to the resident during this time frame, which increases constipation. 3/26/14 to 3/31/14 (6 consecutive days) the staff documented administration of [MEDICATION NAME] to the resident,3 times during this time frame, which increases constipation. The March 2014 (MAR) Medication Administration Record [REDACTED] On 3/30/14 at 3:00 AM, the staff administered a [MEDICATION NAME] (a laxative) suppository to the resident for constipation. Further review of the MAR indicated [REDACTED]. The March 2014 (TAR) Treatment Administration Record revealed the staff documented the resident had a pain level of 0 every shift that month. The 3/30/14 at 9:47 AM, nurse's note indicated the resident had a bowel impaction and had not had a bowel movement in 4 days. The note further indicated the staff administered a suppository to the resident with very small results. The note indicated the staff encouraged fluids, fiber, and Milk of Magnesia (a laxative) that morning and the on call physician ordered the staff to administer a Fleets enema (the procedure of introducing liquids into the rectum and colon via the anus to produce a bowel movement) to the resident. The 3/30/14 at 1:35 PM, nurse's note indicated the resident had an extra large bowel movement after the staff administered the fleets enema and the resident reported his/her stomach felt better and he/she no longer had pain. The 3/31/14 at 1:57 AM, nurse's note (a late entry documentation from 3/30/14 at 3:00 AM) stated the staff reported the resident had a difficult bowel movement and administered a [MEDICATION NAME] suppository to the resident and he/she had a small to medium bowel movement. The note further indicated the nurse felt "a large ball" of stool when he/she inserted the suppository into the resident's rectum and the nurse had problems feeling the rectal wall due to the amount of stool in the resident's rectum. The medical record lacked documentation of any other follow up by the staff. The 4/2/14 at 4:28 PM, nurse's note indicated the resident tried to move his/her bowels without success and the staff completed digital stimulation (Circular motion with the index finger in the rectum, which causes the anal sphincter to relax and produce a bowel movement) and the resident had a medium bowel movement. The note indicated the resident still had a moderate to large amount of bowel left in his/her rectum and the staff sent a referral (a fax) to the physician and requested a daily stool medication for the resident. Review of the 4/3/14 fax sent to the physician revealed the staff notified the physician the resident had a large amount of stool at the rectum, which was pasty in nature and contained no hard stool. The fax indicated the resident had internal and external swelling with a slight amount of bleeding and the staff had administered a suppository and milk of magnesia per the physician standing orders. The fax indicated the staff asked the physician if the resident would benefit for treatment from hemorrhoids (are vascular structures in the anal canal which help with stool control. They become pathological or piles when swollen or inflamed). On 4/7/14 the physician responded to the staff's request and directed the staff to administer [MEDICATION NAME] HC (a topical corticosteroid that works by depressing the formation, release and activity of different cells and chemical that cause swelling, redness and itching) , 1 suppository, twice daily, as needed for hemorrhoids. The record revealed no documentation the staff notified or contacted the physician after sending the fax on 4/3/14 until the physician responded 4/7/14, 5 days later. Review of the medical record revealed no further documentation in regards to administration of the [MEDICATION NAME] medication or the status of the resident's hemorrhoids. The 4/7/14 at 9:11 AM, nurse's note indicated the resident had constantly got backed up with bowel movements which created pain from straining to move his/her bowels. The note further indicated the resident "again" cried in pain when he/she attempted a bowel movement on the toilet this morning, and the nurse was unable to assist. The note indicated the resident's stool was very soft with slight blood present and his/her anal area very swollen and protruded out of the rectum. The fax continued to indicate the resident had received suppositories, milk of magnesia and a fleets enema and nothing seemed to work and the staff sent a referral (a fax) to the physician in regards to the resident's condition. The fax requested any other suggestions from the physician. On 4/7/14 the physician responded to administer [MEDICATION NAME] (a laxative) 1 capful, daily and to continue [MEDICATION NAME] suppository for hemorrhoids as previously ordered. The 4/7/14 10:37 AM, nurse's note indicated the staff called the physician's nurse and informed him/her of the interventions provided to the resident with no relief, and the staff awaited the physician's response. The medical record revealed no further documentation regarding the resident's constipation or condition of his/her hemorrhoids. The April 2014 MAR indicated [REDACTED]. The April 2014 (TAR) Treatment Administration Record revealed the staff documented the resident had a pain level of 0 every shift from April 1, 2014 to April 14, 2014. The 4/10/14 physician progress notes [REDACTED]. The progress note indicated the resident's constipation had been accompanied by abdominal pain, bloating, cramping, hemorrhoids, nausea, and rectal bleeding. The note continued to indicate the physician started the resident on [MEDICATION NAME] the previous day and he/she had