Every finding on record at Palma Real

Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 unit refrigerators (resident refrigerator RR #1), 1 of 1 resident freezer (resident freezer RF #1) and 1 of 1 resident walk in pantry ( walk in pantry WP#1) reviewed for storage, preparation and sanitation. The facility failed to ensure items in the refrigerators were sealed, labeled, and dated. The facility failed to ensure food items in the dry storage area were not expired. The facility failed to ensure the staff was using the first in first out method of storage in the dry storage area. The facility failed to ensure food items in the resident's refrigerator and freezer were covered or sealed to prevent exposure to air and cause cross contamination. The facility failed to ensure no personal items were in the kitchen area These failures could place residents at risk of foodborne illnesses. Findings included Observation and Initial tour of the kitchen on 06/07/26 at 10:45 a.m., in the walk-in freezer revealed a box of pancakes, waffles, and beef patties that were not covered or in a sealed container causing the items to be exposed to the air and causing cross contamination. Observation of the refrigerator revealed a pie not dated with expiration date and a box of lemons, lettuce, cucumbers, and onions not in a seal container or covered that were exposed to air and causing cross contamination. Observation of the dry storage area revealed the staff was not using the first in first out method of storage and containers of honey thickener expired on 04/08/26, fruit juice expired on 04/2026, thickened dairy beverage with expired date 06/01/26, and a box of tea bags with expiration date of 05/11/2025 with written date of 04/11/26on the box stored for use. Observation of storage racks revealed a personnel phone, a pack of flour tortillas with no open date, and a loaf of bread with no open date that had been opened and used that morning. In an interview on 06/09/2026 at 9:30 AM with DA C she stated it was important to make sure all items in the dry storage area were not expired and used to feed the residents. DA C stated if residents ate expired food the residents could become ill and possibly get hospitalized with food poisoning. DA C stated she will ensure that the first in first out is used when she stores any items in the dry storage area to ensure expired items are thrown away. DA C stated it was important to make sure items in the refrigerator and freezer are covered and sealed so that the food is not exposed to the air and possibly become contaminated. DA C stated she knew on personal items were to be in the kitchen and did not whose phone was on the rack in the kitchen. DA C stated anyone wo is restocking is responsible for making sure the first in first out was used and the dishwashers are responsible for makie sure expired item are thrown away and the Dietary Manger is responsible for ensuring that it is done. DA C stated the last time she was in-service on storage of food was two weeks ago. In an interview on 06/09/2026 at 9:30 AM with DA D stated he did not know whose phone was on the rack in the kitchen but knew that you are not it have personal items in the kitchen that can cause cross contamination of food or utensils used for cooking or eating. DA D stated all staff are responsible for making sure the items in the dry pantry are stored according to the first in first out method to store the food in the dry storage area. DA D stated it was dangerous to have expired food items still in rotation for use because it can make a resident sick. DA D stated the last time he had a training on stored food was about 2 weeks ago. In an interview on 06-09-2026 at 9:47 am DA F stated She stated expired items should be thrown away immediately when expired. DA F stated the person restocking should be looking at the dates that are on the items they are restocking, so all food items are good to serve to the residents. DA F stated serving expired food can make a resident sick with food poisoning. DA F stated she knew to use the first in first out method for restocking new food supply in the dry storage room. DA F stated she did not know whose phone was on the rack in the kitchen but knows not to have a personal item in the kitchen. The last time she had an in-service on food storage was about 3 weeks ago. In an interview on 06/09/2026 at10:43 AM with the Dietician she stated using expired food items can diminish the quality of the food because it was not at its best. The Dietician stated the use of expired food items could make a resident sick especially for a compromised resident. The Dietician stated all products should have an open date, expiration date with month and year, and received date written on each item. The Dietician stated the DM does inventory every two weeks with all food, but the honey thickener, and thickened dairy product had not been used in a while and were overlooked. The Dietician stated some items contained the expiration date on the box and could have been why some items did not have the expiration date, but would make sure kitchen staff was educated on make sure all items have an expiration date with day, month, and year before restocking in dry area storage. The Dietician stated that when the DM had monthly meetings, she had training on different areas of the kitchen that needed attention. The Dietician stated the DM would be having a training session on food storage and dating when she returns to work the following week. In record review of the policy and procedure for food storage was undated and stated Sufficient storage facilities are to keep food safe, and wholesome and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. 4. All food items will be dated with the received date, unless labeled with readable label from the food vender. 5. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled, including the date the package was opened. 9. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. 16. frozen foods c. Foods should be covered, labeled and dated.

Based on record review and interview, the facility failed to provide notice before a transfer or discharge to the resident or the resident's representative in writing and in a language and manner in which they understand for 3 of 5 residents (Resident #25, Resident #53, and Resident #51) reviewed for transfer and discharge. The facility failed to notify Resident #25 and/or their RP of the transfer or discharge with the reasons for the move in writing in a language and manner in which they understand. The facility failed to notify Resident #53 and/or their RP of the transfer or discharge with the reasons for the move in writing in a language and manner in which they understand. The facility failed to notify Resident #51 and/or their RP of the transfer or discharge with the reasons for the move in writing in a language and manner in which they understand. These failures placed residents at risk of not receiving an advocate who could inform them of their options, rights, and the added protection from being inappropriately transferred or discharged . Record review of Resident #51's face sheet, dated 06/09/2026, revealed an [AGE] year-old male with an original admission date of 03/10/2026 with diagnoses of paroxysmal arterial fibrillation (an irregular, rapid heart rhythm that starts and stops suddenly on its own), diastolic congestive heart failure (occurs when the heart's main pumping chamber, left ventricle, stiffens and cannot relax to fill with enough blood between beats, and diabetes a chronic condition where your body either cannot produce enough insulin or cannot effectively use the insulin it makes. Record review of Resident #51's Discharge MDS assessment, dated 03/20/2026, revealed no BIMS score. Record review of Resident #51's Progress notes dated 03/20/26 revealed Family present at bedside and is requesting for the resident to be sent to the hospital due to change in condition. The resident wants to go to, so the physician was notified and received orders to be sent to er. Transportation called. Pending arrival at this time. RP aware. In an interview with Resident #51's Responsible Party, stated she was not present at the time the resident was discharged to hospital and never received a written notice of Resident #51's discharge. The RP stated that the only notification she ever received was via the telephone. In an interview on 06/09/2026 at 10:20 AM, the DON stated the SW notified residents and RPs of planned transfers or discharges, but if a resident went to the ER or had an unplanned discharge or transfer, the nursing staff notified the RP via telephone. The DON stated that no written notifications were being completed for these. In an interview on 06/09/2026 at 2:59 PM, the Administrator stated he sent discharge notices to the ombudsman. The Administrator state the physician, the NP, and the RP were notified via telephone for the transfers, and the only written notification given to the resident or the RP was when residents were discharged from skilled service and the Notice of Medicare Non-Coverage was given to inform them the Medicare covered services were ending. The Administrator stated he was not aware of the transfer/discharge notification regulations. The findings included: Record review of Resident #25's face sheet, dated 06/09/2026, revealed an [AGE] year-old female with an original admission date of 07/09/2023, and a current admission date of 05/08/2026. Pertinent diagnoses included Type 2 Diabetes Mellitus (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body). Record review of Resident #25's Quarterly MDS assessment, dated 06/04/2026, revealed a BIMS score of 01, which indicated severely impaired cognition. Record review of Resident #25's Hospital Transfer Form, dated 05/22/2026, revealed reasons for transfer/discharge and report was called to the hospital. The form also revealed Resident #25's RP was notified via telephone. Record review of Resident #25's hospital discharge paperwork, revealed a hospital admission on [DATE] and a discharge from the hospital on [DATE], but there were no written discharge or transfer information or instructions for the RP. In an interview on 06/09/2026 at 3:56 PM, Resident #25's family stated the facility never sent or gave them anything in writing in regard to and written transfer or discharge information or instructions, but they usually got a phone call with an update. Record review of Resident #53's face sheet, dated 06/09/2026, revealed a [AGE] year-old female with an original admission date of 02/27/2026, and a current admission on [DATE]. Pertinent diagnoses included Diabetes Mellitus (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body). Record review of Resident #53's Quarterly MDS assessment, dated 04/12/2026, revealed a BIMS score of 02, which indicated severely impaired cognition. Record review of Resident #53's Hospital Transfer Form, dated 05/04/2026 (but the transfer date on the form was 03/17/2026), revealed reasons for transfer/discharge and report was called to the hospital. The form also revealed Resident #53's RP was notified via telephone. Record review of Resident #53's progress note, dated 06/08/2025, revealed Resident #53 was re-admitted after hospitalization 05/04/2026 – 06/05/2026, and she was also hospitalized [DATE] – 03/23/2026. In an interview on 06/09/2026 at 3:48 PM, Resident #53's family stated they never received any written notification of Resident #53's transfers or discharges. They stated the only notification they ever received was via the telephone. T In an interview on 06/09/2026 at 10:20 AM, the DON stated the SW notified residents and RPs of planned transfers or discharges, but if a resident went to the ER or had an unplanned discharge or transfer, the nursing staff notified the RP via telephone. The DON stated no written notifications were being completed for these. In an interview on 06/09/2026 at 2:59 PM, the Administrator stated he sent discharge notices to the Ombudsman. The Administrator stated the physician, the NP, and the RP were notified via telephone for the transfers, and the only written notification given to the resident or the RP was when residents were discharged from skilled service and the Notice of Medicare Non-Coverage was given to inform them the Medicare covered services were ending. The Administrator stated he was not aware of the transfer/discharge notification regulations. Record review of the facility's Transfer and Discharge policy, revised 12/02/2025, revealed Policy Explanation and Compliance Guidelines: 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: A. reason and basis for transfer or discharge. B. The effective date of transfer or discharge. C. The specific location. To which the resident is to be transferred or discharged . D. An explanation of the right to appeal. E. The name, address. and telephone number of the state entity which receives such appeal hearing requests. F. Information on how to obtain an appeal form. G. Information on obtaining assistance in completing and submitting the appeal hearing requests. H. The name, address. and phone number of the representative of the Office of the State Long-Term Care Ombudsman. 4. Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30 day requirement apply when the transfer or discharge if effected because: A. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident. E. In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC Ombudsman as soon as practicable before the transfer or discharge.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified for 2 (Resident #25 and Resident #53) out of 5 residents reviewed for care plans.The facility failed to review and revise Resident #25's care plan to remove full code status when Resident #25 became a DNR.The facility failed to remove the intervention of full code from Resident #25's DNR care plan.The facility failed to remove Resident #53's hospice care plan after the hospice orders were rescinded. These failures could place residents at risk for receiving inadequate care and services.The findings included:Record review of Resident #25's face sheet, dated 06/09/2026, revealed an [AGE] year-old female with an original admission date of 07/09/2023, and a current admission date of 05/08/2026. Pertinent diagnoses included Type 2 Diabetes Mellitus (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body).Record review of Resident #25's Quarterly MDS assessment, dated 06/04/2026, revealed a BIMS score of 01, which indicated severely impaired cognition. Record review of Resident #25's physician's order summary, dated 06/05/2026, revealed an order for DNR. Record review of Resident #25's Out of Hospital DNR, revealed the DNR had been signed into place on 05/02/2025.Record review of Resident #25's care plan, initiated 04/21/2026, revealed Resident #25 had a care plan focus for code status of DNR. Interventions included: Inform staff of Code Status and make sure code status was signed and in the active medical record. The care plan also revealed a focus for a code status of full code, initiated 05/28/2026. Interventions included inform staff of code status, and monitor for decrease in change of condition.Record review of Resident #53's face sheet, dated 06/09/2026, revealed a [AGE] year-old female with an original admission date of 02/27/2026, and a current admission [DATE]. Pertinent diagnoses included Diabetes Mellitus (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body).Record review of Resident #53's Quarterly MDS assessment, dated 04/12/2026, revealed a BIMS score of 02, which indicated severely impaired cognition. The MDS assessment did not indicate hospice.Record review of Resident #53's Hospice Revocation Statement, dated 05/04/2026, revealed the reason for revocation was due to seeking aggressive treatments and labs. Record review of Resident #53's physician order summary, reviewed 06/08/2026, revealed no order for hospice.Record review of Resident #53's care plan, initiated 04/27/2026, revealed Resident #53 had a care plan focus for Resident #53: requires hospice and has elected to have hospice to evaluate and treat her. Interventions included: feed Resident #53 if she was unable to feed herself, and monitor for decreased appetite, weight loss, skin breakdown, nausea and vomiting, and report to hospice. In an interview on 06/09/2026 at 8:00 AM, the DON stated Resident #50 was previously on hospice, but the hospice orders had been rescinded, and she was no longer on hospice.In an interview on 06/09/2026 at 8:53 AM, the MDS nurse stated the SW was typically the one who updated the code status in the care plan, but the IDT should have noticed and fixed Resident #25's care plan to reflect the most current code status. She also stated she, or one of the IDT members, should have removed the hospice focus from Resident #53's care plan when hospice was rescinded, but both the DNR and the hospice care plans must have been accidentally overlooked. In an interview on 06/09/2026 at 2:59 PM, the Administrator stated the SW was responsible for updating the care plans with the correct code status. He also stated he was not sure how both the code status care plan and the hospice care plan was accidentally overlooked or missed by the IDT. The Administrator also stated the SW was out of the facility this week and may not be able to be reached. Record review of the facility's Care Plan policy, dated 10/02/2025, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of 6 residents (Resident #54) reviewed for medication errors. The facility failed to hold Resident #54's midodrine (medication that raises blood pressure) when Resident #54's blood pressure was outside of physician's parameters on May 29th, June 2nd, and June 6th of 2026. This failure could place residents at risk for complications such as increased blood pressure, exacerbation of symptoms, and potential hospitalization.The findings include: Record review of Resident #54's face sheet dated 06/09/26 revealed a [AGE] year-old female with an admission date of 05/28/26. Resident #54's pertinent diagnosis included Hypotension (abnormally low blood pressure). Record review of Resident #54's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 15 indicating her cognition was intact. Record review of Resident #54's Comprehensive Care Plan dated 06/09/26 revealed the focus [Resident #54] has hypotension Midodrine initiated on 06/01/26. An intervention listed for this focus included Give medications as ordered. Monitor for side effects and effectiveness. Initiated on 06/01/26. Record review of Resident #54's order summary dated 06/09/26 revealed an order for midodrine 5 MG 1 tablet TID GIVE IF SYSTOLIC BLOOD PRESSURE (top number in a blood pressure reading) LESS THAN 90 initiated on 05/29/26 and discontinued on 06/01/26. Further review revealed an order for midodrine 5 MG 1 tablet TID GIVE IF SYSTOLIC BLOOD PRESSURE LESS THAN 90 related to HYPOTENSION, UNSPECIFIED. **DO NOT TAKE WITHIN 4 HOURS OF BEDTIME** initiated on 06/01/26 and discontinued on 06/08/26. Record review of Resident #1's MAR for May and June 2026 revealed midodrine was administered at the following dates and time slots with associated blood pressures:May 30th, 2026, at 8:00 PM - 103/61 by LVN AJune 2nd, 2026, at 8:00 AM - 96/59 by LVN AJune 2nd, 2026, at 12:00 PM - 106/68 by LVN AJune 6th, 2026, at 12:00 PM - 132/66 by LVN B During an interview with LVN A at 10:25 AM on 06/09/26, LVN A stated she always checked a resident's vitals before administering any blood pressure altering medication to ensure the resident's blood pressure or pulse was within the stated physician's parameters. LVN A stated she should have held the midodrine for Resident #54 on May 30th and both administrations on June 2nd based on the parameters listed in the order. LVN A stated administering midodrine outside of parameters may lead to hypertension (elevated blood pressure) in the resident. LVN A stated hypertension could cause a resident to have a headache, sweating, or redness. During an interview with the DON at 11:08 AM on 06/09/26, the DON stated nurses and med aides should check a resident's vitals as necessary before administering a blood pressure or pulse altering medication. The DON stated based on Resident #54's midodrine order it should not have been administered when her systolic blood pressure was less than 90. The DON stated administering midodrine outside of parameters could lead to hypertension in the resident causing headache, flush, or sweating. During an interview with LVN B at 12:07 PM on 06/09/26, LVN B stated she always checked a resident's vitals before administering any blood pressure altering medication to ensure the resident's blood pressure or pulse was within the stated physician's parameters. LVN B stated she did not believe she administered midodrine to Resident #54 on June 6th, 2026. LVN B stated she must have clicked the wrong button and documented it incorrectly. LVN B stated it looked like she administered midodrine to Resident #54 outside of physician's parameters to Resident #54 on 06/06/26 according to the MAR. LVN B stated administering midodrine outside of physician's parameters could lead to the resident having hypertension. Record review of the facility's policy Medication Administration last revised 12/01/25 revealed the following policy: .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 1 of 4 medication carts (100 Hall Medication Cart) reviewed for labeling and storage. The facility failed to ensure the 100 Hall Nurse Med-Cart was locked and secured on 06/07/2026. This failure could have placed residents at risk of gaining access to unlocked medications and medical supplies which were not prescribed to them and could have caused them harm.The findings included:An observation on 06/07/2026 at 11:29 AM of the 100 Hall Medication Cart, parked in the 100 Hall, revealed an unlocked medication cart which was able to be accessed. The lock was popped out, and the unlocked drawers were able to be accessed. In an interview on 06/08/2026 at 4:28 PM, LVN-E stated she worked on the 100-hall, and she was the one who left the 100-hall medication cart unlocked while she stepped away from it. LVN-E stated she was supposed to lock her medication cart anytime she walked away from it because residents could have accessed medications which had not belonged to them, which could have caused them harm. She stated she had been in-serviced over medication carts and medication storage previously, but she could not remember when the last in-service was. In an interview on 06/09/2026 at 11:03 AM, the ADON stated the nurses had recently been in-serviced about locking their medication carts. She stated this was done for the residents' safety. Record review of the facility's Medication Storage policy, implemented 12/01/2025, revealed Policy Explanation and Compliance Guidelines: 1. General Guidelines: A. All drugs and biologicals will be stored in locked compartments (. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. B. Only authorized personnel will have access to the keys to locked compartments.

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 dining rooms reviewed, and 1 of 5 residents (Resident #25) reviewed for infection control practices. The facility failed to ensure MR performed proper or adequate hand hygiene while assisting with passing meal trays in the dining room on 06/07/2026.The facility failed to ensure the DON performed proper or adequate hand hygiene during wound care on 06/09/2026.The findings included: In a dining room observation on 06/07/2026 between 12:10 PM and 1:00 PM during lunch, MR was observed to perform hand hygiene with ABHS approximately 4 times throughout the dining room lunch observation in which she only rubbed her hands approximately 2-4 seconds each time after applying the ABHS. MR would pass a couple of trays, then sanitize her hands for 2-4 seconds before passing a couple more trays. In an interview on 06/08/2026 at 4:23 PM MR stated she typically sanitized her hands after passing 2-3 trays, and she would put one pump of hand sanitizer on her hands and rubbed her hands for 10-15 seconds until dry. She stated she had not realized she was not rubbing for 10-15 seconds, and 2-3 seconds was not long enough for hand hygiene. MR stated not performing hand hygiene properly could have caused cross-contamination and could have caused the residents to become sick. Record review of Resident #25's face sheet, dated 06/09/2026, revealed an [AGE] year-old female with an original admission date of 07/09/2023, and a current admission date of 05/08/2026. Pertinent diagnoses included Type 2 Diabetes Mellitus (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body). Record review of Resident #25's care plan, initiated 07/21/2025 and revised 07/31/2025, revealed Resident #25 had a Stage 3 Pressure Ulcer to the coccyx (the tailbone is the small triangular bone at the base of the spine). Interventions included: follow facility policies and protocols for the prevention/treatment of skin breakdown, and treatment to pressure ulcer per the physician's orders. Record review of Resident #25's Quarterly MDS assessment, dated 06/04/2026, revealed a BIMS score of 01, which indicated severely impaired cognition. The MDS assessment also indicated Resident #25 had a stage 3 pressure ulcer (injuries to the skin and/or underlying tissue caused by prolonged pressure and can range from mild redness to deep wounds involving muscle and bone) which was present upon admission. In an observation of wound care on 06/09/2026 at 9:36 AM, the DON was observed to have performed hand hygiene multiple times throughout wound care with ABHS in which she only rubbed her hands together for 3-8 seconds each time (only one 8 second hand hygiene noted, multiple 3 seconds hand hygiene, and a 4 second hand hygiene), and she would then hold her hands up to observe them prior to attempting to apply gloves. The DON had difficulty with getting the gloves on her hands every time she attempted throughout wound care. She had to throw multiple gloves away and start over because they kept sticking to her hands. An observation on 06/09/2026 at 4:00 PM revealed the hand sanitizer bag refill was observed to read hand sanitizer gel, 70% alcohol. Directions: apply a small amount to palm. Briskly rub, covering hands with product until dry. An observation on 06/09/2026 at 4:00 PM revealed the hand sanitizer bottle used during wound care was observed to read 70% alcohol hand sanitizer, high efficacy, works within 15 seconds, CDC recommended. Directions: apply a small amount to palm. Briskly rub, covering hands with product until dry. In an interview on 06/09/2026 at 1:35 PM, the DON stated she put enough ABHS to cover her hands and rubbed her hands until dry, which she thought was approximately 10 - 15 seconds. She stated it was what their policy stated to do. The DON stated the only reason her gloves were sticking, and she could not get them on was because the medium gloves were too small for her hands. She stated not performing adequate hand hygiene or proper wound care could have caused cross-contamination or infection. Record review of the facility's Hand Hygiene Policy, dated 12/01/2025, revealed Policy Statement: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: 4. Hand hygiene technique when using an alcohol-based hand rub: A. Apply to palm of one hand the amount of product recommended by the manufacturer. B. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. C. This should take about 20 seconds. Record review of CDC Clean Hands: About Hand Hygiene for Patients in Healthcare Settings, dated 02/27/2022, revealed How to clean hands with an alcohol-based hand sanitizer:1. Put product on hands and rub hands together.2. Cover all surfaces until hands feel dry.3. This should take around 20 seconds. https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 5 residents reviewed for infection control practices. The facility failed to ensure CNA A performed hand hygiene for at least 20 seconds prior to assisting Resident #1's transfer from her bed to the wheelchair. This failure could place residents at risk for healthcare associated cross-contamination and infections caused by improper wound care. Findings include: Record review of Resident #1's face sheet dated 10/27/25 reflected a [AGE] year-old-female with an original admission date of 06/10/21. Diagnoses included arteriovenous malformation of cerebral vessels (abnormal tangle of blood vessels in the brain that creates irregular connections between arteries and veins), cerebral infarction (ischemic stroke occurs when the blood flow to a part of the brain is obstructed), high blood pressure, and COPD (chronic obstructive pulmonary disease).Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 10 (cognition moderately impaired). Resident #1 required substantial/maximal assistance (helper does more than half the effort) with bed to chair transfer. During an observation of handwashing before the bed to chair transfer of Resident #1 on 10/27/25 at 11:20am, CNA A was observed lathering her hands for approximately 6 seconds. In an interview on 10/27/25 at 11:30am, CNA A stated she was nervous and believed she washed her hands for 20 seconds or more. CNA A stated handwashing should be 20 seconds to prevent cross contamination to residents. CNA A stated the last hands-on in-service for handwashing was in September 2025. In an interview on 10/27/25 at 2:39pm, the DON stated all staff should lather their hands for at least 20 seconds to prevent cross contamination. The DON stated washing hands inappropriately could put residents at risk for infection. In an interview on 10/27/25 at 2:50pm, the ADON who was the Infection Preventionist stated, staff should scrub their hands for at least 20 seconds to ensure all germs were washed off and to prevent cross contamination to the residents. The ADON stated it could put residents at risk for infection. The ADON stated there was a hands-on handwashing skills in-service on 09/22/25 and CNA A had no issues. The ADON stated CNA A was probably nervous. Record review of the facility's Handwashing/Hand Hygiene policy dated and reviewed in August 2019 reflected: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of infections.Washing Hands2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.

Based on observation, interview, and record review the facility failed to ensure each resident had the right to be free from abuse for two residents (Resident #1; Resident #2) of 6 residents reviewed for abuse/neglect.The facility failed to prevent resident to resident abuse on 06/20/25 when resident #2 pushed Resident #1 which caused resident #1 to stumble backwards. After being pushed by Resident#2 grabbed a plastic vase and hit Resident #2 on the vase. This failure placed residents at risk for serious injury. Record review of Resident#1 face sheet revealed an [AGE] year-old male initially admitted on [DATE], with diagnoses of Unspecified mood(active) disorder, Dementia (A group of thinking an social symptoms that interferes with daily functioning), , major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Non- Alzheimer's Dementia (A group of dementias that are not caused by Alzheimer's disease, the most common form of dementia. Record review of Resident #1's MDS Quarterly dated 07/31/2025 revealed Resident #1 had a BIMS Score of 04-severe cognitive impairment with behaviors of inattention and disorganized thinking, depressive mood and at times felt isolated. Resident #1 needed partial to moderate help with toileting and dressing ADLs. Resident #1 was able to transfer to toilet and chair with touch assistance. Resident #1 was able to walk up to 50 feet with two turns with moderate assistance. Resident #1 was diagnosed with hypertension and Non- Alzheimer's Dementia (A group of conditions that cause cognitive decline similar to Alzheimer's disease, but with different underlying causes). Record review of Resident #1's Care Plan date 04/21/25 revealed Resident #1 expressed little activity involvement related to activity intolerance date Initiated: 04/21/2025 Revision on: 06/23/2025 Resident #1. Resident #1 is physically aggressive when he feels threatened, and or antagonized by others. Resident #1 has Impaired cognitive function/ dementia or impaired thought processes related to Dementia. Care includes redirection and supervion as needed. Initiated 06/20/25 and Revised on 06/24/25. Resident #1 is physically aggressive when he feels threatened, and or antagonized by others. Refer Resident #1 to Psychiatric/Psychogeriatric services as needed. Staff to Redirect behavior, remind resident that fighting will not be tolerated. Date Initiated: 06/20/2025 Revision on: 06/24/2025. Refer Resident #1 to Psychiatric/Psychogeriatric services as needed. Staff to Redirect behavior, remind resident that fighting will not be tolerated. Date Initiated: 06/20/2025 Revision on: 06/24/2025. Resident #1 has impaired cognitive function/dementia or impaired thought processes related to dementia. Date Initiated: 07/31/2025 Revision on: 08/19/2025. Monitor/record occurrence of for target behavior symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others.) and document per facility protocol. Date Initiated: 04/21/2025 Revision on 04/22/2025.Record review of Resident #1's progress notes dated 06/20/25 written by the Social Worker revealed Resident #1 was seen being confrontational with another resident. Social Worker stepped in and attempted to redirect and stop the two, as other staff came to aid as well. In the mist of the confrontation Social Worker witnessed Resident #1 with the small container in his hand making contact with the Resident #1. Residents separated quickly. Review of Resident's #1's progress note dated 06/20/25 written by LVN A revealed This nurse heard some commotion coming from dining room area and then social worker started yelling for someone to come and help. Upon entering dining room, I saw both residents being separated from one another. After head-to-toe assessment [Resident #1] had no apparent injuries at this time. [Resident #2} also denied any pain RP, and MD called and notified of the altercation. Resident assed for pain, new skin injuries (none noted), vitals taken, RP and MD called and made aware of situation. Progress note dated 06/20/2025 written by DON revealed DON called into dining room due to resident-to-resident altercation. Other employees had already separated both residents. Resident #1 appeared upset and head- to- toe was immediately completed, no skin issued noted. MD and RP was notified by charge nurse LVN A. Review of Resident #1's progress notes dated 06/21/25 written by RN B revealed Resident #1 was observed in dining room this morning and continues to show aggression to another resident by voicing for other resident to not get near him. The resident was easily redirected at this time. Staff aware of situation, usually starts at mealtimes when both residents are in dining room. Care is ongoing and was safety maintained the RP was made aware. Progress note dated 06/21/25 revealed CNA reported she had to remove other residents from Resident #1 table due to he was getting upset and becoming angered. Residents separated and no other issues noted.Record review of Resident #1's incident report conducted by the Administrator/Abuse Coordinator dated 06/20/2025 revealed At approximately 4:30 PM on June 20, 2025, social worker was walking down the hallway when she heard a commotion coming from the dining hall. Upon entering, she observed [Resident #1] standing over [Resident #2]. [Resident #2] then pushed [Resident #1] causing him to stumble backward [Resident#1] quickly regained his balance, reached for a small plastic vase on the table, and struck Resident #2 on the head. At that time, nursing staff and facility management arrived on the scene and successfully intervened, separating the two residents. RP notified NP notified, MD notified. A head-to toe assessment and psychosocial assessment were completed for both residents. [Resident #1]and [Resident #2] were placed on 15-minute checks to ensure safety. [Resident #1] was referred to psych services for further evaluation, and [Resident #2] continues under his existing psych services. MD cleared both residents to come off 15-minute checks and return to the regular facility monitoring on 06/26/25. Record review of Resident #2's Face sheet revealed a [AGE] year-old male initially admitted on [DATE] with diagnosis of Mood Disorder (A mood disorder a serious mental illness that causes persistent and intense changes in a person's mood, energy, and behavior); peripheral vascular disease( A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs); Hypertension( A condition in which the force of the blood against the artery walls is too high); acquired absence of right left below knee; and Non- Alzheimer's Dementia (a group of conditions that cause cognitive decline similar to Alzheimer's disease, but with different underlying causes). Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 09-moderate cognitive impairment and needed some assistance with all ADL's. Resident #2's MDS also revealed disorganized thinking was a behavior continuously present and did not fluctuate. Resident #2's resident mood interview revealed symptoms presence of feeling down, depressed, or hopeless. Resident #2's behavioral symptoms revealed verbal behavioral example given of threatening others, screaming at others, cursing at others, which occurred 1 to 3 days. Resident #2's other behavioral symptoms not directed toward others occurred one to three days. Rejection of care was present 1 to 3 days. Resident #2's MDS revealed he needed moderate to substantial help with toileting, showering, lower body dressing and putting on and taking off footwear. Resident #2's MDS used a manual wheelchair. Record review of Resident #2's Care Plan date initiated 06/18/25 revealed, Resident #2 is at risk for activity intolerance related to major depressive disorder, severe with psychotic symptoms, mood disorder initiated on 12/16/2024 revised on 02/15/2025. Resident #2's care plan revealed has a behavior problem of being accusatory related to major depressive disorder, severe with psychotic symptoms, and mood disorder if reasonable, discuss the resident's behavior. Resident #2 care plan revealed Explanation and reinforcement as to why behavior is inappropriate and/or unacceptable to the resident. Refer to Psych services as needed Initiated on 02/17/2025 Revision on 03/24/2025. Resident #2 care plan revealed he had the potential to be verbally and physical aggressive related to poor impulse control and intervention was to administer medications as ordered and monitor and document for side effects and effectiveness initiate on 12/13/2024 and assess resident's understanding of the situation. Resident #2 care plan revealed to allow time for the resident to express self and feelings towards the situation initiated on12/13/2024 and the interventions were for a psychiatric/psychogeriatric consult as indicated. The DON called into dining room due to a resident-to-resident altercation. Other employees had already separated both residents. Resident #2 was noted with a scratch to left side of head, a scratch and small blood blister to his right hand. Resident #2 refused full head to toe. MD and RP were notified by charge nurse LVN E. And the SW to follow up with psych. Record review of Resident #2's progress notes by the nurse LVN E dated 06/20/2025 revealed the nurse was at the nurse's station and heard someone call for help from the dining room. When the nurse got to the dining room it was noted the resident had an altercation with another resident, employees had already separated the residents, and Resident #2 was being wheeled out of dining room. Resident#2 had not complained of pain or discomfort voiced and tried to do head to toe assessment resident refused. LVN E did note the resident had a small scratch to top of his right-hand, a small blood blister between his index finger and thumb, a small scab like area to left side of forehead. The MD informed. Resident #2 had new orders for UA, CBC, and CMP. The orders were noted, and the resident was also started on every 15 min frequent monitoring to prevent any further incidents. Record review of Resident #2 progress notes dated 06/20/25 revealed the DON was called into the dining room due to a resident-to-resident altercation and other employees had already separated both residents. Resident #2 was noted with a scratch to the point where left side of head, scratch and small blood blister to right hand. Resident #2 refused a full head to toe and the MD and RP were notified by the charge nurse LVN E and the social worker was to follow up with psych. Resident #2 progress notes dated 06/20/25 revealed and the social worker noted Resident #2 was seen being confrontational with another resident and the social worker stepped in and attempted to redirect as other staff came to aid as well and the PCS was notified. Record review of Residents #2 progress notes dated 06/23/25 Resident #2 was being monitored every 15 minutes for an altercation with another resident. Resident # 2 progress notes dated 06/23/2025 revealed team members were keeping the Resident #1 and Resident#2 separated so there was no altercation. In an observation and interview on 08/20/25 at 9:30 AM resident #1 was sitting on his bed watching TV. The state surveyor tried to ask him questions, but he could not hear very well. The state surveyor asked him about the incident with Resident #2 and stated he did not remember any altercation with him and Resident #2. The state surveyor discontinued the interview at that point. In an observation and interview on 08/19/2025 at 10:30AM revealed Resident#1 was observed sitting at the edge of his bed watching TV with the volume up high. The state surveyor asked if she could come in and talk with him, and he did not respond. Resident #1 stated in Spanish he could not hear very well and needed to talk to him very loudly so that he could hear. The surveyor attempted to ask him if he remembered the incident with Resident #2 but only heard some of the question. The surveyor attempted several times to asks questions, but the Resident#2 could not make out what was being asked so the surveyor discontinued the interview. In an observation and interview on 08/19/2025 at 1:42 PM revealed Resident #2 was observed sitting in his wheelchair in front of the nurse's station talking with other residents. Resident # 2 was alert and when he spoke with the other residents was hard to understand and just spoke about random subjects not really follow any type of conversation. The state surveyor asked resident #2 if he could answer some questions, and he stated yes. The state surveyor asked resident #2 if he would like to go to his room and Resident #2 stated he was okay to have the interview where he sat in his wheelchair at the nurse's station. Resident #2 stated he could not remember why or how the incident occurred but did confirm Resident #1 hit him with a truck. Resident #2 stated he did not remember pushing Resident #1. Resident #2 stated there was no argument between them and they had never had any other altercations before. Resident #1 stated he was not afraid of Resident #1 or anyone in the facility. In an interview on 08/19/25 2:26 PM with CNA G stated Resident #1 was always to himself and would get angry with meals if he did not like what was served or did not get what he wanted to eat. CNA G said the resident was often very confused and had to be redirected. CNA G said at one point he did not like anyone sitting with him when he ate. CNA G said the staff had to coax Resident #1in to taking a shower he can get combative at times. CNA G stated the resident had not harmed any staff to her knowledge when he refused to do any of his ADL's. CNA G stated he had a good day if he was getting out of his room and go to the dining room to eat or go to activities. CNA G said a bad day was when the resident stayed in his room most of the day. CNA G stated the last time she had a training on abuse was about month and half ago. CNA G stated when an altercation occurs first thing to do is redirect residents try to get them separated and call for help immediately. CNA G stated a verbal abuse example could be name calling, talking down to a resident, cursing at the resident and tone in their voice in some case. The administrator is the abuse coordinator, and all abuse is to be reported to him immediately.In an interview on 08/19/2025 at 2:49 PM LVN F stated Resident #2 sits in the dining room alone because he likes it. Resident #1is very aggressive with other males and does not like other people around him. CNA G stated she saw Resident #1 began the argument with Resident #2. As Resident #2 left the area serval times to avoid an escalation with Resident #1. CNA G said when Resident #1 sees resident #2 he gets angry, and the staff try to keep Resident #1 and Resident #2 away from each other. CNA G said no other incidents have occurred between Resident #1 and Resident #2. CNA #2 was in the dining room when it occurred over dinner but did not see Resident #2 strike resident #1 with an object and only saw the Resident#! and Resident #2 arguing and the social worker come in and try to separate them. She then began to calm the two residents down. CNA G stated for a while the staff could not have both residents in the dining room at the same time because Resident #1 would get angry. CNA G stated her last abuse training was 2 weeks ago and said the first step to do when an altercation begins is to deescalate the matter by separating the residents and redirect them away from each other and if there is an injury get the nurse an let the abuse coordinator know immediately. In an interview on 08/19/25 at 4:01 PM CNA H stated Resident #1 got agitated he really does not like people around him and especially does not want any one near him in dining room. CNA H stated Resident #1 had never been angry with her while she helped him. Resident #2 was the only one Resident #1 was aggressive with. CNA H walked in the dining room as they were being separated. CNA H said she was Resident #2's nurse for that day and stated Resident #2 was worked up for a while after the incident. CNA H stated Resident #2 had a scratch to his forehead that was scabbed on his head. CNA H stated Resident #2 happened to roll too close to Resident #1 and Resident#1 got angry was what she understood happened in the dining room and what may have started the incident. Resident #2 had no complaints of pain to head and was acting normal and the nurse did neuro checks on him. In an interview on 08/19825 at 4:33 PM with CNA I, she stated she has been a nurse for both residents at different times. CNA I said Resident #1 keeps to himself likes to eat alone has and she had no issues with him being aggressive in any way. CNA I said Resident #1 l does not like to be helped with ADL's and can be combative with staff. CNA I said Resident #2 yells at times when he gets aggravated but has no problems with any other residents. CNA I said Resident #2 gets combative when staff transfers and bathes him. CNA I said there was no history of aggression with either resident against each other. CNA I said all staff know to keep them apart at all times. CNA I was not present on the day of incident. CNA I stated when she returned two days later, she saw no injuries on either resident. In an interview with 08/19/25 at 4:20 PM the ADON she said she saw the Social Worker and nurses separated Resident #1 and Resident #2 from each other in an altercation that occured in the dining room at dinner time. The ADON said resident #1 had a center piece in his hand and Resident # 2 had a wound that looked like an old scab on his forehead. The ADON stated she was not present during the altercation and arrived after the social worker yelled out for help so she did not see if there was contact made between the residents. The ADON said the staff stayed with Resident #1 and Resident #2 was taken to his room. The ADON said neither resident had altercation with any other residents or staff before this incident occurred. The ADON said the abuse coordinator was immediately notified as well as MD and RP. The treatment Nurse / unit manger did an assessment the next day to give a more thorough head-to-toe. The ADON said as she spoke with Resident #1, he stated Resident #2 had the vase and he took it away from him. The ADON stated she did not consider the incident abuse since both residents had mental issues. The ADON said the last time she had abuse training was 2 weeks ago. The stated staff is trained to deescalate situations that can turn into altercations between residents or staff and residents. The abuse coordinator is to be told immediately of any abuse that occurs in the facility. In an interview on 08/19/25 at 5:20 PM with LVN A she stated she was there during the altercation but understood from conversations in the dining room Resident #1 had walked in the dining room and saw Resident #2 was sitting in Resident #1 spot he likes to sit in and the altercation began. CNA A stated she heard the Social Worker began yelling for help as she quickly made her way to the dining room and tried