not received any as needed stool softeners or suppositories. The physician's exam revealed the resident had copious (abundant: produced or existing in large quantities) hard stool in his/her vault, the physician diagnosed the resident with fecal impaction, and the physician manually removed the resident's impaction in the physician's office. On 4/10/14 at 1:30 PM, observation revealed the resident, seated in his/her wheelchair, being assisted by 2 staff. The resident screamed and cried out in pain. The staff assisted the resident to his/her bed with the sit to stand lift, while the resident screamed and cried during the transfer and stated he/she had pain and hurt. Nurse D came into the resident's room and notified the staff the resident had an appointment soon and to get the resident back into his/her wheelchair. The staff assisted the resident back into his/her wheelchair, with the sit to stand lift, and the resident continued to scream he/she was in pain in his/her bottom and abdomen. The staff had administered a [MEDICATION NAME] at 1:15 PM to the resident. On 4/10/14 at 1:42 PM, observation revealed the resident cried and moaned in pain while seated in his/her wheelchair in the dining room. A staff member and other residents seated at the table attempted to reassure the resident and told him/her everything would be okay. Observation further revealed the resident breathing fast and shallow, and when he/she adjusted or moved in his/her wheelchair, he/she moaned and grimaced with each movement. On 4/10/14 at 2:00 PM, observation revealed the resident, seated in his/her wheelchair, in the dining room, and stated his/her "bottom hurt" and told the staff he/she had to urinate. Continued observation revealed the staff assisted the resident to the bathroom with a sit to stand lift, the resident barely held on as the staff lifted him/her up with the lift, he/she kept his/her knees bent and did not stand straight up. When seated on the toilet the resident cried and stated "I can not sit here like this, it hurts so bad to pee". Continued observation of the resident's rectum revealed the resident had multiple layers of purple and red colored tissue protruding, from the resident's rectum to his/her urethra (the vessel through which urine passes after leaving the bladder) On 4/10/14 at 2:29 PM, observation revealed the resident seated in his/her wheelchair in the front living area of the facility. Continued observation revealed the resident grimaced and had his/her hand to his/her face at the resident's forehead. On 4/10/14 at 1:30 PM, Nurse D stated the resident had abdominal pain and problems with his/her bowels. Nurse D further verified the resident had an appointment with the physician at 3:00 PM so the staff attempted to distract him/her with an activity. On 4/10/14 at 1:40 PM, Nurse D acknowledged the resident's pain and expressed concern that providing pain medication to the resident would increase his/her constipation. Nurse D reported the resident had problems with his/her bowels for about a week and a half, and stated the resident's hemorrhoids were so inflamed the resident was not able to push bowel through the inflamed and swollen tissue. On 4/16/14 at 10:30 AM, Nurse D verified the staff had not administered the resident the [MEDICATION NAME] suppositories as ordered by the physician. On 4/21/14 at 10:52 AM, Administrative Nurse E verified he/she expected the staff to use the physician ordered pharmalogical intervention of the [MEDICATION NAME] suppositories to relieve the resident from inflammation and pain associated with the resident's hemorrhoids. On 4/23/14 at 9:15 AM, Physician Office Nurse U verified the physician saw the resident on 4/10/14. Physician Office Nurse U further verified the physician saw the resident due to copious (large) amounts of hard stool and the physician manually removed the impaction (lubricate the anus and use one gloved finger with a scoop-like motion to break up the fecal mass) during the visit. Physician Nurse U further verified the [MEDICATION NAME] suppository would have helped with inflammation which would decrease the resident's pain caused by his/her hemorrhoids. On 4/24/14 at 5:15 PM, Physician T verified the resident's lack of bowel movements in March contributed to the resident's fecal impaction. Physician T stated the facility had not notified him/her of the resident's lack of bowel movements in March and if the facility had contacted the physician the resident's fecal impaction could have been avoided by prescribing the resident a daily bowel medication. Physician T further verified the [MEDICATION NAME] suppositories would have helped with the resident's pain and inflammation of his/her hemorrhoids. The facility's 6/2013 Bowel Protocol and Bowel Tracking policy instructed the nurse to complete a physical assessment of the gastrointestinal system, resident and staff interview and notification of the resident's physician for any resident who had inadequate bowel function manifested by the absence of regular bowel movements in excess of 3 days. The policy further indicated the staff would implement the following bowel protocol as established by the physician's orders [REDACTED]. The facility failed to provide Resident #8 with physician ordered interventions to assist the resident with pain relief for inflamed hemorrhoids associated with continued constipation and failed to provide the resident with interventions to produce a bowel movement before impaction occurred. - Resident #21's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 3/16/14, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 3 and exhibited no behaviors. The MDS further indicated the resident required extensive assistance from 2 staff for transfers, dressing and toileting and extensive assistance from 1 staff for eating. The MDS indicated the resident had no skin conditions but was at risk for a pressure ulcer. The 4/9/14 care plan directed the staff to observe the resident's skin when providing cares and to notify the nurse of any redness, open areas or abnormalities. Review of the care plan revealed no mention of bruises or interventions to prevent the resident from bruising. The 3/17/14 at 2:51 PM, nurse's note indicated the resident had a large black and blue bruise which measured 5.5 (cm) centimeters by 4 cm in a circular pattern, a small purple bruise 1.5 cm by 2 cm circle on the resident's wrist, a 1 cm by 2 cm circular healing bruise purple with yellow surrounding it,a 1 cm by 0.8 cm small bruise healing and a 1 cm by 1 cm small healing darker colored bruise. On 3/13/14 the staff sent a fax referral form to the physician to notify him/her of the resident's bruises. On 3/21/14 the physician responded to the fax, and directed the facility to evaluate the staff and the environment to determine the cause of the resident's bruises. The physician inquired if all of the bruised areas were on the resident's wrists or if the bruises were in different locations. The physician stated that if the staff determined no apparent cause or multiple areas he/she directed the staff to obtain a (CBC) Complete Blood Count (a blood laboratory test). Upon the surveyor's request the staff provided no facility investigation to identify the root cause of the resident's bruising or that staff had obtained a CBC on the resident as directed by the physician. The 3/29/14 weekly skin assessment indicated the resident's bruises continued to resolve. The facility failed to provide skin assessments for the resident for April 2014 when requested and the clinical record included no other documentation concerning the resident's bruises. On 4/10/14 at 8:00 AM, observation revealed the resident seated in the dining room in his/her wheelchair eating the morning meal with assistance of the staff. Observation revealed no foam protection located on the edge of the table. On 4/10/14 at 11:17 AM, observation revealed the resident seated in his/her wheelchair in the living room area with a quarter sized dark purple bruise on his/her right hand. On 4/14/14 at 1:15 PM, observation revealed the resident lying in bed covered with a blanket with his/her side rails in the up position calling out for help. Continued observation revealed housekeeping staff notified the staff the resident wanted assistance. Continued observation at 1:53 PM revealed the nursing staff assisted the resident with a mechanical lift and the resident screamed while the staff provided care to the resident. On 4/14/14 at 4:44 PM, observation revealed the resident seated in the living area of the facility in his/her wheelchair. The resident now had quarter size purple bruising on both of his/her hands. On 4/16/14 at 3:07 PM, Nurse Aide I stated the resident may get the bruises when the staff transferred him/her with the mechanical lift because the resident grabbed him/herself really tight when the staff tried to provide care. On 4/21/14 at 10:36 AM, Nurse F verified the staff had not included intervention in the resident's comprehensive plan of care to instruct the staff on ways to help prevent bruises when they provided care to the resident. On 4/21/14 at 10:52 AM, Administrative Nurse E verified the facility does look into bruises of unknown origin and if the staff were to know the cause of the bruising the facility does not do an investigation. Administrative Nurse E further verified the staff should put a foam piece on the dining table to prevent the resident from hitting his/her arms on the table. The facility's 10/2012 Unusual Occurrence Record policy instructed the staff to complete a head to toe assessment, notify the physician, (DPOA) Durable Power of Attorney, the Director of Nursing, the facility's executive director and the medical director to perform a review of the unusual occurrences. The facility failed to implement interventions to prevent further bruises from developing for Resident #21. -Resident #41's medical records revealed the 3/01/2014 physician's orders [REDACTED]. impairment in the ability to communicate resulting from a [MEDICAL CONDITION], laryngeal malignancy (cancer that forms in tissues of the larynx (area of the throat that contains the vocal cords and is used for breathing, swallowing, and talking) and [MEDICAL CONDITION] reflux, (a condition in which the stomach contents (food or liquid)leak backward from the stomach into the esophagus (the tube from the mouth to the stomach). The significant change (MDS) Minimum Data Set 3.0 assessment, dated 2/28/2014, indicated the resident cognitively intact with a (BIMS) Brief Interview for Mental Status score of 15. The MDS indicated the resident required limited staff assistance for bed mobility and transfers. The MDS indicated the resident required supervision with dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident had physical and verbal behaviors directed towards others and received antipsychotic and antidepressant medications daily. The 2/26/2014 care plan, updated on 4/13/2014, directed the staff to redirect and remove the resident from difficult situations and consult the physician as needed. The care plan indicated the resident had difficulties with others and may strike out at times. Review of the care plan revealed no information of what potentially triggered the behavior and no individualized interventions for staff to implement during the behavior. Review of the care plan revealed no individualized interventions related to the resident's purging behavior. The April 2014 physician orders [REDACTED]. 