to help separate the residents. LVN A stated she could not recall what exactly occurred or what happened afterward the dining room clearly but did recall Resident #1 was terribly upset and Resident #2 was taken to his room. CNA A said she assisted with calming Resident #1 and recalled he stated he was going to hit Resident #2. When Resident #1 was asked if he hit Resident #2, he said he did not hit him with plastic vase. In an interview on 08/19/2025 5:45 PM with Social Work was in her office heard scuffle and someone yelled leave me alone! The SW quickly ran into the dining room and when she arrived and saw Resident #1 and Resident #2 had hands on each other. Resident #2 was in his wheelchair and had his breaks on and could not move backward to get away. Resident # 2 was trying to get way from Resident #1as he was standing in front of him and shoved resident #2 away Resident #1 then stumbled back and almost fell. The SW stated Resident #1 had a plastic vase in his hands and tried to take away. SW stated she was calling for help and could not confirm that Resident #1 stuck Resident #2 with the vase. The SW stated as help arrived, she was able to take the vase away from Resident #1. Resident #2 had a old scratch and scab on his forehead. The SW stated she just saw the forehead injuries was not aware of the hand injury. The SW stated no other altercations before this one and after the staff just try to keep him away from each other. The SW stated neither resident has had any other altercations with other residents. The SW said she followed up with the family, resident physician, psychological evaluations, and how both residents continued with their care. The SW stated Resident #1 continues to be territorial about his dining room spot, so staff try to make sure it is available for him if he eats in the dining room. Record review of the facility's Abuse Protocol dated 04/2019 Indicated: The Patient has the right to be free from Abuse, neglect mistreatment of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treating the Patient's symptoms. Our facility will not condone Patient Abuse, neglect, mistreatment misappropriation of patient property and exploitation (collectively Patient Abuse by anyone, including staff members, other Patients, consultants, volunteers, staff of other agencies serving the Patient consultants volunteers, staff of other agencies serving eh Patient, family members, legal guardians, sponsors, friends or other individuals. Abuse is defined as the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by a individual, including a caretaker, of goods or services that are necessary to attain or maintain physical or mental and psychosocial well-being. Instances of abuse of all Patient/Resident, irrespective of any physical or mental condition, cause physical harm pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 2 (Resident #1; Resident#2) out of 6 residents reviewed for care plans. The facility failed to update Resident #1's care plan regarding an altercation with Resident #2 on 6/20/25.The facility failed to update Resident #2's care plan regarding an altercation with Resident #1 on 06/20/25.This failure could place resident at risk for receiving inadequate care and services.Record review of Resident#1 face sheet revealed an [AGE] year-old male initially admitted on [DATE], with diagnoses of Unspecified mood(active) disorder, Dementia (A group of thinking an social symptoms that interferes with daily functioning), , major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Non- Alzheimer's Dementia (A group of dementias that are not caused by Alzheimer's disease, the most common form of dementia. Record review of Resident #1's MDS Quarterly dated 07/31/2025 revealed Resident #1 had a BIMS Score of 04-severe cognitive impairment with behaviors of inattention and disorganized thinking, depressive mood and at times felt isolated. Resident #1 needed partial to moderate help with toileting and dressing ADLs. Resident #1 was able to transfer to toilet and chair with touch assistance. Resident #1 was able to walk up to 50 feet with two turns with moderate assistance. Resident #1 was diagnosed with hypertension and Non- Alzheimer's Dementia (A group of conditions that cause cognitive decline similar to Alzheimer's disease, but with different underlying causes). Record review of Resident #1's Care Plan date 04/21/25 revealed Resident #1 expressed little activity involvement related to activity intolerance date Initiated: 04/21/2025 Revision on: 06/23/2025 Resident #1. Resident #1 is physically aggressive when he feels threatened, and or antagonized by others. Resident #1 has Impaired cognitive function/ dementia or impaired thought processes related to Dementia. Care includes redirection and supervion as needed. Initiated 06/20/25 and revised on 06/24/25. Resident #1 is physically aggressive when he feels threatened, and or antagonized by others. Refer Resident #1 to Psychiatric/Psychogeriatric services as needed. Staff to Redirect behavior, remind resident that fighting will not be tolerated. Date Initiated: 06/20/2025 Revision on: 06/24/2025. Refer Resident #1 to Psychiatric/Psychogeriatric services as needed. Staff to Redirect behavior, remind resident that fighting will not be tolerated. Date Initiated: 06/20/2025 Revision on: 06/24/2025. Resident #1 has impaired cognitive function/dementia or impaired thought processes related to dementia. Date Initiated: 07/31/2025 Revision on: 08/19/2025. Monitor/record occurrence of for target behavior symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others.) and document per facility protocol. Date Initiated: 04/21/2025 Revision on 04/22/2025.Record review of Resident #1's progress notes dated 06/20/25 written by the Social Worker revealed Resident #1 was seen being confrontational with another resident. Social Worker stepped in and attempted to redirect and stop the two, as other staff came to aid as well. In the mist of the confrontation Social Worker witnessed Resident #1 with the small container in his hand making contact with the Resident #1. Residents separated quickly. Review of Resident's #1's progress note dated 06/20/25 written by LVN A revealed This nurse heard some commotion coming from dining room area and then social worker started yelling for someone to come and help. Upon entering dining room, I saw both residents being separated from one another. After head-to-toe assessment [Resident #1] had no apparent injuries at this time. [Resident #2} also denied any pain RP, and MD called and notified of the altercation. Resident assed for pain, new skin injuries (none noted), vitals taken, RP and MD called and made aware of situation. Progress note dated 06/20/2025 written by DON revealed DON called into dining room due to resident-to-resident altercation. Other employees had already separated both residents. Resident #1 appeared upset and head- to- toe was immediately completed, no skin issued noted. MD and RP was notified by charge nurse LVN A. Review of Resident #1's progress notes dated 06/21/25 written by RN B revealed Resident #1 was observed in dining room this morning and continues to show aggression to another resident by voicing for other resident to not get near him. The resident was easily redirected at this time. Staff aware of situation, usually starts at mealtimes when both residents are in dining room. Care is ongoing and was safety maintained the RP was made aware. Progress note dated 06/21/25 revealed CNA reported she had to remove other residents from Resident #1 table due to he was getting upset and becoming angered. Residents separated and no other issues noted.Record review of Resident #1's incident report conducted by the Administrator/Abuse Coordinator dated 06/20/2025 revealed At approximately 4:30 PM on June 20, 2025, social worker was walking down the hallway when she heard a commotion coming from the dining hall. Upon entering, she observed [Resident #1] standing over [Resident #2]. [Resident #2] then pushed [Resident #1] causing him to stumble backward [Resident#1] quickly regained his balance, reached for a small plastic vase on the table, and struck Resident #2 on the head. At that time, nursing staff and facility management arrived on the scene and successfully intervened, separating the two residents. RP notified NP notified, MD notified. A head-to toe assessment and psychosocial assessment were completed for both residents. [Resident #1]and [Resident #2] were placed on 15-minute checks to ensure safety. [Resident #1] was referred to psych services for further evaluation, and [Resident #2] continues under his existing psych services. MD cleared both residents to come off 15-minute checks and return to the regular facility monitoring on 06/26/25. Record review of Resident #2's Face sheet revealed a [AGE] year-old male initially admitted on [DATE] with diagnosis of Mood Disorder (A mood disorder a serious mental illness that causes persistent and intense changes in a person's mood, energy, and behavior); peripheral vascular disease( A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs); Hypertension( A condition in which the force of the blood against the artery walls is too high); acquired absence of right left below knee; and Non- Alzheimer's Dementia (a group of conditions that cause cognitive decline similar to Alzheimer's disease, but with different underlying causes). Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 09-moderate cognitive impairment and needed some assistance with all ADL's. Resident #2's MDS also revealed disorganized thinking was a behavior continuously present and did not fluctuate. Resident #2's resident mood interview revealed symptoms presence of feeling down, depressed, or hopeless. Resident #2's behavioral symptoms revealed verbal behavioral example given of threatening others, screaming at others, cursing at others, which occurred 1 to 3 days. Resident #2's other behavioral symptoms not directed toward others occurred one to three days. Rejection of care was present 1 to 3 days. Resident #2's MDS revealed he needed moderate to substantial help with toileting, showering, lower body dressing and putting on and taking off footwear. Resident #2's MDS used a manual wheelchair. Record review of Resident #2's Care Plan date initiated 06/18/25 revealed, Resident #2 is at risk for activity intolerance related to major depressive disorder, severe with psychotic symptoms, mood disorder initiated on 12/16/2024 revised on 02/15/2025. Resident #2's care plan revealed has a behavior problem of being accusatory related to major depressive disorder, severe with psychotic symptoms, and mood disorder if reasonable, discuss the resident's behavior. Resident #2 care plan revealed Explanation and reinforcement as to why behavior is inappropriate and/or unacceptable to the resident. Refer to Psych services as needed Initiated on 02/17/2025 Revision on 03/24/2025. Resident #2 care plan revealed he had the potential to be verbally and physical aggressive related to poor impulse control and intervention was to administer medications as ordered and monitor and document for side effects and effectiveness initiate on 12/13/2024 and assess resident's understanding of the situation. Resident #2 care plan revealed to allow time for the resident to express self and feelings towards the situation initiated on12/13/2024 and the interventions were for a psychiatric/psychogeriatric consult as indicated. The DON called into dining room due to a resident-to-resident altercation. Other employees had already separated both residents. Resident #2 was noted with a scratch to left side of head, a scratch and small blood blister to his right hand. Resident #2 refused full head to toe. MD and RP were notified by charge nurse LVN E. And the SW to follow up with psych. Record review of Resident #2's progress notes by the nurse LVN E dated 06/20/2025 revealed the nurse was at the nurse's station and heard someone call for help from the dining room. When the nurse got to the dining room it was noted the resident had an altercation with another resident, employees had already separated the residents, and Resident #2 was being wheeled out of dining room. Resident#2 had not complained of pain or discomfort voiced and tried to do head to toe assessment resident refused. LVN E did note the resident had a small scratch to top of his right-hand, a small blood blister between his index finger and thumb, a small scab like area to left side of forehead. The MD informed. Resident #2 had new orders for UA, CBC, and CMP. The orders were noted, and the resident was also started on every 15 min frequent monitoring to prevent any further incidents. Record review of Resident #2 progress notes dated 06/20/25 revealed the DON was called into the dining room due to a resident-to-resident altercation and other employees had already separated both residents. Resident #2 was noted with a scratch to the point where left side of head, scratch and small blood blister to right hand. Resident #2 refused a full head to toe and the MD and RP were notified by the charge nurse LVN E and the social worker was to follow up with psych. Resident #2 progress notes dated 06/20/25 revealed and the social worker noted Resident #2 was seen being confrontational with another resident and the social worker stepped in and attempted to redirect as other staff came to aid as well and the PCS was notified. Record review of Residents #2 progress notes dated 06/23/25 Resident #2 was being monitored every 15 minutes for an altercation with another resident. Resident # 2 progress notes dated 06/23/2025 revealed team members were keeping the Resident #1 and Resident#2 separated so there was no altercation.In an interview with on 08/20/25 at 6:00pm The ADON stated the IDT team was responsible for the entry any new information to the care plans like change in condition and incidents. The SW was responsible for any behavior updates for each resident's care plan. The importance of updating the care plans is to ensure the resident is getting the appropriate care and the documentation of any change in condition and new orders from the physician are implemented. The ADON could not say why the altercation between Resident #1 and Resident #2 was not documented,. The preventive measure of the 15 min checks for each resident was implemented, and the preventive measure of keeping the two residents apart so that another incident did not occur between the two residents were not documented in the care plan interventions as well. In an interview on 09/20/25 at 9:23 AM the DON stated the nurse managers, ADON, and DON were responsible for updating the care plan for the residents. The DON stated the social worker is responsible for the behavior updates. The DON stated the team was documenting the falls with the intervention and incidents documented. The DON stated social worker and IDT as a whole are responsible for updating care plans for falls, incidents or any significate changes. The DON stated any changes in condition or incidents are discussed as a team and documented. The DON stated there was no updates or interventions for the care plans for these two residents and could not say why the care plans were not updated for Resident #1 and Resident #2. The DON stated will do in-service with IDT team ensure all documentation of any the change of condition and an incident of any type occurs is entered into the care plan with the interventions. The DON stated the incident was not an abuse allegation because both residents had dementia and was reported to the abuse coordinator. Resident #1 stays in his room seldomly comes out and Resident #2 stays on his side of the facility and close to room and the staff keeps an eye on him as he was a fall risk.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation and sanitation. 1. The facility failed to ensure non-stick pans were not missing the coating. The facility failed to ensure coffee cups and bowls were clean. The facility failed to ensure product were 18 inches from the ceiling in the walk-in refrigerator and freezer. The facility failed to ensure spices were not open to air. The facility failed to ensure the walk-in freezer did not have ice accumulation inside of it. The facility failed to ensure the FSM appropriately followed infection control practices when the FSM grabbed the top of resident dessert cups by top rims with bare hands, while passing out meal trays to 5 of 24 residents in the dining room during lunch on 04/15/25. 2. The facility failed to ensure the FSM appropriately followed infection control practices when the FSM grabbed the top of resident dessert cups by top rims with bare hands, while passing out meal trays to 5 of 24 residents in the dining room during lunch on 04/15/25. These failures could place residents who received meals and/or snacks from the kitchen and satellite kitchens at risk for food contamination and food borne illness. Findings included: 1. During the initial tour and observation of the kitchen on 04/15/25 at 8:35 am revealed 4 non-stick type pans with flaking and scrape marks in the coating. There were 58 of 58 coffee cups that were stained and scratched. There were 4 of 12 plastic bowls with what appeared to be hardened food substance on and in them. The dirty cups and bowls were on the clean rack. There were 10 of 19, 21-ounce containers of spices that were open to air. There were 5 boxes of product and 11, 1-gallon containers in the walk-in refrigerator that were stacked less than 6 inches from the ceiling. There were 7 boxes of product in the walk-in freezer that were stacked less than 6 inches from the ceiling. There was ice accumulation behind the fan/condenser and ice droplets on the ceiling of the walk-in freezer. In an interview with the FSM on 04/15/25 at 8:35 am, she said she had worked in her position at the facility for 2 years. She said the non-stick pans became bare of the coating due to wear and tear. She said the kitchen staff used metal utensils in the non-stick pans because they were not allowed to use plastic because plastic chipped off. She said she was trained that way by the former dietary manager two years ago. She said she followed rules, wrong or right. She said it was not right to have used metal utensils in non-stick pans. She said the right thing to do was to use plastic or rubber utensils in the non-stick pans because that kind of material would not scratch or harm the coating. She said the non-stick pans would be more expensive to replace than plastic or rubber utensils. She said food got stuck in the non-stick pans when the coating was scratched. She said bacteria could get stuck in the scratches on the non-stick pans, then the bacteria could transfer to the food, which would transfer to the resident's and make them sick. She said she did not know if non-stick coating was toxic, but the chips of it could get into the food and make residents sick. She said she had new cups to replace the stained and scratched cups but had not put them out yet. She said the dirty cups and bowls were on the clean racks and coffee cart that was being used for service. She said she did not know why she had not already removed the stained and scratched cups when she got the new ones. She said all kitchen staff was responsible for making sure dishes were clean before they were used, and she was ultimately responsible. She said she would not want to drink from the dirty coffee cups. She said the dirty bowls looked like they had old oatmeal stuck to them. She said the open spice containers were supposed to be closed at all times to ensure insects, dust, or moisture did not contaminate the contents. She said contaminated spices could change the flavor of the food and make residents sick. She said the boxes in the walk-in refrigerator and freezer were a lot less than18 inches from the ceiling. She said the stacked boxes were a fire safety hazard because they blocked the sprinklers. She said the ice droplets on the ceiling of the walk-in freezer were because it was in defrost mode. She said she knew about the ice build-up behind the fan in the walk-in freezer because she broke it (the ice) off whenever she cleaned the walk-in freezer. She said it (the ice build-up) was always like that. She said she had not notified the MS about the ice build-up in the walk-in freezer. She said the process for reporting kitchen needs was for her to tell the MS verbally. Observation and interview with the FSM and RD during dining services on 04/15/25 at 12:46 pm revealed 4 of the dirty cups had been used for service and drank from by some of the residents (unknown). The FSM said she did not know why the cups were on the resident's table and they had definitely been used. The RD said the dirty cups on the table should never have been used due to cross contamination and because of the potential to make resident's sick. During an observation of dining on 04/15/25 at 12:51 PM the FSM was observed grabbing dessert cups from the top of the lid while she passed out dessert to 5 of 25 residents. In an interview on 04/15/25 at 01:02 PM the FSM stated by grabbing the dessert cups from the lids, it could contaminate the dessert cups and make residents sick through cross contamination. The FSM stated she did not realize she was grabbing the dessert cups from the lid and was just handing them out to residents. The FSM stated she had just told the staff serving not to grab cups from the top only from the bottom. The FSM stated there is no official staff training for serving food to residents in the dining room. In an interview on 04/16/25 at 03:40 PM the DON stated staff should not grab resident dessert cups from the top of the lids due to infection and cross contamination. The DON stated staff should grab the dessert cups from the side or bottom. The DON stated the last infection control in-service was done monthly and all staff are included. The DON stated the facility held a Skilled Fair on 02/5/25, and all staff were required to attend for hands on infection control training. In an interview on 04/17/25 at 11:58 AM the IP stated staff should not be grabbing any cups from the top because they could get their hands in the food and cross contamination could occur. The IP stated staff should be grabbing cups either underneath or on the side to avoid touching the rim of the cup. The IP stated infection control in-services are conducted at least once a month with all staff. In an interview with the MS on 04/17/25 at 3:53 pm, he said he worked at the facility for [AGE] years. He said the process of getting kitchen repairs done was for the FSM to tell him verbally. He said there were no logs or electronic reporting system, just word of mouth. He said he was unaware of the ice build-up on the condenser fan box and ceiling of the walk-in freezer. He said he had seen boxes stacked in the walk-ins within a foot of the ceiling. He said stacking boxes within 6 inches of the ceiling in the walk-ins was a no-no. He said boxes stacked that high could cause a fire safety hazard by blocking the sprinklers should there be a fire. He said the boxes and containers should be only 18 inches from the ceiling. He said he never said anything to the FSM or kitchen staff or in-serviced them about the potential fire safety hazard. He said there was no way to track repairs because there were no logs for any repairs other than maybe emails. 2. During an observation of dining on 04/15/25 at 12:51 PM the FSM was observed grabbing dessert cups from the top of the lid while she passed out dessert to 5 of 25 residents. In an interview on 04/15/25 at 01:02 PM the FSM stated by grabbing the dessert cups from the lids, it could contaminate the dessert cups and make residents sick through cross contamination. The FSM stated she did not realize she was grabbing the dessert cups from the lid and was just handing them out to residents. The FSM stated she had just told the staff serving not to grab cups from the top only from the bottom. The FSM stated there is no official staff training for serving food to residents in the dining room. In an interview on 04/16/25 at 03:40 PM the DON stated staff should not grab resident dessert cups from the top of the lids due to infection and cross contamination. The DON stated staff should grab the dessert cups from the side or bottom. The DON stated the last infection control in-service was done monthly and all staff are included. The DON stated the facility held a Skilled Fair on 02/5/25, and all staff were required to attend for hands on infection control training. In an interview on 04/17/25 at 11:58 AM the IP stated staff should not be grabbing any cups from the top because they could get their hands in the food and cross contamination could occur. The IP stated staff should be grabbing cups either underneath or on the side to avoid touching the rim of the cup. The IP stated infection control in-services are conducted at least once a month with all staff. Record review of kitchen in-services dated 01/03/25 Dish Machine Cleaning, 02/20/25 Grease Fire Guidelines, 02/25/25 Cleaning Schedule, 03/04/25 Time Management/Food Carts, 04/15/25 Stained Cup ware/Bowls. Record review of the facility policy revised 03/19 titled, Food Storage revealed under #4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and bulk foods .11. Food is stored a minimum of 8 inches above the floor and 18 inches from the ceiling on clean racks or other clean surfaces .#14. All refrigerator units are kept clean and in good working condition at all times. Record review of facility's Infection Control policy dated February 2025 stated: 1. The facility must establish an infection prevention and control program (IPCP) that must include: a. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. This applies to all Patients, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment. References: FDA Food Code 2022 Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A)Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Ch. 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. (C) Except as specified in (D) of this section, if used with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned throughout the day at least every 4 hours.