1) [MEDICATION NAME],100 (mg) milligrams, 1 a day, for [MEDICAL CONDITION] 2) [MEDICATION NAME], 400 mg, 2 a day for convulsions 2/17/14 3) [MEDICATION NAME], 0.5 mg, 2 a day for fractured skull cranial injury 4) [MEDICATION NAME] sprinkles,125 mg, 4 times a day for convulsion 5) [MEDICATION NAME], 50 mg, ( HS) bedtime for [MEDICAL CONDITION] 6) [MEDICATION NAME], 0.5 mg, every night at bedtime The medications were started on 2/17/2014. On 4/10/2014 at 9:10 AM, observation revealed the resident sat in a wheelchair in his/her room. Observation revealed the resident had a voice box, (a battery operated medical device placed under the jawbone producing vibration to allow speech) in his/her hands, and asked the surveyor and staff for new batteries for the voice box. The resident's speech was inaudible, had a very soft tone and most of the time unable to hear the words or sentences the resident tried to express. Observation of staff revealed difficulty with understanding the resident's needs and wants. The 1/11/2014 at 2:15 PM, nurse's notes indicated the staff observed the resident and another resident shoving each other and staff tried to separate the two residents and take the residents to their individual rooms. The 1/31/2014 at 5:10 PM, nurse's notes indicated the resident made an inappropriate hand gesture toward another resident in the dining room, and the staff observed a third resident encouraging the inappropriate behavior. Staff informed the resident the behavior was unacceptable and he/she had to go to his/her room if the behavior continued. The 2/08/2014 at 8:16 PM, nurse's notes indicated the resident grabbed a staff member by the hair and banged his/her head against the wall and punched him/her in the chest. The nurse spoke with the resident and he/she appeared to be smiling and calm when the nurse entered the room after the incident. The 2/23/2014 at 1:45 PM, nurse's notes indicated the resident was very agitated during the shift and demanded that his/her family member would come to the facility. The staff called the family and they could not come to the facility on this day. The resident stated he/she wanted to go to home. The 2/31/2014 (SSD) Social Service Designee assessment indicated the resident was alert and oriented and had a BIMS score of 15. The SSD reported the resident displayed behavioral symptoms directed towards others and had no signs or symptoms of [MEDICAL CONDITION]. The 4/13/2014 at 2:05 PM, nurse's note indicated a resident came down the hallway by Resident #41's room, yelling, and cussing and Resident #41 came out of his/her room, followed the resident down the hall, then started punching him/her in the face 2-3 times before the Certified Medication Aide separated the two residents. The note indicated Resident #41 had no injuries to his/her hands and the staff asked the other resident if he/she had any injuries and the resident pointed to the top of his/her head, and staff determined no redness or bruising noted The 4/21/2014 at 11:17 AM, nurse' s notes indicated the staff had sent a fax to the physician stating the resident had emesis (the action or process of vomiting) from his/her stoma (an opening either natural or surgically created which connected a portion of the body cavity to the outside environment) and he/she had wiped blood tinged sputum on the walls in his/her room. The note stated the physician provided no new orders. On 4/13/2014 at 12:55 PM, Nurse Aide X stated in the past the resident ate his/her meals in the dining room but he/she had a few physical altercations with other residents and now eats all of his/her meals in his/her room. Nurse Aide X indicated the resident had behaviors, and when he/she does, they redirect him/her. On 4/15/2014 at 2:10 PM, Nurse Aide X stated the resident ate his/her meals in his/her room and then would stick his/her finger in his/her stoma and vomit the food in the waste paper basket and the toilet. Nurse Aide X stated the resident no longer comes out of his/her room. Nurse Aide X verified the facility had a care plan book in the nurse's station but it was not current or updated with the current plan of care for the resident. Nurse Aide X verified the resident eats, purges, then ask for something else to eat. Nurse Aide X verified the resident had altercations with other residents, and the staff had to separate the residents. On 4/15/2014 at 2:45 PM, Administrative Nurse E verified the resident has had altercations with other residents and staff. Administrative Nurse E verified the resident does eat and then purge (self induced vomiting). Administrative Nurse E verified the resident's care plan does not have individualized interventions for the resident for aggression and/or purging. The January 2011 Unmanageable Residents policy indicated each resident would be provided a safe place of residence. If a residents ' behavior would become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately, provide safety and notify the DON, and the resident's representative. The facility failed to assess and document Resident #41's psychosocial needs in order to provide the necessary care and services to maintain the highest practicable, physical, mental, and psychosocial well- being. - Resident # 49's quarterly (MDS) Minimum Data set 3.0 assessment, dated 3/20/2014, indicated the resident had severely impaired cognition with a (BIMS) brief Interview for Mental Status score of 7. The MDS further indicated the resident required total assistance with toilet use and personal hygiene, and required extensive assistance for bed mobility, transfers, and dressing. The MDS indicated the resident frequently rejected care. The resident received scheduled pain medications with indicators of pain observed. The 1/29/2014 care plan instructed the staff to administer routine and as needed pain medications as ordered. The care plan further instructed the staff to monitor and document the level of pain using a pain rating scale of 0-10, and to monitor and document relief obtained. The staff would provide pharmacological and /or non-pharmacological measures, and establish causative factors and ways to alleviate them. Review of the 3/25/2014 physician's orders [REDACTED]. - [MEDICATION NAME] 25 (mcg) micrograms, [MEDICATION NAME], every 72 hours, for pain (initiated on 2/17/2014). - [MEDICATION NAME] 5/325 (mg) milligrams, every 4-6 hours, as needed for acute pain, (initiated on 1/15/2014). Review of the monthly (MAR) Medication Administration Record [REDACTED] - February 2014, Staff had administered, [MEDICATION NAME] 5/325 mg, as needed on 2/01,2/02,2/03,2/04,2/05,2/06,2/07,2/08,2/09,2/10, 2/11, 2/12, 2/13/2014. - March 2014 resident received the [MEDICATION NAME] on 3/01/3/02/3/03/3/04/3/05,3/06/3/07, 3/14 and 3/19/2014. - April 2014 resident did not receive any Lotrab from the 1st to the 17 th. Review of the nurses notes revealed the following: The 3/16/2014 at 3:51 PM, nurse's notes stated on 03/14/14 the nurse requested liquid [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME] for resident. The notes indicated the staff had to feed the resident his/her meals and assist the resident with total ADL cares. The 3/20/2014 at 1:31 PM, nurse's notes, indicated the resident had been refusing scheduled medications. Hospice was in the facility today, visited with the resident and nurse and mentioned discontinuing the resident's scheduled medications but keeping the as needed [MEDICATION NAME] and [MEDICATION NAME]. The staff attached the (MAR) Medication Administration Record [REDACTED]. The 4/07/2014 at 5:32 AM, nurse's notes, indicated the resident woke up at 3:00 PM moaning and the nurse offered him/her pain medication and administered the [MEDICATION NAME] 0.25 mg sublingual.(under the tongue) On 4/21/2014 at 2:49 PM, the resident had been hollering out more often in pain. The resident had an order for [REDACTED]. The resident reported pain and hollers out in pain more often then before. The nurse faxed the physician for an increase in the resident's pain medication On 4/22/2014 6:27 AM, the nurse's notes stated the physician increased the resident's [MEDICATION NAME] from 25 mcg to 50 mcg every 72 hours. On 4/10/2014 at 7:50 AM, observation revealed the resident hollering out from his/her room foul language, the resident stated "I need pain medication". Nurse W verified the resident received his/her scheduled pain medication as ordered and does have as needed pain medication. On 4/10/2014 at 4:20 PM, observation revealed the resident hollering out from his/her room "hey", "hey " and the surveyor went to the resident's room and asked him/her if he/she was needing something and he/she stated "I will pay you $1000.00 dollars to get me out of here". The surveyor asked the resident if he/she was in pain and he/she stated "Yes" and the surveyor went immediately to the nurse and notified him/her the resident had complained of pain. On 4/10/2014 at 3:10 PM, Nurse W stated the resident had received his/her scheduled pain medication as physician ordered but had not received any [MEDICATION NAME] 5/325 mg as needed for acute pain. Nurse W verified the resident was on hospice services but he/she unable to provide a [DIAGNOSES REDACTED]. Nurse W assisted a nurse aide to reposition the resident and he/she expressed less discomfort. On 4/14/2014 at 2:55 PM, Nurse V stated the resident started on the hospice care 4 months ago after returning form the hospital and he/she had been on the same dosage of pain medication the entire time. Nurse V indicated the resident may require an increase in pain medication dosage, and also verified the staff had the option to administer the as needed pain medication for break thru pain. Nurse V stated the resident had a antianxiety medication, [MEDICATION NAME], that they would administer as a last resort for the resident's increased anxiety. On 4/16/2014 at 3:10 PM, Administrative Nurse E verified "last week" the resident had a kinked/knot in his/her biliary bag (biliary drain is a tube to drain bile from your liver and drains into the collection bag placed over the end of the drainage tube) and he/she "straightened" the tubing out and after that the resident had not displayed as much pain or discomfort and the biliary drainage appeared to flow better. Administrative Nurse E stated the resident frequently refused care, became "violent", sometimes curses and would hit the staff. The facility's Pain Assessment and Management policy,undated, directed the staff to assess all residents for pain, interventions implemented to reduce or relieve pain, and effectiveness of interventions re-evaluated in a timely manner. The policies and procedures set forth are not intended to supercede the professional judgement of a licensed nurse or other professional. The policy stated when a resident elects the hospice benefit, the facility will ensure coordination of the plan of care to address the residents pain management goals and approaches. The facility will notify the hospice provided of uncontrolled or increased pain and unexpected changes in resident condition. The hospice provider will be apprised of noted undesirable side effects affecting the resident's comfort. The facility failed to adequately provide treatment to Resident # 49 for effective pain management, follow physicians orders and to notify the physician of inadequate pain management. - Resident # 45's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 1/2/14