Based on observation, interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, including but not limited to the right to make choices about aspects of his or her life in the facility that were significant tothe resident for one (1) of ten (10) residents reviewed for self-determination. (Resident #4) Resident #4 was not given the choice to drink sodas or eat candy sent to her as gifts from family. Staff were stored candy, and sodas in an office and was not given access to items when she wanted to consume them. The gifts were held without permission from Family Member #A who had power of attorney over her. This failure could place all residents dependent on staff, at risk of their needs and preferences not being met by the facility. Findings included: Record review of Resident #4's Face Sheet dated 04/16/25 reflected a [AGE] year-old female admitted [DATE] with diagnoses of Chronic obstructive pulmonary disease, Dementia, major depressive disorder, heart failure, osteoarthritis, essential hypertension, and pneumonia. Record review of Resident #4's quarterly MDS dated [DATE] reflected a BIMS score of 04 indicating the resident was severely cognitively impacted. Review of Section G, Functional Status reflected for eating, Resident #4 was able to feed herself with assistance of tray set up by staff. Record review or Resident #4's Care Plan revealed Resident #4 needs minimal help of feed herself. Resident #4 is dependent on staff for activities of daily living needs substantial to maximal assistance in areas. Resident# 4 needed help to be transfered from wheelchair to bed or bathroom. Resident #4 is encouraged to join activities daily with other residents. Review of Resident #1's Physician Progress Notes dated 02/01/25 revealed the following: NAS diet(No salt added excludes salt during cooking and preparation, and restricts certain foods), Ground Texture regular/ thin consistency Record review of resident #4's April 2025 Physician Orders revealed no diabetes diagnosis or food restrictions. Review of Resident #4's weight record revealed a 3.0% weight gain from 04/04/25. In observation on 04/15/25 at 9:30 AM Resident #4 revealed she had no candy or snacksin her room. Four sodas were in a bottom drawer in her night stand. The gifts of lotions were on her night and the satin pillow cases were not on her pillows. In an interview on 04/15/25 at 1:58 with Resident #4's Family Member #A, she said sent Resident#4 a gift to the facility for the resident's birthday, Family Member #A claimed she called the facility and found out the gift she send her was not given her mother and was held back due to a request from another family member. Family Member #B, requested the gift be held until she arrived in March. Family Member #A called the facility and found out from a staff member Residen t#4's candy was being held in one of the staff offices. Family Member #A also sent a Valentines gift with several hygiene items, and she also found out some of the items were held. Family Member #A claimed she had sent her some hair products, satin pillowcases, and candy. She was told that the candy was being held by Social Worker and Activities Directors office and her lotions were at the nurse's desk. Family Memeber #A was upset as she felt that her mother had no access to her treats, she had sent her and did not understand why they treats were being kept from her as she has no diet restrictions. In an interview on 04/16/2025 at 1:30pm Resident #4 stated that she did not have any of the candy or sodas her daughter had sent her. The resident stated she could not recall any other gifts other than her birthday gifts and did not get all her gifts from staff. The resident could not recall where her satin pillow cases were located as they were not on her pillows. In an interview on 04/16/25 at 2:05 CNA A she stated the satin pillowcases given to the resident as gifts were with laundry services to be washed . CNA A stated the resident has sodas in her nightstand drawer so that only she had access to them. CNA A remembered the gifts and soda but did not remember the resident having any candy in her room. In an interview on 04/16/25 at 4:01 pm with Business Office Manager she stated the mail is brought to the business office and then it is distributed to the residents unopened. The business office manger stated she had spoken with Family Member #B and was told to hold Resident #4's gift till she arrived in March. She stated Family Member #B goes often to see the Resident #4 so she did what was asked of her.The Business Office Manger stated family #A found out and asked for the gifts to be given to Resident #4 immediately. She stated the package was taken by the Activities Director and the Social Worker and was to be given to the resident. In an interview on 04/16/25 at 4:22pm with social worker she stated the gift was received in January and Family Member #B had asked staff to hold the gift till she arrived in March. Family Member #B oversees the resident's finances but Family Member #A has Power of Attorney over Resident #4. The social worker stated she and the activities director opened the gift so that the items could be inventoried and kept as the resident had plenty of candy and sodas already. When Family Member # A found out the gifts were kept from Resident #4, she ask to speak to the activities director or social worker to see why the gift were held from her. The activities direct took the gift to resident#4 and video chatted with Family Member #A to show Resident#4 opening the birthday gifts but the candies were kept in the office. The Social Woker stated the activities director used the candies from the birthday and Valentine's gifts as an incentive to motivate the resident to be more involved in activities around the facility. The social worker stated Family Member #A was sending large amounts of candy and soda that is why it was kept in the office. Review of the facility's Statement of Resident's Rights dated August 2022 reflected the resident is to be supported by the facility in exercising his or her rights

Based on observations, interviews, and record reviews the facility failed to ensure residents who entered the facility received care and treatment consistent with professional standards of practice to prevent pressure ulcers and a resident with pressure ulcers receives necessary treatment and service to promote healing and/or prevent further development of skin breakdown or pressure ulcers, for two (Resident #214 and Resident#50) of two residents reviewed for prevention and maintenance of pressure ulcers. The facility failed to ensure Resident #214 and Resident #50, who were identified as at risk of developing pressure ulcers, received necessary treatment and services thru proper use of low air loss air mattresses, which was chosen as prophylaxis to prevent the development of or worsening of pressure ulcers. This failure could place residents at risk of developing pressure ulcers for worsening of existing pressure ulcers. The findings included: Record review of Resident #214's Face Sheet dated 04/15/2025 documented a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of Sepsis, and history of traumatic brain injury. Record review of Resident #214's five-day MDS assessment dated [DATE] indicated Resident #214 -Had Indwelling catheter, genitourinary obstructive uropathy(a blockage in ther urinary track, occurs whe urine flow is impeded leading to urine backflowand potential kidney damage), malnutrition, respiratory failure, oxygen therapy, suctioning as needed Bipap/CPAP(Bilevel Positive Airway machine is a device that helps people breathe by providing air at different pressure levels when inhaling and exhailing /continuous positvie airway pressure a device used to treat sleep apnea and other breathing disorders by delivering a constan flow of pressureized air though a mask) -Was totally dependent for bed mobility, transfers, toilet use, and bathing -Was always incontinent or urine and bowel - Had one pressure ulcer at admission in the Coccyx area(located at the bottom of the spine, just below the sacrum) and was at risk of developing additional pressure ulcers -Skin/Ulcer Treatment: pressure reduce device for bed Record review of Resident #214's Consolidated April 2025 Care Plan indicated Pressure Ulcer Prevention Assess for appropriate footwear Date Initiated 04/11/2025. Barrier Cream Date Initiated 04/11/2025 Revision on 04/11/202; 5 Encourage out of bed Date Initiated 04/11/2025. Revision on 04/11/2025; Encourage to float heels as tolerated Date Initiated 04/11/2025 Revision on 04/11/2025. Pressure Redistribution Mattress Date Initiated: 04/11/2025 Revision on 04/11/2025; Therapy disciplines to screen, evaluate, and treat as indicated; Turn and reposition q 2 hours and as needed. Keep body in good alignment Date Initiated: 04/11/2025 Revision on: 04/11/2025; Use suspension devices, pillows, and/or wedges to reduce pressure on heels and boney prominences Date Initiated: 04/11/2025 Revision on 04/11/2025. Record review of Resident #214's April 2025 Physician Orders indicated air mattress ordered 04/13/2025. Record review of Resident #214's April 2025 weight log indicated Resident #214 was 139 pounds. Record Review of -Resident #214's Wound Assessment Report dated 04/11/2025 indicated: -Wound Type: Pressure Ulcer -Wound Location: Coccyx: unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) -Date Wound Identified: 04/11/25, present at admission -Drainage: Exudate moderate (serous clear watery fluid, which is separated from solid elements) -Measurement = Length 8.5cm, Width 8.5 cm, depth-0 -Wound Bed: Epithelial Tissue: Boggy (tissue or area this is soft, spongy, and may feel wet to touch) -Wound Edges: Attached edges appears flush with wound bed or as a sloping edge -Surrounding Skin: Erythema (redness of the skin may be intense bright red to dark red or purple) -Fragile: skin that is at risk for breakdown Record review of Resident #214's Skin-Acute Care Plan dated 04/20/2025 documented Pressure Ulcer: unstageable Coccyx related to accident, decreased mobility, incontinence, friction/shear .Approach: Pressure relief device: Air Mattress; Reposition every two hours; Treatment as ordered . In an interview on 04/17/25 at 02:33 PM LVN A stated she was taking care of Resident #214 on Monday, 04/14/2025 and on Tuesday, 04/15/25. LVN A recalled Monday, 04/14/2025 going into his room reviewed all mattress control settings but could not recall what settings the bed was on. LVN A stated she took care of Resident #214 on Tuesday, 04/15/2025 but could not recall checking his bed settings on that day. LVN A stated she was trained on the air mattress on Friday, 04/11/25 when the mattress was set up. She stated not having the correct weight on the settings could cause a breakdown of the skin. Observation of Resident #214 on 04/15/25 at 9:06 AM revealed the resident was lying in bed on his back in 30-degree angle and was asleep. The bed had indicated Medline air mattress, and the pressure was set at max 400lbs. Record review of Resident #214's Change in Condition Report dated 04/15/25 documented Skin Status Evaluation noted a change in the condition of the residents skin pressure ulcer. New onset Grade 2 or higher-pressure ulcer/injury, or progression of pressure of ulcer/injury despite interventions. Unstageable pressure ulcer presents to Coccyx area wound bed exhibiting slough. And is unstageable due to necrotic(black/dead) tissue. Care Plan stated refer to specalized practioner for specialized treatment. Interview with the DON on 04/15/25 at 4:00 PM revealed she stated she was aware Resident #214 had a current pressure ulcer and was in use of a low air loss air mattress. The DON said Resident #214's mattress pump should be set at the correct setting according to the resident's weight. The DON said each nurse caring for the R #214, as well as the Treatment Nurse, should be checking the low air loss mattress and pumps at the beginning of and throughout their shift for correct settings as per the physician orders and or manufacturer instructions. The DON said the all staff in contact with the resident are responsible for ensuring and implementing these practices. The DON said the purpose of the low air loss mattress was to prevent and treat pressure injuries. The DON said if the mattress was set over R #214's weight, the mattress was too firm placing the resident at risk for pressure injury worsening or possibly acquiring a new pressure injury. The DON stated the resident was admitted with the pressure ulcer staged at unstagable and a diagnosis of sepsis the resident was admitted to hospital for wound debribment Review of the undated Medline Supra CXC Low Air Loss and Alternating Pressure Mattress Manufacturer Recommendations documented .Use for prevention and stage1 through 4 pressure ulcers; pump alarms to indicate low pressure, Adjustable to patients' weight for customized therapy, 300lb weight capacity .Directions for Use: .Pressure adjust knob controls the air pressure output. When turning clockwise the output pressure will increase. [NAME] versa for decreasing air pressure. Please consult your physician for a suitable setting . 2. Record review of Resident #50's Face Sheet dated 04/15/2025 documented a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of Alzheimer's disease unspecified, other amnesia, pain unspecified, restlessness and agitation, repeated falls, and history of falling. Record review of resident #50s quarterly MDS assessment dated [DATE] indicated Resident #50 -Had a Brief Interview of Mental Status of 01 (severe cognitive impairment) -Was totally dependent for bed mobility, transfers, toilet use, and bathing -Was at risk of developing pressure ulcers but does not have any pressure ulcers -Skin/Ulcer Treatment: pressure reduce device for bed and chair . Record review of #50's care plan revealed o Potential for Impaired Skin Integrity as evidenced by Braden Scale for Predicting Pressure Ulcer Risk High Risk for Pressure Ulcer Initiated on 04/15/2025. Educate resident and representative about the proper usage of pressure reducing devices Date Initiated: 04/15/2025. Evaluate skin integrity. Initiated on 04/15/2025. Low Air Mattress initiate on 04/15/2025. Record review of #50 physician's orders dated 04/15/25 revealed resident is to have weekly head to toe skin assessments and a low air loss mattress to be checked for proper functioning. Observation of Resident #50 on 04/15/25 at 9:10 AM revealed the air mattress was set at 350lbs on her proactive mattress. In an interview with LVN #B on 04/17/25 at 9:54 AM she stated the air mattress for resident #50 was a preventive measure as she had pressure ulcers in the past. LVN#B stated she incorrect setting on the air mattress can contribute to a pressure ulcer getting worse. LVN B also stated if a resident is on preventive measure the incorrect setting can create new ulcers for the resident if the resident is at high risk for pressure ulcers. LVN she received training for air mattress settings about a week ago. Interview with the DON on 04/15/25 at 4:00 PM revealed she stated she was aware Resident #214 had a current pressure ulcer and was in use of a low air loss air mattress. The DON said R #214s mattress pump should be set at the correct setting according to the resident's weight. The DON said each nurse caring for the R #214, as well as the Treatment Nurse, should be checking the low air loss mattress and pumps at the beginning of and throughout their shift for correct settings as per the physician orders and or manufacturer instructions. The DON said the all staff in contact with the resident are responsible for ensuring and implementing these practices. The DON said the purpose of the low air loss mattress was to prevent and treat pressure injuries. The DON said if the mattress was set over R #214's weight, the mattress was too firm placing the resident at risk for pressure injury worsening or possibly acquiring a new pressure injury. Review of the undated Proactive Protekt Aire 6000 Pressure and Low-Air-Loss Therapy Mattress Replacement Systems Manufacturer's Instructions documented .Caution: Please cover the mattress with a cotton sheet to avoid direct skin contact and for the patient's comfort, Users can adjust the pressure level of the air mattress to a desired firmness by themselves or according to the suggestions from a health care professional. It is recommended to press Auto Firm on the panel when the mattress is first inflated. User can the easily adjust the air mattress to a desired firmness according to the patient's weight and comfort.

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 3 (Residenst #30, #34, and #55) of 4 residents reviewed for accuracy and completeness of clinical records. The facility failed to obtain and/or revise advanced directive orders for Residents #30, #34, and #55. This deficient practice could affect residents who require care and monitoring and place them at risk of receiving or not receiving advanced directives to meet their needs. The findings were: 1.Record review of Resident #30's face sheet revealed a [AGE] year-old female with an admitted [DATE] and initial and original admitted s of [DATE]. Diagnoses included Diabetes, stroke with subsequent weakness on both sides and speech deficit, heart disease, depression, kidney failure, morbid obesity, schizophrenia, psychosis, impaired vision, and anxiety. Record review of Resident #30's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognition. She was independent with eating, required moderate assistance with upper body dressing, rolling left and right, sitting up, chair to bed transfers, and personal hygiene. She required substantial assistance with oral hygiene, toileting, and lower body dressing. She utilized a motorized wheelchair, was frequently incontinent of bladder and occasionally incontinent of bowel. Record review of Resident #30's care plan dated [DATE] revealed Resident #30 requested Code Status of: Full Code (perform CPR-cardiopulmonary resuscitation) Date Initiated: [DATE] Revision on: [DATE]. Record review of Resident #30's active physician orders revealed no code status ordered. There was no code status in her order summary or on her profile page. In an interview with the DON on [DATE] at 1:47 pm, she said Resident #30 did not have Advanced Directives for resident #30 and did not know how it could have happened because the care plans pulled from the physician orders. She said the facility transitioned to their electronic health record system starting on [DATE] and had been refining it ever since. She said advanced directives were reviewed on admission, during a care coordination meeting on ([DATE]) after admission, as needed, significant changes or a care plan meeting. She said the nurse managers reviewed the orders and the SW reviewed the code statuses of all new admissions and care plans and significant changes. She said the SW entered and inputs the advanced directive orders-she just missed it. The DON said she was responsible for overseeing accuracy and completion. She said she missed it too. She could not say how often advanced directives were reviewed. 2.Record review of Resident #34's face sheet revealed an [AGE] year-old female with an admitted [DATE]. Diagnoses included respiratory failure, dementia, high blood pressure, and heart failure. Record review of Resident #34's admission MDS dated [DATE] revealed a BIMS score of 09, indicating moderate cognitive impairment. She required supervision with eating, oral hygiene, and positioning in bed. She required moderate assistance with sitting up, lying down, and upper body dressing. She required substantial assistance with all other ADL's including transferring and mobility via wheelchair. She was always incontinent of bladder and bowel. Record review of Resident #34's care plan dated [DATE] revealed Resident #34 requested Code Status of: Full Code Date Initiated: [DATE] Revision on: [DATE]. Record review of Resident #34's active physician orders revealed no code status ordered. There was no code status in her order summary or on her profile page. In an interview with the DON on [DATE] at 1:47 pm, she said Resident #34 did not have Advanced Directives and did not know how it could have happened because the care plans pulled from the physician orders. She said the facility transitioned to their electronic health record system starting on [DATE] and had been refining it ever since. She said advanced directives were reviewed on admission, during a care coordination meetings, after admission, as needed, significant changes or a care plan meeting. She said it was on her admission assessment dated [DATE] (confirmed). She said the nurse managers reviewed the orders and the SW reviewed the code statuses of all new admissions and care plans and significant changes. She said the SW entered and inputs the advanced directive orders-she just missed it. The DON said she was responsible for overseeing accuracy and completion. She said she missed it too. She could not say how often advanced directives were reviewed. 3.Record review of Resident #55's face sheet revealed a [AGE] year-old female with an admitted [DATE] and original and initial dates of [DATE]. Diagnoses included obesity, stroke with subsequent inability to speak or swallow, anoxic (lack of oxygen) brain damage, gastrostomy tube, depression, anxiety, high blood pressure, heart failure, liver failure, convulsions (seizures), and history of sudden cardiac arrest. Record review of Resident #55's initial admission MDS dated [DATE] revealed a BIMS score of 00 indicating severe cognitive impairment. She was dependent on staff for all ADL's and required a mechanical lift for transfers. She could sit in a wheelchair but could not propel one. She was always incontinent of bladder and bowel. Record review of Resident #55's care plan dated [DATE] revealed Full Code dated initiated [DATE] and revised on [DATE]. Record review of Resident #55's active physician orders revealed no code status ordered. There was no code status in her order summary or on her profile page. In an interview with the DON on [DATE] at 2:27 pm, she said Resident #55's advanced directives were not on her profile. She said it was not in the physician orders. She said her Care plan coded her as a full code. She said it was missed by the SW and by reviewers including herself. She said if there was not a code status in the system, the resident would be a full code, even if their wishes were to be a DNR (Do Not Resuscitate). She said staff knew the resident's code status by looking at their profile or the physician's orders. She said Resident #55 did not have a code status ordered, so she would be a full code. She said every nurse that had seen her chart would have seen there was no code status, and no one brought it to her attention so she could have fixed it much sooner. She said the SW could input orders, but the nurses had to confirm the orders. In an interview with the SW on [DATE] at 3:39 pm, she said her role in advanced directives was to make sure they were in the charts and to ask the residents if they want to be DNR or Full Code. She said the nurses do it on the weekends. She said she thought she put Resident #55's advanced directive in her chart but she just missed it. She said the outcome could be that if something happened, there would be a lot of chaos. She said advanced directives defaulted to Full Code. She said if Resident #55 was a DNR, she would have gotten CPR against her and her family's will. She said there were a lot of people that saw that but did not make anyone aware. She said it was her responsibility. She said she must have missed Resident #30 and Resident #34's as well. Record review of the facility policy dated [DATE], titled, Advanced Directives revealed under #1. An Acknowledgement Receipt for Advance Directives/Medical Treatment Decisions must be completed for each Patient upon admission and upon any change in the status of the Patient's Advance Directives. #5. The Advanced Directive report must be reviewed daily for all Patients. The Social Worker or designee must verify the Advance Directive report for accuracy to ensure the clinical record reflects the current advanced directive status and use it to monitor the existence of a DNR.