The facility had a census of 45 residents. The census included 25 residents. Based on observation, record review and interview, the facility failed to ensure 2 of 2 residents received proper treatment and care for [MEDICAL CONDITION] (an incision in the windpipe made to relieve an obstruction to breathing) and respiratory services to prevent upper respiratory care for the 2 residents reviewed for respiratory services. (# 40 and # 38) Findings included: - The 3/4/14 physician's orders [REDACTED]. Resident #40's Medicare 5 day/Significant change (MDS) Minimum Data Set 3.0 assessment, dated 3/10/14, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15 which indicated intact cognition. The assessment revealed the resident required extensive assistance of one staff member for bed mobility, transfers, dressing, toileting, and limited assistance of one staff member for personal hygiene. The assessment further revealed the resident had a [MEDICAL CONDITION], and required suctioning and used oxygen. Further review of the resident's medical record revealed [REDACTED]. The 3/19/14 care plan directed the staff to provide daily [MEDICAL CONDITION] care and to suction (a force that causes a fluid or solid to be drawn into an interior space) the [MEDICAL CONDITION] as needed per the physician's orders [REDACTED]. The 3/4/14 physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the resident's March and April 2014 (TAR) Treatment Administration Record and the nurse's notes revealed the staff had not documented to indicate the staff provided the physician ordered [MEDICAL CONDITION] care provided to the resident on the following dates and times: 3/10/14- 4-5 AM and 7-10 PM 3/18/14- 7-10 PM 3/25/14- 7-10 PM 3/29/14- 7-10 PM 4/6/14- 7-10 PM 4/8/14 - 7-10 PM 4/9/14- 7-10 PM 4/11/14- 7-10 PM The 4/15/14 at 12:14 AM, nurse's note stated the resident had shortness of breath and had requested staff suction him/her. The note further stated the staff administered a breathing treatment as ordered by the physician. On 4/16/14 at 11:10 AM, observation revealed the following: Restorative Aide X assisted the resident to his/her room, and the resident had a gurgling noise when breathing. Administrative Nurse F washed his/her hands, took the Passey-Muir Valve (a device placed on the hub of the [MEDICAL CONDITION] that re-directs air flow through the vocal cords enabling improved communication) and the inner cannula out of the resident's [MEDICAL CONDITION] and placed them directly on the resident's nightstand with no barrier. The resident coughed and expelled approximately one cup of yellowish/green colored phlegm (thick, mucus secreted in the respiratory passages) from the [MEDICAL CONDITION] onto his/her shirt. Administrative Nurse F asked the resident if he/she needed suctioned, and the resident shook his/her head yes. Administrative Nurse F opened the three drawer plastic storage bin and could not find a suction catheter to attach to the suction tubing of the suction machine. The resident continued to struggle by gasping air to get his/her breath and to cough, then expelled more phlegm. Administrative Nurse F put on the call light for assistance to which a nurse aide responded. Administrative Nurse F told the aide to ask Nurse D to come to the resident's room. The resident's face turned red in color, as he/she continued to cough. The resident's breathing became labored (increased effort to breathe) Nurse D responded at 11:26 AM and Administrative Nurse F stated he/she needed a catheter to suction the resident. Nurse D left the room, came back in and stated he/she needed the key to the supply room. (16 minutes since the resident initially displayed the respiratory difficulty) Another nurse aide came to the room and stated the call light had not been turned off. Administrative Nurse F again asked the resident if he/she needed suctioned, he/she shook his/her head yes. At 11:30 AM, Nurse D brought the suction catheter to the room, looked at the resident's portable oxygen tank then stated, "it's almost empty," and verified he/she needed a new one. Administrative Nurse F picked up the Passey-Muir Valve from the nightstand and placed it back on the resident's [MEDICAL CONDITION]. The resident coughed, the valve flew off [MEDICAL CONDITION] landed under the bed. Administrative Nurse F opened [MEDICAL CONDITION] and Care Kit and then looked for the valve, which he/she found under the resident's bed. Administrative Nurse F placed the cap in [MEDICAL CONDITION], sprayed it with sterile saline (a sterile solution of sodium chloride), wiped it off with gauze and placed it back onto the resident's [MEDICAL CONDITION]. Administrative Nurse F placed the package of sterile gloves on the resident's bed, opened it and began to put on the right hand glove, trying to maintain a sterile field, then put on the left hand glove. Administrative Nurse F picked up the suction catheter package and stated, "I guess I should have opened this first." Administrative Nurse F stated he/she would go for help and Administrative Nurse F then went over to the resident's closed door, grasped the