Based on interviews and record reviews, the facility failed to ensure a PASRR evaluation was completed on newly admitted residents prior to admission or after admission for 1 (Resident #48) of 5 residents reviewed for PASRR screenings. The facility failed to ensure Resident #48's PASRR L1 screening dated 12/10/24 accurately reflected his diagnoses of mental illness. There was no evidence that Resident #48 was referred to a Level 2 PASRR Screening and Evaluation. This failure could affect residents by placing them at risk for not receiving needed treatments and services. Findings included: Record review of Resident #48's face sheet revealed a [AGE] year-old male with an admitted [DATE] and original and initial admitted s of 12/11/24. Diagnoses included major depressive disorder, recurrent, severe with psychotic symptoms, and mood (affective) disorder dated 12/13/24, unspecified dementia with mood disturbance dated 12/16/24. Record review of Resident #48's quarterly MDS report 03/17/25 revealed a BIMS score of 8 indicating moderate cognitive impairment. He was dependent on staff for all transfers. He required substantial assistance with toileting, lower body dressing, and footwear, moderate assistance with showering and positioning, supervision with upper body dressing and personal hygiene, and set-up with oral hygiene and eating. He utilized a wheelchair and could self-propel short distances. He was always incontinent of bladder and bowel. Record review of Resident #48's PL1 from a local hospital dated 12/10/24 was negative for MI (mental illness), ID (intellectual disability), and DD (developmental disability). There were no other PL1 screenings for Resident #48. Record review of Resident #48's Care Plan dated 12/11/24 revealed he was at risk for Activity Intolerance r/t major depressive disorder, severe with psychotic symptoms, and mood disorder Date Initiated: 12/16/2024 Revision on: 02/15/2025. He was at risk for Impaired Social Interaction r/t major depressive disorder, severe with psychotic symptoms, mood disorder Date Initiated: 12/16/2024 Revision on: 02/15/2025. He had a behavior problem of being accusatory r/t major depressive disorder, severe with psychotic symptoms, mood disorder. He places himself on the floor and crawls to the doorway or hallway Date Initiated: 12/13/2024 Revision on: 02/15/2025. He used anti-anxiety medications (Ativan) r/t Adjustment issues, Anxiety disorder Date Initiated: 12/16/2024 Revision on: 02/15/2025. He used psychotropic medications Ativan, Depakote, Fluoxetine r/t Mood disorder, anxiety, and mood disturbance Date Initiated: 12/13/2024 Revision on: 02/15/2025. He had a mood problem r/t Disease Process Major depressive disorder with psychotic features; yells and curses, removes clothing and presents himself naked to others, accusatory, places self on floor, and crawls on floor. Date Initiated: 12/13/2024 Revision on: 02/15/2025. Record review of Resident #48's mental health warrant dated 01/09/25 revealed he was transferred to a local psyche facility for assessment due to exposing himself to staff and did not have the urgency to cover up when visitors came including children. He yelled at staff and threw his briefs on the floor. He used his bed to urinate and defecated on and refused to leave his briefs on. He was verbally aggressive with staff and had no regard to other residents. He was combative with care and at times would not allow care. He threatened to leave (the facility) and kill himself by throwing himself out of the window. He was impulsive, refused medication, and tried to hit staff. The document was signed by the SW Returned 01/22/25 with no med changes and no new diagnoses. In an interview with the MDS on 04/17/25 at 2:15 pm revealed Resident #48 was admitted from a local hospital on 12/10/24 with a negative PL1. She said they (the facility) submitted what the local hospitals provided. She said a Form 1012; Mental Illness/Dementia Resident Review (used to assist nursing facilities in determining whether a resident with a negative PASRR Level 1 Screening form needs further evaluation for mental illness, or when an individual's diagnosis was changed) should have been sent for Resident #48 because his diagnoses included major depressive disorder, recurrent, severe with psychotic symptoms, and mood (affective) disorder dated 12/13/24. She said she just missed it. The MDS said she would submit a Form 1012 today. She said a Form 1012 was for when a resident had a negative PL1 needed further evaluation for mental illness or if the diagnosis changed. In an interview with the SW on 04/17/25 at 2:18 pm, she said she just was not thinking about PASRR when everything was going on with him at the time she submitted a mental health warrant on Resident #48. She said the IDT worked as a group when a resident's behaviors were getting to be a problem. The SW said per protocol, if the resident was in the hospital within 30 days of their most recent admitted , they would not re-submit. She said the guideline did not specify if the PL1 should be resubmitted if there was a change within those 30 days. In an interview with the DON on 04/17/25 at 2:22 pm, she said Resident #48 was seen by psyche on 12/13/24. She said he returned from the local psyche hospital on 01/22/25. She said there was no PL1 reinitiated as a positive after his return. Record review of the facility policy dated November 2016, titled, Patient Care Management System revealed under 7. Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASRR recommendations. If a facility disagrees with the findings of the PASRR, it must indicate its rationale in the resident's medical record.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: A. Food temperature was not taken prior to serving meal. B. Hot foods were served at an unsafe temperature level. These failures could place residents who eat foods prepared in the kitchen at risk of cross contamination and food-borne illnesses. Findings include: During observation and interview on 02/22/24 at 8:03 AM the Kitchen Aide was plating food. The Kitchen Aide stated no, temperatures had been taken. Further observation of the temperature log revealed , no temperatures were logged in for AM of 2/22/24. The Kitchen Aide took the temperatures of food. Temperatures revealed scrambled eggs temperature of 165 degrees, puree eggs temperature was 167 degrees. The Kitchen Aide stated she was very busy and rushed and that she did not take time to take temperatures. The Kitchen Aide stated that not checking if food was at the correct temperature required could cause food borne illness. Upon the test tray observation on 02/22/24 @ 8:13am, the oatmeal had a temperature of 177 degrees. This temperature was taken by the investigator with the Dietary Manager present. The Dietary manager stated the required temperature of the oatmeal should be at 165 degrees. She stated she did not know why the temperature was much higher. The temperature log for 02/22/24 indicated the oatmeal was logged under cereal and the temperature was documented at 166 degrees. The Dietary Manager stated she did not how the oatmeal was logged at 166 degrees, but the test tray oatmeal had a temperature of 177 degrees, she stated that she did not know how it could be at 177 degrees. During interview on 02/22/24 at 9:02 AM the Dietary Manager stated that food temperatures are required to be taken at serving place before serving. The Dietary Manager stated that this failure could place resident at risk for cross contamination and food borne illness. She stated the Food warmer was set at 135 degrees to preserve temperature. The Dietary Manager stated she oversaw the temperature logs, if not her then, the cook in the morning or evening are trained to check food temperature log. She stated serving a tray with a temperature high could result in a resident being burned or harmed. During interview on 02/23/24 at 2:13 PM the Administrator stated the Dietary Director oversaw that policies are being followed. The Administrator stated staff are trained upon hire and as needed. The Administrator stated these failures could result in dissatisfaction of food served, cross contamination and foodborne illnesses. The Administrator stated she followed up with the Dietary Manager to confirm in-services were completed. Record review of In- Service Training Report Topic: Time/Temperature Control/ Logging Temperatures dated 7/21/22 conducted by Dietary Director and signed by all dietary staff. Record review of policy Food temperature, not dated, revealed 3. Record reading on Food Temperature Chart (form 401) at beginning of tray line and end of tray line. 4. Acceptable serving temperatures are: Eggs, omelets 140 degrees- 155 degrees.

Based on observations, interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #4 and #36), reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Residents #4 and #36 in that: 1) Resident #4's Care Plan dated 02/24/23 failed to indicate her Code status was either DNR or Full Code 2) Resident #36's Care Plan dated 02/20/23 failed to indicate a specific therapeutic diet These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs. The Findings include: 1)Record review of the admission record dated 08/02/19 for Resident #4 revealed Resident #4 was an [AGE] year-old female. Resident #4's diagnoses included epilepsy, pneumonia, heart failure, reflux, moderate protein calorie malnutrition, a history of urinary tract infections, cognitive communication deficit, fainting, a history of falls, COPD, dementia, insomnia, depression, and symptoms and signs concerning food and fluid intake. 1)Record review of Resident # 4's MDS assessment dated [DATE] indicated a BIMS of 4-severe cognitive impairment, required set-up for eating, and was dependent on staff for all other ADL's. Resident # 4's mood was documented as having little/no interest or pleasure in doing things. Resident #4 was to have a mechanically altered diet as well as a therapeutic diet. Record review of Resident # 4's physician orders dated prior to 02/24/23 indicated DNR for Code Status. STATUS: Active (current). Record review of Resident #4's care plan dated 02/24/23 indicated a Code status of DNR with a goal of Code Status will be maintained over the next 90 days or until resident or family desires a change. The interventions included inform staff of FULL CODE STATUS. STATUS: Active (current). 2)Record review of the admission record dated 11/08/20 for Resident #36 revealed Resident #36 had a re-entry date of 10/22/23 and was a [AGE] year-old female. Resident #36's diagnoses included a stroke with right sided weakness, diabetes, high blood pressure, depression, insomnia, dementia, nutritional deficiency, schizoaffective disorder, anxiety, reflux, and was a smoker. Record review of Resident # 36's MDS assessment dated [DATE] indicated Resident #36 was cognitively intact with a BIMS of 15, required set-up for eating and substantial to partial assistance for all other ADL's. The MDS dated [DATE] indicated Resident #36 required a mechanically altered diet. Record review of Resident #36's physician orders revealed a diet for Regular Diet dated 12/23/23 and 03/01/23. The physician orders did not include a regular ground diet, LCS (low concentrated sweets) NSOT (no salt on tray) until 02/20/24. Record review of Resident #36's care plans dated 02/20/23, indicated no care plan for a therapeutic diet. There was an entry dated 08/30/23 for a protein supplement 30ml once daily x 30 days. STATUS: Active (current). There was an entry that indicated Resident #36 had no natural teeth or tooth fragments with an intervention to provide a mechanically altered diet (grind meat) dated 08/30/23 STATUS: Active (current). Record review of Resident #36's Nursing Admission assessment dated [DATE] indicated under Nutrition: Own Teeth? With the answer yes, Specialized Diet required? Answer No, Check all that apply-difficulty chewing. Interview on 02/21/24 at 9:03 am with Resident #36 stated she was getting a regular diet and sometimes they chopped it up, but they were not supposed to. Resident #36 stated it was ok with her (that they chopped it) because she has had a dominant side stroke and eating made her tired. Resident #36 stated she wore a bridge in her mouth. Interview on 02/23/24 at 10:22 am with the ADM stated the care plans were a team effort-everyone does their part. they recently did a validation review with the corporation around the end of December to make sure the care plans were complete and accurate. The ADM stated they did education and action plans (PIP=performance improvement plans) for missing a diet, specialty wheelchairs, fall preventions, and others-she stated she could not remember nor could pull up the link from the validation review on her computer. The ADM stated each department was ultimately responsible for care plans and review the care plans weekly. The ADM stated she and the DON were ultimately responsible for the accuracy and timeliness of all care plans. The ADM stated there was always room for improvement and they discussed care plans in their monthly QAPI meetings and care plans were always important. Review of Care Plans, Comprehensive Person-Centered facility Policy revised 03/2022 stated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 12. The IDT reviews and updates the care plan: a. when there has been a significant change in the resident's condition. b. when the desired outcome is not met. c. when the resident has been readmitted to the facility from a hospital stay. d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interviews and record review, the facility failed an adequately equipped system allowed residents to call for staff assistance through a communication system for 1 (Resident #45) of 8 residents reviewed for call light button placement. The facility failed to ensure that Resident #45 ' s call light was functioning properly. This failure put residents at risk of not being able to call for assistance when needed. Findings included: Record review of Resident #45 ' s face sheet dated 02/20/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #45 ' s Admission Note dated 02/20/2024 revealed he had diagnoses including dementia, left hip surgery, urinary tract infection/ extended-spectrum beta-lactamase (enzymes or chemical produced by germs that make it harder to treat with antibiotics. It is a type of urinary tract infection). He had memory deficits, contact isolation and was on fall precautions, Record review of Resident #45 ' s baseline care plan dated 02/20/2024 revealed he needed extensive assistance from one person to bathe, for toileting and for walking. He required limited assistance from one person to move around in bed, and to transfer between surfaces. He was at risk of falling, and his call bell was to be in place. He had a cognitive impairment. The level or type of impairment was not specified in the care plan. In observation and interview on 02/20/24 at 09:57 AM, Resident #45 revealed he had been waiting a long time for someone to come to ask them to refill his water jug. He was not able to remember how long he had been waiting. When asked how he called for help he said he pressed the call light, which he then demonstrated. It was observed that the light on the wall (an indicator that the call light had been activated) did not light up, and observation of the light outside Resident #45 ' s room also did not light up. Resident #45 stated that the call light had not worked since the resident was moved to that room on 02/16/2024. In interview and observation on 02/20/2024 at 12:00 PM, C.N.A 1 was observed pressing Resident #45 ' s call light button and pushed the call light cord into the wall, with no change. C.N.A. 1 was observed to push Resident #45 ' s call light button again and went into the hall to see if the light went on. She stated that the call light was not working, and she needed to let the maintenance man know so he could fix it. C.N.A. 1 stated that she did not know that the call light had been broken and the resident rarely used it C.N.A. 1 stated the harms to a call light not working she stated that a resident could get hurt or have a serious accident. In an interview on 02/21/24 at 12:03 PM, the Maintenance Director said he had not heard anything from any of the staff in regard to a call light not functioning. The Maintenance director stated if there was an issue with something not working in a residents room he would correct it immediately. The Maintenance Director stated that the staff will add it to the maintenance log and he will review, fix, then add that it had been resolved. The Maintenance said not having a working call light put the resident at risk of not getting the help she needed. He said when something was broken a note could be put in a notebook at the front of the facility and usually maintenance staff would come down and get it fixed right away. The maintenance director stated that a new room should be checked by Maintenance and Housekeeping Director before a resident was moved in. During an interview on 02/21/24 at 11:10 AM with CNA 2, she stated the risk could be an injury if the residents are not able to use the call light for help. The resident still did not have a functioning call light. When asked how often the call lights should be checked if functioning, she stated every time the staff enters the room. If the call light is broken it is that person's job to go immediately to inform the maintenance and add it to the Work Order book. This interview related to the specific failure because this C.N.A. was working with the resident during the time that the call light was broken and had not noticed that the residents call light was broken or submitted a work order. The resident had a broken call light and it had been broken 02/16/2024 to 02/20/2024. During an interview with the Housekeeping Director on 02/21/24 @ 1:14 PM, she stated that she does not remember filling out those forms Guardian Angel Checklist forms), but that it was her writing, and she must have Just missed it. She state a residents residing in a room with a call light that was not working properly, could result in a resident being seriously hurt or ill because they cannot come out to ask for help like a regular resident at the facility. Record Review of the Maintenance logs from the dates 02/16/2024 to 02/22/2024 : There had not been a work order submitted since 11/2023. Record review of the housekeeping log from 02/26/2024 to 02/22/2024 : There had been forms completed by the Housekeeping Director stating that the room Resident #45 was transferred to for contact isolation was ready and there were no issues with the room. Record review of the facility Call Lights: Accessibility and Timely Response policy dated 02/2023 revealed, The purpose of this policy was to assure the facility was adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. Staff will ensure the call light was within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident ' s room.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one laundry room reviewed for environment. -The facility failed to properly document the deep cleaning tasks that were performed for dates 02/22/24 and 02/23/24. The facility failed to properly document the Lint Collection tasks for dates 02/21/24 and 02/22/24. -The facility failed to properly scrub their hands for at least 20 seconds with soap and water to prevent cross contamination and infection. -The facility failed to properly dispose and maintain the lint accumulation in the facility dryers in a timely manner. This failure could put residents at risk for an unsafe environment. Findings include: Record review of the Laundry Deep Cleaning Chart on 02/23/24 at 11:53 AM indicated that the deep cleaning tasks had not been completed on 02/22/24 or 02/23/24. Record review of the Laundry Lint Trap Log on 02/23/24 at 11:52 AM indicated that the laundry lint trap cleaning had not been documented for the dates of dates 02/20/24 from 06:00 AM through 02:00 PM and 02/23/24 from 06:00 AM through 11:00 AM. Observation on 2/23/24 at 12:20 PM during the laundry room inspection, LS was observed to walk to the sink, scrubbed her hands with soap and water for only 9 seconds before rinsing her hands of soap and water and handling clean linen. Further inspection revealed the lint collector area beneath the dryer had large football sized clumps of lint accumulated on the electrical component at the top of the lint collector area. In addition, the Laundry Deep Cleaning Chart and the Laundry Lint Trap Log had not been completed. In an interview on 2/23/24 at 12:42 PM, the LS stated she had not gotten around to the Lint Trap Log yet today because she had been busy all morning. She stated, I have never seen that form (deep cleaning chart) before. She stated the lint was accumulated around the electrical outlet because, I don't touch anything up there. I don't want to break it, so I just leave it alone. She stated there could be a fire if the lint was not emptied out completely. LS stated, I don't remember the length of time I should wash my hands. She stated that germs could spread if hand washing was not performed correctly. In an interview on 2/23/24 at 12:20 PM with the HD, she stated she was going to be doing an in-service immediately with LS. She stated the LS had just started on 02/03/2024, and was nervous during the interview with the Investigator. The HD stated that the Laundry Lint Trap Log was to be filled out every hour immediately after the lint has been cleaned out of the lint collector. The Laundry Deep Cleaning chart should be filled out every day immediately after the task has been completed. The HD stated all staff are given in-services on hand hygiene monthly, and LS had just completed hers at the beginning of the month. HD stated the lint not being cleaned out properly could result in a fire in the laundry room. She stated the forms should be filled out properly to be able to facilitate keeping the laundry room clean and sanitized for the residents clothing. The HD stated not washing their hands properly could result in bacteria and infection spreading to the residents. In an interview with the Administrator on 02/23/24 at 01:13 PM, she stated the LS was new and just completed all her trainings recently. The Administrator stated she does not know why the LS could not demonstrate or speak about proper hand hygiene because they are in-serviced monthly on infection control. Record review of the facility provided Infection Control Policy from Laundry and Linen. (Revised January 2014) reflected, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Record review of the facility provided Hand Washing/Hand Hygiene policy dated Qtr 3, 2018 reflected, This facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub for the following situations: g. Before and after separating soiled and clean linen at all times h. wash hands before handling clean linen k. After handling used dressings, contaminated equipment, etc. m. After removing gloves.

Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one of the residents (R# 1) of five that were reviewed for infection control and transmission-based precautions policies and practices, in that: a.CNA A did not cleanse the catheter tubing while providing catheter care. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Record review of R#1's Face Sheet dated 11/13/2023, admitted [DATE], documented a [AGE] year-old male with the following diagnoses of: Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dysphagia (swallowing difficulties), chronic ischemic heart disease, benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty). Record review of R #1's MDS dated [DATE], revealed R#1 had a 02/15 BIMS score documenting a severe cognitive impairment. R#1 was coded to have an indwelling catheter. R#1 also required extensive assistance of staff to assist in activities of daily living. Record review of R #1's Comprehensive Care Plan date initiated 10/19/2023 revealed, R#1 has a foley catheter and was at risk for increased UTI's. due to urinary retention. Interventions: change the foley catheter, tubing, and bag per order. Ensure leg strap or other method to secure catheter is in place unless contraindicated. Monitor urine for odor, color, sediments and amount of urine, and report abnormalities to MD. Encourage PO and fluid intake within dietary limits. Keep tubing/bag below the bladder, do not kink tubing. Perform catheter care per order. Record review of R#1's Physician Order dated 03/09/2023 revealed: Indwelling catheter care every shift with soap and water or may use wipes as appropriate/ desired by patient. During an observation on 11/13/2023 at 12:53PM, while providing catheter care on R#1, CNA A cleaned the penile area but did not cleanse from the meatus (opening) outward for at least 4 inches of catheter tubing. During an interview on 11/13/2023 at 1:14PM, CNA A stated she was given a competency check off yearly on foley care. CNA A stated she was nervous and should have cleaned the catheter tubing to prevent infection. CNA A stated by not cleaning the catheter tubing, R#1 could have potentially been exposed to infection, which could have led to a urinary tract infection which can affect the well-being of R#1. CNA A stated the urinary discharge could potentially infiltrate the urinary system and cause a terrible infection which could affect R#1's safety. CNA A stated she normally cleans the catheter but forgot this time. CNA A stated she was last in-serviced about foley catheter care a couple of weeks ago. During an interview on 11/13/2023 at 1:28PM, the DON stated CNA A was taught to cleanse penile area, followed by cleaning the tubing. The DON stated CNA A should have cleansed the catheter tubing as a standard of care to promote infection control. The DON stated by omitting the catheter tube cleaning, the well-being of R#1 could have been compromised. The DON stated R#1 potentially could have contracted an infection, and if not treated, R#1 could experience altered mental status, frequent urination, or worse sepsis. The DON stated all clinical staff are given competency skills checkoffs via online education portal, which includes foley catheter care. The DON stated peri-care (Perineal Care) in-services are conducted periodically and as needed. Record Review of the facility's Perineal Care Protocol, dated 02/2022, stated: If catheter is present, stabilize the catheter, then gently wipe the catheter tubing with new wipe from the meatus outward for at least 4 inches of tubing. Record Review of the facility's Nurse Aide Proficiency Audit dated 08/14/2023 documents a passing evaluation regarding infection control and catheter care for CNA A. Record review of the facility's Peri-care (Perineal Care) In-service Training Report dated 11/10/2023, reflected CNA A was in attendance.