doorknob with the inner aspects of both his/her wrists and attempted to open the door. Administrative Nurse F could not get the door opened and stated "I'll just take off the gloves." The resident still had not been suctioned and he/she continued to sit in his/her wheelchair with the nasal cannula from the portable oxygen in place but the tank almost empty. The resident continued to breath with pursed lips, and periodically coughed. Administrative Nurse F opened the catheter package, poured saline into [MEDICAL CONDITION] tray, put on another pair of sterile gloves and attached the catheter to the suction machine tubing. Administrative Nurse F took the [MEDICAL CONDITION] cap off the resident's [MEDICAL CONDITION] with his/her left hand, placed it back onto the resident's nightstand and began to suction the resident with his/her right hand. Administrative Nurse F suctioned more phlegm from the resident's [MEDICAL CONDITION] and the resident's face remained red in color. Administrative Nurse F asked the resident if he/she wanted to continue with the suctioning and the resident stated he/she felt better. Administrative Nurse F picked up the inner cannula from the night stand, placed it back into the [MEDICAL CONDITION] and put the cap back on. Administrative Nurse F asked the resident if he/she was short of breath and he/she stated yes, and the resident used pursed lips to try to catch his/her breath. Administrative Nurse F asked the resident if he/she wanted his/her Duo-Neb (a breathing treatment used to open airways) and the resident shook his/her head yes. Administrative Nurse F stated the resident usually received his/her Due-Neb treatment at lunch and asked the resident if he/she had been to lunch yet. The resident whispered, "No, I'm not going to the dining room because I do not feel good." Administrative Nurse F asked the resident if he/she wanted a cup of coffee, the resident shook his/her head no. Administrative Nurse F rinsed out the suction machine bottle, bagged the trash and pushed the resident in his/her wheelchair out of the room toward the supply room. Administrative Nurse F removed the portable oxygen tank and replaced it with a full tank. This surveyor asked Administrative Nurse F how long the tank lasted, and he/she stated he/she was unsure, but maybe 3 hours. Administrative Nurse F turned the tank to 3 liters and placed the nasal cannula onto the resident and then pushed him/her into the dining room even though the resident stated he/she had not wanted to go to the dining room. At 11:50 AM, Administrative Nurse F verified he/she had not completed a thorough assessment on the resident's respiratory status after he/she suctioned the resident. On 4/16/14 at 11:55 AM, Nurse D stated the staff changed out the resident's portable oxygen tank whenever he/she told them it needed changed. Nurse D further stated the facility had no system to document when the staff changed the oxygen tanks. On 4/16/14 at 12:35 PM, observation revealed the following: The resident laying half on the bed with his/her legs hanging off the bed. Observation further revealed the resident's oxygen nasal cannula laying on the resident's wheelchair seat. The resident had difficulty speaking, his/her skin pale and he/she had trouble breathing. Certified Medication Aide J used a pulse oximeter (a device that measured the oxygen saturation of arterial blood) to check his/her oxygen saturation level which revealed a level of 79% (normal oxygen saturation was 90-100%). Certified Medication Aide J immediately applied the resident's humified air (the administration of oxygen at concentrations greater tahn that in ambient air) tube, connected to the oxygen concentrator, directly to the resident's [MEDICAL CONDITION] and the resident's oxygen saturation level increased to 83%. Certified Medication Aide J stated he/she needed to get the nurse. Administrative Nurse F returned to the resident's room at 12:39 PM, obtained another oxygen saturation reading of 93% but used a different pulse oximeter. Administrative Nurse F assessed the resident's lungs, heart rate, and obtained the resident's blood pressure (pressure of the blood within the arteries). The resident began to cough, his/her face began to turn red and stated he/she wanted to lay down. On 4/16/14 at 3:00 PM, observation revealed the resident alone in his/her room, seated on the side of the bed, with obvious respiratory gurgling. The resident's color pale and he/she had a difficult time speaking as the resident inhaled, he/she made a gurgling sound. Further observation revealed the resident shook his/her head yes when this surveyor asked the resident if the nurse was aware of the situation. The resident sat on his/her side of the bed until 2 ambulance staff assisted him/her. On 4/16/14 at 3:15 PM, observation revealed the resident transported via ambulance to the community hospital. On 4/16/14 at 3:16 PM, Nurse K stated the nurse aide called him/her into the resident's room and he/she observed the resident's hands and face bluish/purple and he/she had difficulty catching his/her breath. The nurse obtained on the resident a oxygen saturation reading of 71% on 5 liters per [MEDICAL CONDITION]. Nurse K further stated the staff contacted the physician who ordered the staff to transport the resident to the hospital emergency room . Nurse K further stated the facility had not trained him/her to perform [MEDICAL CONDITION] care or suctioning on the resident but he/she had obtained training at a previous employment. On 4/16/14 at 4:30 PM, Nurse Aide S stated the resident was on continuous oxygen and was recently been