Based on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5% for 1 of 2 Residents (Resident #26) reviewed for medication administration errors, in that: MA A administered 26 medications of which 8 were administered to Resident #26 50 minutes after they were scheduled, which resulted in a 30% medication error rate. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #26's face sheet, dated 1/5/2022, revealed an admitted [DATE] with diagnoses which included pain, hypertension [high blood pressure], neuralgia [a sharp, shocking pain that follows the path of a nerve], pain, and hypokalemia [a low level of potassium in the blood. Potassium helps control how muscles, the heart, and the digestive system work]. A record review of Resident #26's quarterly MDS, dated [DATE], revealed Resident #26 was an [AGE] year-old female assessed with a mildly impaired cognition. A record review of Resident #26's physician's orders revealed Resident #26 was to receive the following medications daily at 7:00 AM: docusate 100mg two times daily for constipation; furosemide 40mg two times daily for edema; gabapentin 100mg three times daily, for neuralgia; hydralazine 25mg two times a day for high blood pressure; hydrocodone 10mg, acetaminophen 325mg three times a day, for pain; labetalol 200mg two times daily, for high blood pressure; lisinopril 10mg two times daily, for high blood pressure; and potassium chloride 10 mEq two times a day for low potassium. During an observation on 1/5/2023 at 8:50 AM revealed MA A administered medications to Resident #26 at 8:50 AM which were scheduled for 7:00 AM. The medications were as follows: docusate 100mg two times daily for constipation; furosemide 40mg two times daily for edema; gabapentin 100mg three times daily, for neuralgia; hydralazine 25mg two times a day for high blood pressure; hydrocodone 10mg, acetaminophen 325mg three times a day, for pain; labetalol 200mg two times daily, for high blood pressure; lisinopril 10mg two times daily, for high blood pressure; and potassium chloride 10 mEq two times a day for low potassium. During an interview on 1/5/2023 at 8:52 AM MA A stated she administered Resident #26's 7:00 AM medications at 8:50 AM, late, due to her duties to administer medications to the facility's entire census of 62 residents. MA A stated she began her duties a 6:00 AM and was scheduled for a 16-hour day. MA A stated she had been employed as the MA for longer than a year and was late due to other duties besides medication administration. MA A stated, You saw me in the dining room assisting residents with their meals. MA A stated Resident #26 was not the last resident who needed medications. MA A stated she still had many more residents to administer medications to. MA A stated she had not alerted anyone to her late medication administration. MA A stated her supervisor was the ADON. MA A stated it was her responsibility to administer medications on time meaning 1 hour prior and/or 1 hour after the scheduled time; 7 AM meds no later than 8 AM. MA A stated there may be risks if residents did not receive medications on time. During an interview on 1/5/2022 at 2:20 PM the ADON stated she was MA A's supervisor, and she was not given a report about MA A's late medication pass. The ADON stated MA A was responsible for administering medications for Residents at the time the medications were scheduled and if she could not, MA A should have reported the failure to the ADON. The ADON stated if she had learned of the late medication administration, she could have intervened to ensure residents received their medications as scheduled. A record review of the facility's medication error rate policy was not possible due to the request for a policy, made of the ADON and the Administrator on 1/5/2022 at 2:20 resulted in a policy titled medications which did not address the medication error rate.

Based on observation, interview and record review the facility failed to develop and implement policies and procedures that prohibit neglect for one Resident (R #1) of 15 residents reviewed for neglect . The facility failed to assess or monitor R #1 to determine when a change of condition occurred that required physician notification or immediate medical intervention. R#1 was hospitalized and diagnosed with [REDACTED]. R#1 remained in the hospital at the time of the visit. These failures placed in identification of an Immediate Jeopardy (IJ) on 05/22/14 at 9:35 p.m. While the IJ was removed on 05/25/14 at 11:45 a.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility continuing to in-service staff and monitor the Plan of Removal. These failures could place all residents at a higher risk of neglect and delay medical treatment, care, services, incur complications and/or hospitalization or possible death. The findings were: The facility's Policy and Procedures for Abuse Protocol dated March 2012 revealed; "our facility will not condone Patient abuse, neglect, mistreatment or...by anyone, including staff members,..." The facility defines neglect as the "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." R#1's Face Sheet dated 05/02/14 revealed a [AGE] year old male admitted to facility on 05/01/14 from Hospital "BB." Hospital "BB's" Discharge Records for R#1 dated 05/01/14 identified R#1's Medical History and Physical with End-stage liver disease due to primary biliary [MEDICAL CONDITION] ([DIAGNOSES REDACTED] disease in which the bile ducts in your liver are slowly destroyed) , [MEDICAL CONDITION] Varices, Mallory-Weiss tear (tear in the esophagus associated with pressure caused by vomiting or coughing), Portal Hypertensive Gastropathy (changes in the mucosa of the stomach associated with [MEDICAL CONDITION] of the liver), Ascites (accumulation of fluid in the abdomen), Hypertension and [DIAGNOSES REDACTED] (enlargement of the spleen), Hepatic [MEDICAL CONDITION] (loss of brain function that occurs when the liver is unable to remove toxins from the blood), and [MEDICAL CONDITION]. Lab tests conducted included, Ammonia level was 56 (according to nim on 06/11/14 the normal amonia range is 15-45 micrograms per deciliter). R#1's admission orders [REDACTED]. R#1's [DIAGNOSES REDACTED]. According to [MEDICATION NAME].org retrieved 06/11/14 revealed [MEDICATION NAME] adverse reactions to [MEDICATION NAME] include nausea, vomiting, constipation, stomach aches, [MEDICAL CONDITION], chemical driven liver damage. R#1's Nursing assessment dated [DATE] had kidney and/or urinary problems and his color was jaundiced. R #1 was alert and oriented times three (aware of person, place, and time.) R#1 utilized a urinal and bedpan. The Nutritional/Fluid section of the Nursing Assessment was not completed. R#1's Interim Plan of Care dated 05/01/14 revealed R#1 required one staff person for assistance with mobility and utilized a cane. R #1's speech was normal and R#1 was alert. The fluid section was not completed on the Interim Plan of Care. R#1's Care Plan for [MEDICAL CONDITION] dated 05/02/14 revealed R#1 had a [MEDICAL CONDITION] and was at risk for increased pain and limited ambulation. The goal of the Care Plan was for R#1's pain to be controlled within one hour of intervention and be able to return to previous functioning when R#1's fracture was healed. The approaches to be utilized by licensed nursing staff were: -provide therapy and restorative care per order -monitor incision for signs and symptoms of infection-increased drainage, temperature, redness and report to the Physician. -keep the Physician and Responsible Party informed of resident's progress -assist with ADLs/repositioning every two hours/PRN-use positioning devices for proper body alignment. R#1's Care Plan dated 05/02/14 revealed there was not a Care Plan for R#1's use of a Diuretic-[MEDICATION NAME] or dehydration. According to Hospital "BB's" Discharge Records dated 05/01/14 identified R#1's Medical History and Physical lab test results for amonia level was 56 (according to nim on 06/11/14 the normal amonia range is 15-45 micrograms per deciliter). R#1's Comprehensive Metabolic Profile dated 05/02/14 revealed: -Sodium-134 Reference Range (136-145) -Potassium-3.5 Reference Range (3.5-5.1) -Chloride-106 Reference Range (98-107) -Creatinine-0.6 Reference Range (0.7-1.3) R#1's History and Physical dated 05/06/14 revealed R#1's was admitted from Hospital "BB" for rehabilitation of a Partial Hip Replacement. R#1's current [DIAGNOSES REDACTED]. R#1's past history/[DIAGNOSES REDACTED]. R #1's Nutrition Screen dated 05/06/14 revealed R #1 preferred to eat breakfast, lunch and dinner in his room. R #1 was on a Liberal Renal Diet. R #1's Nutrition assessment dated [DATE] revealed R #1's estimated fluid needs were 1936 cubic centimeters (CC=unit of volume) per day. R #1 was on a Liberal Renal Diet. R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had clear speech; made himself understood; understood others; was not cognitively impaired (able to make decisions, no cues/supervision required); required extensive assistance from one staff person with bed mobility, transferring dressing, toileting and bathing. R #1 was totally dependent on one staff for locomotion/transfer on and off the unit. R #1 was always continent of bowel and bladder; was not dehydrated; required surgical wound care and weighed 142 pounds (lbs). R #1 had active [DIAGNOSES REDACTED]. R #1 received a diuretic. R #1 was on a scheduled pain regimen. R #1's life prognosis was not less than six months. R #1 participated in the MDS assessment and was expected to be discharged back to the community. R #1's MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision Sections did not include Dehydration/Fluid Maintenance as concern areas. R #1's 24 Hour Report/Change of Condition Report dated 05/11/14 for the 10:00 p.m. to 6:00 a.m. shift and completed by the Charge Nurse, LVN "A" revealed R #1 had complaints of "nausea and vomiting." R #1's 24 Hour Report/Change of Condition Report dated 05/11/14 and not signed by the Charge Nurse who completed the documentation for the 6:00 a.m. to 2:00 p.m. shift revealed R #1 had "N/V (nausea and vomiting) last night." R #1's Skilled Daily Nurses Note dated 05/11/14 did not have documentation indicating R #1 experienced nausea and vomiting during the night. R #1's 24 Hour Report/Change of Condition Report dated 05/12/14 and completed by the Charge Nurse, LVN "A" for the 10:00 p.m. to 6:00 a.m. shift revealed R #1 had "N/V episode", [MEDICATION NAME] administered at night. R #1's Skilled Daily Nurse's Notes dated 05/12/14 revealed R #1 had an episode of "nausea and vomiting" at night. R #1 was given [MEDICATION NAME] (medication for nausea) for relief, tolerated well and effective. R #1's undated 24 Hour Report/Change of Condition Report for the evening shift (2:00 p.m. to 10:00 p.m.) and not signed revealed R #1 "requests to see dr. (doctor) ASAP (as soon as possible) did not specify reason other than that change noted. ? ammonia levels need to be checked? Call Dr. for lab [MEDICATION NAME] (pain medication) PRN.", was documented on the report. Meal Intake Guide dated December 2011 revealed the Meal Intake Guide measures by utilizing the following guidelines: -Refused-0%=resident refused meal or consumed only one or two bites of each item, -Poor Intake -25%=2-approximately 25% of entree or 50% of one item consumed, -Fair Intake-50%=3-Approximately half of food was consumed (i.e., 50% of entree, 25% of vegetable and soup is left), -Good Intake-75%=4-Majority of the meal is consumed, but a significant amount of one or more items is left (i.e.. 25% of entree, or 75 % of vegetable is left), -All-100%=5=Entire meal is consumed except for a minimal amount of food (i.e., less than 25% of vegetable is left). There was not an indication that fluid was considered a part of the meal consumed. R #1's Meal Intake Record dated 05/03/14 through 05/19/14 revealed R #1 consumed the breakfast meal at the following percentages: -50% of his breakfast on seven days -75% of his breakfast on three days -25% on one day -100% on one day There was no documentation for 05/02/14, 05/06/14, 05/12/14, 05/14/14, 05/18/14 or 05/19/14. Fluid consumption was not documented for any of the breakfast meals. R #1's Certified Nurse Aide (CNA) Activities of Daily Living (ADL) Tracking Record for eating dated 05/13/14 through 05/17/14 for the 6:00 a.m. through 2:00 p.m. shift revealed R #1 required set up with meals and no assistance with eating. The ADL Tracking Record was not completed for all the days R #1 was a resident in the facility. Fluid consumption was not documented for any of the breakfast meals. R #1's Meal Intake Record dated 05/03/14 through 05/19/14 revealed R #1 consumed the lunch meal at the following percentages: -25% of lunch on one day -50% of lunch for seven days -75% of lunch for four days There was no documentation for 05/02/14, 05/04/14, 05/07/14, 05/11/14 or 05/15/14. R #1's CNA ADL Tracking Record for eating dated 05/13/14 through 05/17/14 for the 6:00 a.m. through 2:00 p.m. shift revealed R #1 required set up with meals and no assistance with eating. The ADL Tracking Record was not completed for all the days R #1 was a resident in the facility. Fluid consumption was not documented for any of the lunch meals. R #1's Meal Intake Record for the evening meal dated 05/03/14 through 05/19/14 revealed the Meal Intake Record was not completed for the evening meal from 05/02/14 through 05/16/14. R #1 refused his dinner meal on 05/17/14. There was no documentation for the dinner meal on 05/18/14. Fluid consumption was not documented for any of the evening meals. R #1's CNA-Activities of Daily Living (ADLs, bathing, dressing, grooming, eating, toilet use) Tracking Record for eating dated 05/08/14 through 05/16/14 for the 10:00 p.m. through 6:00 a.m. shift revealed: (A) ADL Record: R #1 required oversight, encouragement or cueing with set up help only. -The ADL Tracking Record was not completed for 05/02/14, 05/03/14, 05/04/14, 05/05/14, 05/06/14, 05/07/14, 05/11/14, 05/14/14, 05/17/14, 05/18/14 or 05/19/14. Fluid consumption was not documented for any of the breakfast meals. R #1's undated Daily Care Guide for the Certified Nurse Aides (CNAs), revealed R #1 was a fall risk and required one person physical assistance with transfers, bathing, dressing and toileting. R #1 required set up only with eating. The interventions to be utilized by staff were assist with bathing, grooming and shaving. R #1 had a [MEDICAL CONDITION] and utilized a wheelchair. R #1's CNA-ADL Tracking Record for eating dated 05/13/14 through 05/17/14 for the 2:00 p.m. through 10:00 p.m. shift revealed: (A) ADL Self-Performance-R #1 required oversight, encouragement or cueing with set up help only. -The ADL Tracking Record was not completed from 05/02/14 through 05/12/14, 05/18/14 or 05/19/14. Fluid consumption was not documented for any of the breakfast meals. R #1's CNA-ADL Tracking Record for toileting dated 05/02/14 through 05/19/14 for the 6:00 a.m. to 10:00 p.m. shift, 2:00 p.m. through 10:00 p.m. shift and the 10:00 p.m. through 6:00 a.m. shift revealed: (A) ADL Self- R #1 required limited assistance from one person. No output was recorded on the Tracking Record for R #1. The Tracking Record was not complete. R #1's Nurses Notes revealed the following: Nurses Notes: -From 05/14/14 through 05/17/14 revealed no documentation of R #1's condition (skin turgor, mucous membranes, vital signs), approximately 4 days and 4 hours. R #1's Nurse's Notes dated 05/18/14 revealed R #1's Family Member (FM) "TT" was in the facility to check on him and also expressing R #1's pain medications needed to be changed to as needed (PRN). FM "TT" expressed that R #1 was "always dazed and lethargic attributed to Loratab administration every four hours." R #1's Nurses Notes dated 05/19/14 at 11:00 a.m. revealed R #1 "displayed confusion. Pt.(patient) not able to respond appropriately to questions when asked. Pt doesn't complain of pain." Physician "DD" paged once. R #1's Nurses Notes dated 05/19/14 at 11:20 a.m. revealed "Pt. family in-house and was concerned of pt condition. Informed family Dr. (Physician "DD") has been paged to inform of pt condition. No answer. Pt cont (continues) with confusion. Pt c/o (complains) of lt (left) abdominal pain, increased. Medicated pt with [MEDICATION NAME] 10/325 mg one PO. Pt family insisted on sending pt out to hospital. Via family request wanted pt sent out to (Hospital "BB") immediately." According to the American Medical Directors Association, www.amda.com, retrieved on 05/30/14 entitled Changing Perspectives on LTC Nutrition & Hydration, How To Handle Hydration & Fluid Maintenance, "...Individuals who have had previous episodes of fluid and electrolyte imbalance and have conditions that place them at risk for fluid and electrolyte imbalance should be monitored...The timely identification and management of earlier, more subtle stages of fluid and electrolyte imbalance can often prevent progression to full-blown dehydration..." R #1's Emergency Medical Transportation (EMT) documentation dated 05/19/14 from the ambulance company revealed: -EMT arrived at (nursing facility) at 11:49 a.m. -R #1 had an Altered Mental Status with severe jaundice noted to the skin and eyes, lips chapped with sores to lips and tongue. The family stated to Emergency Medical Service Employee that a change in R #1's mental status was noted by them (Family Members "VV" and "UU") on the 12th of May. Nurse (LVN "B") at bedside stated a decrease noted today. Pt. was a total lift by two to stretcher. Bolus (a dose of a substance given intravenously) given 200 ml-during transport-slight increase in systolic pressure. R #1 talked but did not make sense of words. -Pt was alert, confused, hallucinations -Symptoms-Change in responsiveness, pain, weakness -Impression-Altered level of consciousness/abdominal pain. -initial Patient Acuity: Critical -11:58 a.m.-Blood Pressure (BP)-104/56, Heart Rate-58, Respirations 18, -11:59 a.m.-Oxygen initiated at two liters per minute -11:59 a.m.-Peripheral Intravenous initiated. R #1's Physician Quality Reporting System dated 05/19/14 from Hospital "BB" revealed R #1 had decreased mental status, confusion, lethargy, speech/cognition abnormalities were slowed, dysarthria (slurred speech), dry mucous membranes (sign of dehydration), sclera icterus (yellowing of the eyes), decreased responsiveness and was disoriented. R #1 had abdominal pain, generalized weakness and increased jaundice. Labs: Complete Blood Count -WBC 14 Reference Range (4.0-11.0) -HGB-10.4 Reference Range (13.5-17.5) -HCT 29 Reference Range (36-46) Chemistries: -"BUN 32 H" Normal range 6-20, -"Potassium 1.6" Normal ranges 3.6 to 5.2, -"Sodium 129 L" Normal ranges 135 to 145, -"Chloride 89" Normal ranges 96-106" Clinical Impression-"Dehydration, [MEDICAL CONDITION], Hyponkalemia (low levels of potassium in the blood) and Hepatic [MEDICAL CONDITION] (liver damage). Clinical Impression-Dehydration, [MEDICAL CONDITION] (low sodium blood levels), Hyponkalemia (low potassium level in blood) and Hepatic [MEDICAL CONDITION] (liver damage). According to www.mayoclinic.org on 06/03/14, [MEDICAL CONDITION] is a condition that occurs when the level of sodium (electrolyte) in your blood is abnormally low. If you get dehydrated, your body loses fluids and electrolytes. Medications that increase your risk of [MEDICAL CONDITION] include thiazide diuretics as well as some antidepressants and pain medications. According to www.umm.edu on 06/03/14, Hepatic [MEDICAL CONDITION] is the loss of brain function that occurs when the liver is unable to remove toxins from the blood. Hepatic [MEDICAL CONDITION] may be triggered by: dehydration, abnormalities (especially a decrease in potassium) from vomiting, or from treatments such as or taking diuretics ("water pills"). Severe symptoms may include: ? Abnormal movements or shaking of hands or arms ? Disorientation ? Drowsiness or confusion ? Slurred speech ? Slowed or sluggish movement People with hepatic [MEDICAL CONDITION] can become unconscious, unresponsive, and possibly enter a coma. Hospital "BB's" Complete Emergency Department Record dated 05/20/14 page 5 revealed:[MEDICAL CONDITION] Screening result was "Positive [MEDICAL CONDITION]", and R#1's "tongue is cracked and dry. Lips are dry and cracked." R#1 is "lethargic. Speech is difficult to understand." Hospital "BB's" Chemistry Lab Results dated 05/21/14 for R#1 indicated his Amonia Levels were at 101. According to www.mayoclinic.org on 05/30/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." On 05/21/14 at 9:05 a.m., FM "TT" stated R#1's condition began to decline approximately 05/12/14. R#1 did not call FM "TT" or FM "UU" before going to bed as he normally did. On 05/13/14, R#1 did not call or answer his personal phone. On 05/15/14 FM "TT" said she called the facility and was told R#1 was asleep. FM "TT" said she was not able to get in touch with R#1 from 05/13/18 through 05/17/14. FM "TT" and FM "UU" visited R#1 on 05/17/14 at approximately 10:30 p.m. and observed R#1's hands shaking. FM "TT" said R#1's dinner tray was still on his bedside table and he had not eaten the food. R#1 told FM "TT" and FM "UU" he was being forced to take his pain medications. FM "TT" said she gave R#1 a strawberry soda and he spilled the soda on the bed. FM "UU" told LVN "A" he no longer wanted R#1 on scheduled pain medication every four hours. LVN "A" stated he would write an order for [REDACTED]. FM "TT" said she called the facility on 05/18/14 and LVN "B" would not give her information if the pain medication had been discontinued. FM "TT" stated she called the Director of Nurses (DON) and told the DON R#1 was not eating or drinking and R#1 was very disoriented. FM "TT" said she shared her concerns about R#1's ammonia levels being high due to his [MEDICAL CONDITION] of the Liver. The DON told FM "TT" she would have lab work completed on 05/19/14. FM "TT" said she and FM "UU" went to the facility on [DATE] and found R#1 in a fetal position and R#1 would not respond to her or FM "UU." FM "TT" said R#1 was jaundiced prior to being admitted to nursing facility but on 05/19/14 R#1's eyes were lemon yellow and sunken, his lips were cracked and dried blood was around his mouth. FM "TT" said there was no water pitcher or cups in the room. FM "TT" said she went out of the room to find a nurse and LVN "B" was in the hall. FM "TT" said she asked LVN "B" about R#1's lab results and LVN "B" asked, "What are you talking about? He (R#1) did not have orders for labs." FM "TT" said she want R#1 taken to the hospital. LVN "B" told her (FM "TT"), 'they will just take levels and send him back with lactalose." FM "TT" said she went back into R#1's bedroom and FM "UU" had given R#1 had three small glasses's of water. LVN "B" went back into the room and said he had paged the doctor and was waiting for a return call. LVN "B" said he had spoken to the DON and was told to get an order for [REDACTED].