hospitalized for [REDACTED]. On 4/16/14 at 4:00 PM, Administrative Nurse E stated the nursing staff had been trained by the respiratory therapist at the hospital prior to the resident's admission to the facility. Administrative Nurse E further stated the facility had not provided any recent training for new nurses regarding [MEDICAL CONDITION] care and the staff did not complete nurse competency tests. On 4/17/14 at 10:37 AM, Physician T stated the resident had a history of [REDACTED]. The ambulance transported the resident to the hospital emergency room for thick secretions, and the hospital changed the resident's inner cannula, and completed testing workup to rule out pneumonia. The resident's oxygen saturation levels were within normal limits, and the hospital kept the resident overnight for observation. The physician further stated there had been a history of [MEDICAL CONDITION] and the hospital had provided education to the facility staff. Physician T further stated the facility staff did not contact the hospital regarding the resident until he/she was in distress. The physician further stated the fax he/she received that morning (the day after the 4/16/14 hospitalization ) stated the the staff had suctioned the resident and the resident's oxygen saturations were within normal limits (the resident's oxygen saturations had ranged from 71-93% during the observation) The 4/16/14 emergency room Treatment Summary stated the resident admitted due to shortness of breath and [MEDICAL CONDITION]. The summary further stated a verbal report from the emergency transport staff revealed the resident's oxygen saturations were in the 70's. The summary stated all other details about the resident's care were unknown as the physician attempted to contact the nurse at the facility and was unable to reach him/her. The summary stated the facility had not provided any other documentation. The hospital staff administered a breathing treatment of [REDACTED]. On 4/21/14 at 11:30 AM, Administrative Nurse E stated he/she expected the nursing staff to ensure the resident had the proper suctioning and [MEDICAL CONDITION] supplies and he/she would expect the resident to receive proper [MEDICAL CONDITION] care. Administrative Nurse E verified the resident did not received proper [MEDICAL CONDITION] care. The facility's 2001 Suctioning the Lower Airway policy stated the purpose of the procedure was to remove secretions, maintain a patent airway, and prevent infections of the lower respiratory tract. The policy directed the staff to monitor the resident's pulse, and oxygen saturation during suctioning and to assess for the following signs and symptoms of respiratory distress, [MEDICAL CONDITION], diminished breath sounds, gurgling and decreased oxygen saturation. The policy further stated a supply of suction catheters, sterile gloves, and flush solution must be available at all times. The facility failed to ensure provision of prompt [MEDICAL CONDITION] care to avoid respiratory distress for Resident #40 who had a [DIAGNOSES REDACTED]. - Resident #38's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 2/27/14, indicated the resident had intact cognition with a (BIMS) Brief Interview of Mental status of 15 and resisted care at times. The MDS further indicated the resident required limited assistance from 1 staff for bed mobility, transfers, and personal hygiene and he/she received oxygen therapy. The 3/19/14 care plan instructed the staff to administer oxygen per nasal canula (nose piece) and to monitor and document the resident's respiratory status as needed for respiratory distress. The 3/25/14 physician's orders [REDACTED]. Review of the medical record revealed on 11/13/14, 1/9/14, and 2/14/14 the physician ordered antibiotics medications for (URI) upper respiratory infections (an upper respiratory tract infection, in an infectious process of any of the components of the upper airway). On 4/10/14 at 9:30 AM, observation revealed the resident lying in bed in his/her room with a oxygen nasal cannula in place and the oxygen concentrator on. Continued observation revealed the resident's nasal cannula caked with a light colored substance around the nose piece and throughout the tubing. Further observation of the resident's room revealed the resident's mouth piece to his/her nebulizer mouth piece (breathing treatment) laid un-bagged on the bedside table. On 4/15/14 at 8:03 AM, observation revealed the resident lying in bed in his/her room with a nasal cannula in place and the oxygen concentrator on. Continued observation revealed the resident's nasal cannula caked with a light colored substance around the nose piece and throughout the tubing. Further observation of the resident's room revealed the resident's mouth piece to his/her nebulizer mouth piece laid un-bagged on the bedside table. On 4/21/14 at 10:52 AM, Administrative Nurse E verified the staff should bag the resident's nasal canula and nebulizer mouth piece to prevent the spread of infection. Administrative Nurse E further verified the staff should change out the resident's oxygen tubing every 7 days or as needed when visually soiled to prevent the spread of infection. The facility's 8/2011 Departmental Respiratory Therapy Prevention of Infection policy instructed the staff to change the oxygen cannula and tubing every 7 days, or as needed. The policy further instructed the staff to keep the oxygen canula and tubing used in a plastic bag when not in use. The facility failed to provide respiratory care in a manner that prevents the spread of infection for Resident #38, who had a history of [REDACTED].