#1's room and assessed him prior to calling the ambulance. FM "TT" said when the Paramedics arrived they asked how long R#1 had been in this condition? LVN "B" said since this morning. FM "TT" said she and FM "UU" told the EMT they had noticed a change in R#1 around 05/12/14. EMT "M" stated, "that's more like it." The EMTs placed R #1 in the ambulance and told FM "TT" and FM "UU" to give them a few minutes to stabilize R #1. On 05/21/14 at 1:20 p.m. , at Hospital "BB" R#1 was observed lying in bed and unresponsive to surveyor's questions. R#1 stared at surveyor with his mouth open. R#1's lips were cracked and R#1 had scabs on his bottom lip and the corner of the left side of his mouth. R#1 had an ulcer along the right side of his tongue. The skin on R#1's right and left arms was dry and flaky. R#1's eyes were sunken and yellow. On 05/21/14 at 1:25 p.m. , FM "TT" said she and FM "UU" arrived at nursing home on 05/19/14 at approximately 10:00 a.m. and observed R#1 lying in a fetal position. FM "TT" said, "I thought he (R#1) was dead." On 05/22/14 at 2:20 p.m. FM "TT" stated R#1's Physician at Hospital "BB" stated R#1 "may not make it through this." On 05/22/14 at 12:15 p.m. Licensed Vocational Nurse/Minimum Data Set Coordinator (LVN/MDSC) stated R #1 did not trigger for a dehydration Care Plan due to the MDS had been not been coded correctly. On 05/22/14 at 2:45 p.m. the DON stated it was not the facility's policy to document or monitor a resident's intake and output. The DON said if a resident was on fluid restrictions the resident's care plan had a break down of fluid per meals and shifts. On 05/22/14 at 2:10 p.m. LVN "C" stated she did not monitor resident's intake or output. The CNAs told the Charge Nurse if a resident was not urinating, drinking or eating. LVN "C" said residents who got dehydrated got really confused and their physical appearance changed. LVN "C" stated she had never seen R #1 from under the covers. LVN "C" stated even during R #1's initial assessment he kept covering up. LVN "C" stated when R #1 was admitted to (facility) he was "very alert." On 05/22/14 at 2:20 p.m. FM "TT" stated R #1's Physician at Hospital "BB" stated R #1 "may not make it through this." On 05/22/14 at 3:25 p.m., LVN "A" stated he had started working with R #1 on 05/12/14. LVN "A" said when he started working with R #1 he looked lethargic and dazed. LVN "A" stated R #1 "was a very sick man and everyone knew from the beginning he (R #1) was not doing good." R #1 had an episode of nausea and vomiting during one of LVN "A's" shifts and LVN "A" gave R #1 [MEDICATION NAME] (nausea medication). LVN "A" said on 05/17/14 FM "TT" and FM "UU" visited R #1. FM "UU" asked LVN A" about R #1's labs and LVN "A" told FM "UU" R #1 did not have any labs in his chart. FM "UU" stated FM "UU" wanted R #1's scheduled pain medication changed to as needed. LVN "A" stated he did not record intake or output on residents. LVN "A" said the CNAs "may document intakes and outputs. Making sure they (residents) get fluids is the main goal. LVN "A" said R #1 had two or three sodas in his room at a time. On 05/22/14 at 4:00 p.m. CNA "D" said CNAs were not required to write down a resident's intake and output of fluids. CNA "D" said R #1 had sodas in his room and always asked for ice but not for water. CNA "D" stated the only information the CNAs documented was how much food a resident ate after each meal. On 05/22/14 at 4:45 p.m., the DON stated the facility did not not have any residents on intake and output. The CNAs only documented the percentage of food eaten by a resident. On 05/22/14 at 5:00 p.m. the Registered Dietitian (RD) stated it was her understanding there was not a requirement to monitor a residents intake and output unless there was a physician's orders [REDACTED]." The RD said the nursing staff tell her nine out of 10 times the color of a residents urine or if a resident is not drinking much. On 05/22/14 at 5:40 p.m. LVN/MDSC stated even if a resident did not trigger for a care plan during the MDS assessment each resident's hydration needs to be monitored. On 05/22/14 at 5:50 p.m. CNA "E" stated she did not know which residents were at risk of dehydration or if residents were getting enough fluids. CNA "E" said the CNAs did not write down intake and output of fluids. CNA "E" stated she passed out water to all residents except residents on thickened liquids. CNA "E" said she would not know how much a resident drank out of a pitcher or out of a glass. CNA "E" said the Charge Nurses would tell the CNAs who to "keep and eye on for so and so." On 05/22/14 at 6:00 p.m. CNA "F" stated she did not write down intake and output for residents at risk of dehydration. CNA "F" stated the charge nurses told CNAs which resident the CNAs needed to make sure had water. CNA "F" stated a resident who was dehydrated would be weak, have weight loss and become dizzy. On 05/22/14 at 6:10 p.m. CNA "G" stated CNAs had to ask the Charge Nurse which residents were at risk for dehydration or the the Charge Injures told them who to watch for dehydration. CNA "G" stated CNAs did not write anything down on a resident's ADL sheet regarding intake and output. CNAs let the Charge Nurses know if a resident did not urinate. CNA "G" said she would tell a nurse if a residents urine was dark or smelly, if a resident was not drinking fluid, if a resident was pale, clammy, or his/her lips were cracking. CNA "G" stated on 05/18/14 R #1 told her he needed the nurse. CNA "G" stated she told LVN "H" but did not know if LVN "H" went into R #1's room. CNA "G" stated the next time she went into R #1's room he asked to talk to a doctor. CNA "G" stated on 05/18/14 R #1 was moaning in pain the whole day. CNA "G" stated R #1 said asked her to leave his food in his room but he did not eat. CNA "G" said on 05/18/14 R #1 drank half a glass of tea and half a glass of water but she did not know the exact amount. CNA "G" did not document the intake of fluids for R #1. CNA "G" said residents who were dehydrated could go into shock and their body could shut down. On 05/22/14 at 6:35 p.m. LVN "H" stated she did not document intake or output on residents unless there was a physician's orders [REDACTED]. LVN "H" stated the CNAs reported to the Charge Nurse if a resident was not eating or drinking but she was not sure if the CNAs documented information regarding intake and output. LVN "H" stated residents needed hydration for their heart and lungs to work. Dehydration would affect a resident by the resident's body shutting down. LVN "H" stated that on 05/17/14 and 05/18/14 a CNA told her R #1 was complaining. LVN "H" went into R #1's room and he stated he needed his medication. LVN "H" said on 05/18/14 the CNA told her R #1 said he had vomited. LVN "H" stated she went into R #1's room and R #1 was forcing himself to throw up. LVN "H" stated their was "red phlegm" on the bed from the red soda he had drank. LVN "H" stated she did not notify the Physician because she thought R #1 "was pretending." LVN "H" stated she did not document the episode. On 05/22/14 at 7:10 p.m. LVN "C" stated the nurses did not document intakes and output on residents at risk for dehydration. LVN "C" said the "CNAs may, but she does not." LVN "C" stated she did not know which residents were at risk for dehydration nor was there a list of residents at risk for dehydration at the nurse's station. LVN "C" stated a dehydrated resident would "shrivel up" and their organs would begin to shut down if the resident did not get enough fluids. LVN "C" stated she did not know if a resident on fluid restrictions was getting too much fluid other than the [MEDICAL TREATMENT] company told how much fluid was taken out of the resident. On 05/22/14 at 7:30 p.m. the DON stated intake and output was not completed on residents at risk of dehydration unless the resident was admitted from the hospital or the facility physician ordered an intake and output on a resident. The DON stated the facility did not have any residents on intake or output. The DON said the staff, nurses and CNAs knew who was a dehydration risk by the disease process and the 24 hour reports. The DON said the aides knew who was on thickened liquids. The DON said water was passed throughout the day but the CNAs would not know how much water was drank by a resident. She said if the CNAs were concerned about a resident who was dehydrated the CNA could fill out a "Stop and Watch" a slip of paper they gave to the nurse regarding the CNAs concern about a resident. The DON said a resident who was at risk of dehydration would be monitored for urine output and skin turgor (elasticity). The DON stated she "expected the nurse to monitor for dehydration. The DON said "it was important to monitor intake and output so a resident did not end up in kidney failure, dehydration could lead to kidney failure." The DON stated she did not do an assessment on R #1 on 05/19/14. The DON stated she was responsible for the Assistant Director of Nurses, all other nurses and CNAs. She said, "ultimately I am over everyone." On 05/22/14 at 8:40 p.m. the Administrator and the DON stated there was not a facility policy on intakes and outputs for residents at risk of dehydration. On 05/23/14 at 2:30 p.m. LVN "B" stated in an interview R #1 had told him when he (R #1) was first admitted "I know ya'll don't want to enter my room. I (R #1) see people passing by and ya'll don't help me." LVN "B" stated there was one episode of R #1 having nausea and vomiting but LVN "B" did not remember the day nor did he document the episode of nausea and vomiting in R #1's Nurse's Notes or on the 24 Hour Nursing Report. LVN "B" stated R #1 never wanted water, R #1 asked for ice for his sodas and water he kept in his room. LVN "B" stated the morning of 05/18/14 LVN "A" told him (LVN "B") about the change regarding R #1's scheduled pain medications not being administered every four hours to only as needed. LVN "B" stated he had been told R #1 was not on skilled services therefore he did not have to document unless their was a change of condition. LVN "B" stated the morning of 05/19/14 he was in R #1's room and R #1 appeared confused. LVN "B" stated he did not notify the physician. LVN "B" stated at approximately 10:00 a.m. to 10:45 a.m. he was in the hall and FM "TT" asked him if R #1's labs had been drawn? LVN "B" stated he did not know anything about labs and would speak to the DON. LVN "B" stated FM "TT" wanted R #1 sent to the hospital. LVN "B" stated he told FM "TT" the facility could get immediate orders (STAT) and do the same services as the hospital. LVN "B" stated he attempted to call Physician "DD" but Physician "DDs" voice mail was not set up to take messages. LVN "B" stated he went and spoke with the DON who told him she was writing the order for the labs. LVN "C" stated he took R #1's vital signs but he wrote them on a piece of paper and did not document in R #1's medical chart. LVN "B" stated R #1 was confused but his vital signs were normal. On 05/27/14 at 1:05 p.m. Director of the EMT (DEMT) "O" stated she r

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for one Resident (R #1) of 15 Residents reviewed for provision of care and services. The facility failed to assess or monitor R #1 to determine when a change of condition occurred that required physician notification or immediate medical intervention. R#1 was hospitalized and diagnosed with [REDACTED]. R#1 remained in the hospital at the time of the visit. These failures placed in identification of an Immediate Jeopardy (IJ) on 05/22/14 at 9:35 p.m. While the IJ was removed on 05/25/14 at 11:45 a.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility continuing to in-service staff and monitor the Plan of Removal. These failures could place all residents at a higher risk of neglect and delay medical treatment, care, services, incur complications and/or hospitalization or possible death. The findings were: R#1's Face Sheet dated 05/02/14 revealed a [AGE] year old male admitted to facility on 05/01/14 from Hospital "BB." Hospital "BB's" Discharge Records for R#1 dated 05/01/14 identified R#1's Medical History and Physical with End-stage liver disease due to primary biliary [MEDICAL CONDITION] ([DIAGNOSES REDACTED] disease in which the bile ducts in your liver are slowly destroyed) , [MEDICAL CONDITION] Varices, Mallory-Weiss tear (tear in the esophagus associated with pressure caused by vomiting or coughing), Portal Hypertensive Gastropathy (changes in the mucosa of the stomach associated with [MEDICAL CONDITION] of the liver), Ascites (accumulation of fluid in the abdomen), Hypertension and [DIAGNOSES REDACTED] (enlargement of the spleen), Hepatic [MEDICAL CONDITION] (loss of brain function that occurs when the liver is unable to remove toxins from the blood), and [MEDICAL CONDITION]. Lab tests conducted included, Ammonia level was 56 (according to nim on 06/11/14 the normal amonia range is 15-45 micrograms per deciliter). R#1's admission orders [REDACTED]. R#1's [DIAGNOSES REDACTED]. According to [MEDICATION NAME].org retrieved 06/11/14 revealed [MEDICATION NAME] adverse reactions to [MEDICATION NAME] include nausea, vomiting, constipation, stomach aches, [MEDICAL CONDITION], chemical driven liver damage. R#1's Nursing assessment dated [DATE] had kidney and/or urinary problems and his color was jaundiced. R #1 was alert and oriented times three (aware of person, place, and time.) R#1 utilized a urinal and bedpan. The Nutritional/Fluid section of the Nursing Assessment was not completed. R#1's Interim Plan of Care dated 05/01/14 revealed R#1 required one staff person for assistance with mobility and utilized a cane. R #1's speech was normal and R#1 was alert. The fluid section was not completed on the Interim Plan of Care. R#1's Care Plan for [MEDICAL CONDITION] dated 05/02/14 revealed R#1 had a [MEDICAL CONDITION] and was at risk for increased pain and limited ambulation. The goal of the Care Plan was for R#1's pain to be controlled within one hour of intervention and be able to return to previous functioning when R#1's fracture was healed. The approaches to be utilized by licensed nursing staff were: -provide therapy and restorative care per order -monitor incision for signs and symptoms of infection-increased drainage, temperature, redness and report to the Physician. -keep the Physician and Responsible Party informed of resident's progress -assist with ADLs/repositioning every two hours/PRN-use positioning devices for proper body alignment. R#1's Care Plan dated 05/02/14 revealed there was not a Care Plan for R#1's use of a Diuretic-[MEDICATION NAME] or dehydration. According to Hospital "BB's" Discharge Records dated 05/01/14 identified R#1's Medical History and Physical lab test results for amonia level was 56 (according to nim on 06/11/14 the normal amonia range is 15-45 micrograms per deciliter). R#1's Comprehensive Metabolic Profile dated 05/02/14 revealed: -Sodium-134 Reference Range (136-145) -Potassium-3.5 Reference Range (3.5-5.1) -Chloride-106 Reference Range (98-107) -Creatinine-0.6 Reference Range (0.7-1.3) R#1's History and Physical dated 05/06/14 revealed R#1's was admitted from Hospital "BB" for rehabilitation of a Partial Hip Replacement. R#1's current [DIAGNOSES REDACTED]. R#1's past history/[DIAGNOSES REDACTED]. R #1's Nutrition Screen dated 05/06/14 revealed R #1 preferred to eat breakfast, lunch and dinner in his room. R #1 was on a Liberal Renal Diet. R #1's Nutrition assessment dated [DATE] revealed R #1's estimated fluid needs were 1936 cubic centimeters (CC=unit of volume) per day. R #1 was on a Liberal Renal Diet. R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had clear speech; made himself understood; understood others; was not cognitively impaired (able to make decisions, no cues/supervision required); required extensive assistance from one staff person with bed mobility, transferring dressing, toileting and bathing. R #1 was totally dependent on one staff for locomotion/transfer on and off the unit. R #1 was always continent of bowel and bladder; was not dehydrated; required surgical wound care and weighed 142 pounds (lbs). R #1 had active [DIAGNOSES REDACTED]. R #1 received a diuretic. R #1 was on a scheduled pain regimen. R #1's life prognosis was not less than six months. R #1 participated in the MDS assessment and was expected to be discharged back to the community. R #1's MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision Sections did not include Dehydration/Fluid Maintenance as concern areas. R #1's 24 Hour Report/Change of Condition Report dated 05/11/14 for the 10:00 p.m. to 6:00 a.m. shift and completed by the Charge Nurse, Licensed Vocational Nurse (LVN) "A" revealed R #1 had complaints of "nausea and vomiting." R #1's 24 Hour Report/Change of Condition Report dated 05/11/14 and not signed by the Charge Nurse who completed the documentation for the 6:00 a.m. to 2:00 p.m. shift revealed R #1 had "N/V (nausea and vomiting) last night." R #1's 24 Hour Report/Change of Condition Report dated 05/12/14 and completed by the Charge Nurse, LVN "A" for the 10:00 p.m. to 6:00 a.m. shift revealed R #1 had "N/V episode", [MEDICATION NAME] administered at night. R #1's undated 24 Hour Report/Change of Condition Report for the evening shift (2:00 p.m. to 10:00 p.m.) and not signed revealed R #1 "requests to see dr. (doctor) ASAP (as soon as possible) did not specify reason other than that change noted. ? ammonia levels need to be checked? Call Dr. for lab [MEDICATION NAME] (pain medication) PRN.", was documented on the report. R#1's Skilled Daily Nurses Notes revealed: 05/11/14 - alert on day and evening shift - skin color was jaundiced on evening shift. There was no documentation for skin color on day or night shift. Resident refused scheduled pain medications 4 p.m. dose. He states he feels drowsy and thinks it (pain medication) is causing it. Will continue to monitor. Resident refused 8 p.m. scheduled pain medicine. Will continue to monitor. 05/12/14 - alert on evening and night shift - evening shift-normal skin color. "Pt with NV episode at HS (night) and given [MEDICATION NAME] for relief-tolerated well and effective. Voices no hip pain at this time; taking [MEDICATION NAME]-scheduled every four hours. Somewhat distraught at times and requires assist for most ADLs; except eating due to mobility issues. Some distress noted at times." 05/13/14-alert on evening and night shift-evening and night shift-normal skin color. "Pt resting well this night and [MEDICATION NAME] help him sleep. Giving as ordered; tolerated well and effective. Deny's (sic) pain, but is on an every four hour [MEDICATION NAME] regimen. Hip fx (fracture) area appears to be getting better according to pt. Assist for most ADLs due to some mobility issues. Slight distress is seen at times." 05/13/14 was the last Skilled Daily Nurse's Notes for R#1. From 05/14/14 through 05/17/14 revealed no documentation of R#1's condition (skin color, mental status, skin turgor, mucous membranes, vital signs), approximately 4 days and 4 hours. Meal Intake Guide dated December 2011 revealed the Meal Intake Guide measures by utilizing the following guidelines: -Refused-0%=resident refused meal or consumed only one or two bites of each item, -Poor Intake -25%=2-approximately 25% of entree or 50% of one item consumed, -Fair Intake-50%=3-Approximately half of food was consumed (i.e., 50% of entree, 25% of vegetable and soup is left), -Good Intake-75%=4-Majority of the meal is consumed, but a significant amount of one or more items is left (i.e.. 25% of entree, or 75 % of vegetable is left), -All-100%=5=Entire meal is consumed except for a minimal amount of food (i.e., less than 25% of vegetable is left). There was not an indication that fluid was considered a part of the meal consumed. R #1's Meal Intake Record dated 05/03/14 through 05/19/14 revealed R #1 consumed the breakfast meal at the following percentages: -50% of his breakfast on seven days -75% of his breakfast on three days -25% on one day -100% on one day There was no documentation for 05/02/14, 05/06/14, 05/12/14, 05/14/14, 05/18/14 or 05/19/14. Fluid consumption was not documented for any of the breakfast meals. R #1's Certified Nurse Aide (CNA) Activities of Daily Living (ADL) Tracking Record for eating dated 05/13/14 through 05/17/14 for the 6:00 a.m. through 2:00 p.m. shift revealed R #1 required set up with meals and no assistance with eating. The ADL Tracking Record was not completed for all the days R #1 was a resident in the facility. Fluid consumption was not documented for any of the breakfast meals. R #1's Meal Intake Record dated 05/03/14 through 05/19/14 revealed R #1 consumed the lunch meal at the following percentages: -25% of lunch on one day -50% of lunch for seven days -75% of lunch for four days There was no documentation for 05/02/14, 05/04/14, 05/07/14, 05/11/14 or 05/15/14. R #1's CNA ADL Tracking Record for eating dated 05/13/14 through 05/17/14 for the 6:00 a.m. through 2:00 p.m. shift revealed R #1 required set up with meals and no assistance with eating. The ADL Tracking Record was not completed for all the days R #1 was a resident in the facility. Fluid consumption was not documented for any of the lunch meals. R #1's Meal Intake Record for the evening meal dated 05/03/14 through 05/19/14 revealed the Meal Intake Record was not completed for the evening meal from 05/02/14 through 05/16/14. R #1 refused his dinner meal on 05/17/14. There was no documentation for the dinner meal on 05/18/14. Fluid consumption was not documented for any of the evening meals. R #1's CNA-Activities of Daily Living (ADLs, bathing, dressing, grooming, eating, toilet use) Tracking Record for eating dated 05/08/14 through 05/16/14 for the 10:00 p.m. through 6:00 a.m. shift revealed: (A) ADL Record: R #1 required oversight, encouragement or cueing with set up help only. -The ADL Tracking Record was not completed for 05/02/14, 05/03/14, 05/04/14, 05/05/14, 05/06/14, 05/07/14, 05/11/14, 05/14/14, 05/17/14, 05/18/14 or 05/19/14. Fluid consumption was not documented for any of the breakfast meals. R #1's undated Daily Care Guide for the Certified Nurse Aides (CNAs), revealed R #1 was a fall risk and required one person physical assistance with transfers, bathing, dressing and toileting. R #1 required set up only with eating. The interventions to be utilized by staff were assist with bathing, grooming and shaving. R #1 had a [MEDICAL CONDITION] and utilized a wheelchair. R #1's CNA-ADL Tracking Record for eating dated 05/13/14 through 05/17/14 for the 2:00 p.m. through 10:00 p.m. shift revealed: (A) ADL Self-Performance-R #1 required oversight, encouragement or cueing with set up help only. -The ADL Tracking Record was not completed from 05/02/14 through 05/12/14, 05/18/14 or 05/19/14. Fluid consumption was not documented for any of the breakfast meals. R #1's CNA-ADL Tracking Record for toileting dated 05/02/14 through 05/19/14 for the 6:00 a.m. to 10:00 p.m. shift, 2:00 p.m. through 10:00 p.m. shift and the 10:00 p.m. through 6:00 a.m. shift revealed: (A) ADL Self- R #1 required limited assistance from one person. No output was recorded on the Tracking Record for R #1. The Tracking Record was not complete. R #1's Nurses Notes revealed the following: Nurses Notes: -From 05/14/14 through 05/17/14 revealed no documentation of R #1's condition (skin turgor, mucous membranes, vital signs), approximately 4 days and 4 hours. R #1's Nurse's Notes dated 05/18/14 revealed R #1's Family Member (FM) "TT" was in the facility to check on him and also expressing R #1's pain medications needed to be changed to as needed (PRN). FM "TT" expressed that R #1 was "always dazed and lethargic attributed to Loratab administration every four hours." R #1's Nurses Notes dated 05/19/14 at 11:00 a.m. revealed R #1 "displayed confusion. Pt.(patient) not able to respond appropriately to questions when asked. Pt doesn't complain of pain." Physician "DD" paged once. R #1's Nurses Notes dated 05/19/14 at 11:20 a.m. revealed "Pt. family in-house and was concerned of pt condition. Informed family Dr. (Physician "DD") has been paged to inform of pt condition. No answer. Pt cont (continues) with confusion. Pt c/o (complains) of lt (left) abdominal pain, increased. Medicated pt with [MEDICATION NAME] 10/325 mg one PO. Pt family insisted on sending pt out to hospital. Via family request wanted pt sent out to (Hospital "BB") immediately." According to the American Medical Directors Association, www.amda.com, retrieved on 05/30/14 entitled Changing Perspectives on LTC Nutrition & Hydration, How To Handle Hydration & Fluid Maintenance, "...Individuals who have had previous episodes of fluid and electrolyte imbalance and have conditions that place them at risk for fluid and electrolyte imbalance should be monitored...The timely identification and management of earlier, more subtle stages of fluid and electrolyte imbalance can often prevent progression to full-blown dehydration..." R #1's Emergency Medical Transportation (EMT) documentation dated 05/19/14 from the ambulance company revealed: -EMT arrived at (nursing facility) at 11:49 a.m. -R #1 had an Altered Mental Status with severe jaundice noted to the skin and eyes, lips chapped with sores to lips and tongue. The family stated to Emergency Medical Service Employee that a change in R #1's mental status was noted by them (Family Members "VV" and "UU") on the 12th of May. Nurse (LVN "B") at bedside stated a decrease noted today. Pt. was a total lift by two to stretcher. Bolus (a dose of a substance given intravenously) given 200 ml-during transport-slight increase in systolic pressure. R #1 talked but did not make sense of words. -Pt was alert, confused, hallucinations -Symptoms-Change in responsiveness, pain, weakness -Impression-Altered level of consciousness/abdominal pain. -initial Patient Acuity: Critical -11:58 a.m.-Blood Pressure (BP)-104/56, Heart Rate-58, Respirations 18, -11:59 a.m.-Oxygen initiated at two liters per minute -11:59 a.m.-Peripheral Intravenous initiated. R #1's Physician Quality Reporting System dated 05/19/14 from Hospital "BB" revealed R #1 had decreased mental status, confusion, lethargy, speech/cognition abnormalities were slowed, dysarthria (slurred speech), dry mucous membranes (sign of dehydration), sclera icterus (yellowing of the eyes), decreased responsiveness and was disoriented. R #1 had abdominal pain, generalized weakness and increased jaundice. Labs: Complete Blood Count -WBC 14 Reference Range (4.0-11.0) -HGB-10.4 Reference Range (13.5-17.5) -HCT 29 Reference Range (36-46) Chemistries: -"BUN 32 H" Normal range 6-20, -"Potassium 1.6" Normal ranges 3.6 to 5.2, -"Sodium 129 L" Normal ranges 135 to 145, -"Chloride 89" Normal ranges 96-106" Clinical Impression-"Dehydration, [MEDICAL CONDITION], Hyponkalemia (low levels of potassium in the blood) and Hepatic [MEDICAL CONDITION] (liver damage). Clinical Impression-Dehydration, [MEDICAL CONDITION] (low sodium blood levels), Hyponkalemia (low potassium level in blood) and Hepatic [MEDICAL CONDITION] (liver damage). According to www.mayoclinic.org on 06/03/14, [MEDICAL CONDITION] is a condition that occurs when the level of sodium (electrolyte) in your blood is abnormally low. If you get dehydrated, your body loses fluids and electrolytes. Medications that increase your risk of [MEDICAL CONDITION] include thiazide diuretics as well as some antidepressants and pain medications. According to www.umm.edu on 06/03/14, Hepatic [MEDICAL CONDITION] is the loss of brain function that occurs when the liver is unable to remove toxins from the blood. Hepatic [MEDICAL CONDITION] may be triggered by: dehydration, abnormalities (especially a decrease in potassium) from vomiting, or from treatments such as or taking diuretics ("water pills"). Severe symptoms may include: ? Abnormal movements or shaking of hands or arms ? Disorientation ? Drowsiness or confusion ? Slurred speech ? Slowed or sluggish movement People with hepatic [MEDICAL CONDITION] can become unconscious, unresponsive, and possibly enter a coma. Hospital "BB's" Complete Emergency Department Record dated 05/20/14 page 5 revealed:[MEDICAL CONDITION] Screening result was "Positive [MEDICAL CONDITION]", and R#1's "tongue is cracked and dry. Lips are dry and cracked." R#1 is "lethargic. Speech is difficult to understand." Hospital "BB's" Chemistry Lab Results dated 05/21/14 for R#1 indicated his Amonia Levels were at 101. According to www.mayoclinic.org on 05/30/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." On 05/21/14 at 9:05 a.m., FM "TT" stated R#1's condition began to decline approximately 05/12/14. R#1 did not call FM "TT" or FM "UU" before going to bed as he normally did. On 05/13/14, R#1 did not call or answer his personal phone. On 05/15/14 FM "TT" said she called the facility and was told R#1 was asleep. FM "TT" said she was not able to get in touch with R#1 from 05/13/18 through 05/17/14. FM "TT" and FM "UU" visited R#1 on 05/17/14 at approximately 10:30 p.m. and observed R#1's hands shaking. FM "TT" said R#1's dinner tray was still on his bedside table and he had not eaten the food. R#1 told FM "TT" and FM "UU" he was being forced to take his pain medications. FM "TT" said she gave R#1 a strawberry soda and he spilled the soda on the bed. FM "UU" told LVN "A" he no longer wanted R#1 on scheduled pain medication every four hours. LVN "A" stated he would write an order for [REDACTED]. FM "TT" said she called the facility on 05/18/14 and LVN "B" would not give her information if the pain medication had been discontinued. FM "TT" stated she called the Director of Nurses (DON) and told the DON R#1 was not eating or drinking and R#1 was very disoriented. FM "TT" said she shared her concerns about R#1's ammonia levels being high due to his [MEDICAL CONDITION] of the Liver. The DON told FM "TT" she would have lab work completed on 05/19/14. FM "TT" said she and FM "UU" went to the facility on [DATE] and found R#1 in a fetal position and R#1 would not respond to her or FM "UU." FM "TT" said R#1 was jaundiced prior to being admitted to nursing facility but on 05/19/14 R#1's eyes were lemon yellow and sunken, his lips were cracked and dried blood was around his mouth. FM "TT" said there was no water pitcher or cups in the room. FM "TT" said she went out of the room to find a nurse and LVN "B" was in the hall. FM "TT" said she asked LVN "B" about R#1's lab results and LVN "B" asked, "What are you talking about? He (R#1) did not have orders for labs." FM "TT" said she want R#1 taken to the hospital. LVN "B" told her (FM "TT"), 'they will just take levels and send him back with lactalose." FM "TT" said she went back into R#1's bedroom and FM "UU" had given R#1 had three small glasses's of water. LVN "B" went back into the room and said he had paged the doctor and was waiting for a return call. LVN "B" said he had spoken to the DON and was told to get an order for [REDACTED].#1's room and assessed him prior to calling the ambulance. FM "TT" said when the Paramedics arrived they asked how long R#1 had been in this condition? LVN "B" said since this morning. FM "TT" said she and FM "UU" told the EMT they had noticed a change in R#1 around 05/12/14. EMT "M" stated, "that's more like it." The EMTs placed R #1 in the ambulance and told FM "TT" and FM "UU" to give them a few minutes to stabilize R #1. On 05/21/14 at 1:20 p.m. , at Hospital "BB" R#1 was observed lying in bed and unresponsive to surveyor's questions. R#1 stared at surveyor with his mouth open. R#1's lips were cracked and R#1 had scabs on his bottom lip and the corner of the left side of his mouth. R#1 had an ulcer along the right side of his tongue. The skin on R#1's right and left arms was dry and flaky. R#1's eyes were sunken and yellow. On 05/21/14 at 1:25 p.m. , FM "TT" said she and FM "UU" arrived at nursing home on 05/19/14 at approximately 10:00 a.m. and observed R#1 lying in a fetal position. FM "TT" said, "I thought he (R#1) was dead." On 05/22/14 at 2:20 p.m. FM "TT" stated R#1's Physician at Hospital "BB" stated R#1 "may not make it through this." On 05/22/14 at 12:15 p.m. Licensed Vocational Nurse/Minimum Data Set Coordinator (LVN/MDSC) stated R #1 did not trigger for a dehydration Care Plan due to the MDS had been not been coded correctly. On 05/22/14 at 2:45 p.m. the DON stated it was not the facility's policy to document or monitor a resident's intake and output. The DON said if a resident was on fluid restrictions the resident's care plan had a break down of fluid per meals and shifts. On 05/22/14 at 2:10 p.m. LVN "C" stated she did not monitor resident's intake or output. The CNAs told the Charge Nurse if a resident was not urinating, drinking or eating. LVN "C" said residents who got dehydrated got really confused and their physical appearance changed. LVN "C" stated she had never seen R #1 from under the covers. LVN "C" stated even during R #1's initial assessment he kept covering up. LVN "C" stated when R #1 was admitted to (facility) he was "very alert." On 05/22/14 at 2:20 p.m. FM "TT" stated R #1's Physician at Hospital "BB" stated R #1 "may not make it through this." On 05/22/14 at 3:25 p.m., LVN "A" stated he had started working with R #1 on 05/12/14. LVN "A" said when he started working with R #1 he looked lethargic and dazed. LVN "A" stated R #1 "was a very sick man and everyone knew from the beginning he (R #1) was not doing good." R #1 had an episode of nausea and vomiting during one of LVN "A's" shifts and LVN "A" gave R #1 [MEDICATION NAME] (nausea medication). LVN "A" said on 05/17/14 FM "TT" and FM "UU" visited R #1. FM "UU" asked LVN A" about R #1's labs and LVN "A" told FM "UU" R #1 did not have any labs in his chart. FM "UU" stated FM "UU" wanted R #1's scheduled pain medication changed to as needed. LVN "A" stated he did not record intake or output on residents. LVN "A" said the CNAs "may document intakes and outputs. Making sure they (residents) get fluids is the main goal. LVN "A" said R #1 had two or three sodas in his room at a time. On 05/22/14 at 4:00 p.m. CNA "D" said CNAs were not required to write down a resident's intake and output of fluids. CNA "D" said R #1 had sodas in his room and always asked for ice but not for water. CNA "D" stated the only information the CNAs documented was how much food a resident ate after each meal. On 05/22/14 at 4:45 p.m., the DON stated the facility did not not have any residents on intake and output. The CNAs only documented the percentage of food eaten by a resident. On 05/22/14 at 5:00 p.m. the Registered Dietitian (RD) stated it was her understanding there was not a requirement to monitor a residents intake and output unless there was a physician's orders [REDACTED]." The RD said the nursing staff tell her nine out of 10 times the color of a residents urine or if a resident is not drinking much. On 05/22/14 at 5:40 p.m. LVN/MDSC stated even if a resident did not trigger for a care plan during the MDS assessment each resident's hydration needs to be monitored. On 05/22/14 at 5:50 p.m. CNA "E" stated she did not know which residents were at risk of dehydration or if residents were getting enough fluids. CNA "E" said the CNAs did not write down intake and output of fluids. CNA "E" stated she passed out water to all residents except residents on thickened liquids. CNA "E" said she would not know how much a resident drank out of a pitcher or out of a glass. CNA "E" said the Charge Nurses would tell the CNAs who to "keep and eye on for so and so." On 05/22/14 at 6:00 p.m. CNA "F" stated she did not write down intake and output for residents at risk of dehydration. CNA "F" stated the charge nurses told CNAs which resident the CNAs needed to make sure had water. CNA "F" stated a resident who was dehydrated would be weak, have weight loss and become dizzy. On 05/22/14 at 6:10 p.m. CNA "G" stated CNAs had to ask the Charge Nurse which residents were at risk for dehydration or the the Charge Injures told them who to watch for dehydration. CNA "G" stated CNAs did not write anything down on a resident's ADL sheet regarding intake and output. CNAs let the Charge Nurses know if a resident did not urinate. CNA "G" said she would tell a nurse if a residents urine was dark or smelly, if a resident was not drinking fluid, if a resident was pale, clammy, or his/her lips were cracking. CNA "G" stated on 05/18/14 R #1 told her he needed the nurse. CNA "G" stated she told LVN "H" but did not know if LVN "H" went into R #1's room. CNA "G" stated the next time she went into R #1's room he asked to talk to a doctor. CNA "G" stated on 05/18/14 R #1 was moaning in pain the whole day. CNA "G" stated R #1 said asked her to leave his food in his room but he did not eat. CNA "G" said on 05/18/14 R #1 drank half a glass of tea and half a glass of water but she did not know the exact amount. CNA "G" did not document the intake of fluids for R #1. CNA "G" said residents who were dehydrated could go into shock and their body could shut down. On 05/22/14 at 6:35 p.m. LVN "H" stated she did not document intake or output on residents unless there was a physician's orders [REDACTED]. LVN "H" stated the CNAs reported to the Charge Nurse if a resident was not eating or drinking but she was not sure if the CNAs documented information regarding intake and output. LVN "H" stated residents needed hydration for their heart and lungs to work. Dehydration would affect a resident by the resident's body shutting down. LVN "H" stated that on 05/17/14 and 05/18/14 a CNA told her R #1 was complaining. LVN "H" went into R #1's room and he stated he needed his medication. LVN "H" said on 05/18/14 the CNA told her R #1 said he had vomited. LVN "H" stated she went into R #1's room and R #1 was forcing himself to throw up. LVN "H" stated their was "red phlegm" on the bed from the red soda he had drank. LVN "H" stated she did not notify the Physician because she thought R #1 "was pretending." LVN "H" stated she did not document the episode. On 05/22/14 at 7:10 p.m. LVN "C" stated the nurses did not document intakes and output on residents at risk for dehydration. LVN "C" said the "CNAs may, but she does not." LVN "C" stated she did not know which residents were at risk for dehydration nor was there a list of residents at risk for dehydration at the nurse's station. LVN "C" stated a dehydrated resident would "shrivel up" and their organs would begin to shut down if the resident did not get enough fluids. LVN "C" stated she did not know if a resident on fluid restrictions was getting too much fluid other than the [MEDICAL TREATMENT] company told how much fluid was taken out of the resident. On 05/22/14 at 7:30 p.m. the DON stated intake and output was not completed on residents at risk of dehydration unless the resident was admitted from the hospital or the facility physician ordered an intake and output on a resident. The DON stated the facility did not have any residents on intake or output. The DON said the staff, nurses and CNAs knew who was a dehydration risk by the disease process and the 24 hour reports. The DON said the aides knew who was on thickened liquids. The DON said water was passed throughout the day but the CNAs would not know how much water was drank by a resident. She said if the CNAs were concerned about a resident who was dehydrated the CNA could fill out a "Stop and Watch" a slip of paper they gave to the nurse regarding the CNAs concern about a resident. The DON said a resident who was at risk of dehydration would be monitored for urine output and skin turgor (elasticity). The DON stated she "expected the nurse to monitor for dehydration. The DON said "it was important to monitor intake and output so a resident did not end up in kidney failure, dehydration could lead to kidney failure." The DON stated she did not do an assessment on R #1 on 05/19/14. The DON stated she was responsible for the Assistant Director of Nurses, all other nurses and CNAs. She said, "ultimately I am over everyone." On 05/22/14 at 8:40 p.m. the Administrator and the DON stated there was not a facility policy on intakes and outputs for residents at risk of dehydration. On 05/23/14 at 2:30 p.m. LVN "B" stated in an interview R #1 had told him when he (R #1) was first admitted "I know ya'll don't want to enter my room. I (R #1) see people passing by and ya'll don't help me." LVN "B" stated there was one episode of R #1 having nausea and vomiting but LVN "B" did not remember the day nor did he document the episode of nausea and vomiting in R #1's Nurse's Notes or on the 24 Hour Nursing Report. LVN "B" stated R #1 never wanted water, R #1 asked for ice for his sodas and water he kept in his room. LVN "B" stated the morning of 05/18/14 LVN "A" told him (LVN "B") about the change regarding R #1's scheduled pain medications not being administered every four hours to only as needed. LVN "B" stated he had been told R #1 was not on skilled services therefore he did not have to document unless their was a change of condition. LVN "B" stated the morning of 05/19/14 he was in R #1's room and R #1 appeared confused. LVN "B" stated he did not notify the physician. LVN "B" stated at approximately 10:00 a.m. to 1

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition for one Resident (R#1) of 15 residents reviewed provision of care and services. The facility failed to assess or monitor R #1 to determine when a change of condition occurred that required physician notification or immediate medical intervention. R#1 was hospitalized and diagnosed with [REDACTED]. R#1 remained in the hospital at the time of the visit. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/22/14 at 9:35 p.m. While the IJ was removed on 05/25/14 at 11:45 a.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility continuing to in-service staff and monitor the Plan of Removal. These failures could affect all 74 residents placing them at at risk of not receiving proper assessments and care and services required to prevent a delay in medical treatment. The findings were: R#1's Face Sheet dated 05/02/14 revealed a [AGE] year old male admitted to facility on 05/01/14 from Hospital "BB." Hospital "BB's" Discharge Records for R#1 dated 05/01/14 identified R#1's Medical History and Physical with End-stage liver disease due to primary biliary [MEDICAL CONDITION] ([DIAGNOSES REDACTED] disease in which the bile ducts in your liver are slowly destroyed) , [MEDICAL CONDITION] Varices, Mallory-Weiss tear (tear in the esophagus associated with pressure caused by vomiting or coughing), Portal Hypertensive Gastropathy (changes in the mucosa of the stomach associated with [MEDICAL CONDITION] of the liver), Ascites (accumulation of fluid in the abdomen), Hypertension and [DIAGNOSES REDACTED] (enlargement of the spleen), Hepatic [MEDICAL CONDITION] (loss of brain function that occurs when the liver is unable to remove toxins from the blood), and [MEDICAL CONDITION]. Lab tests conducted included, Ammonia level was 56 (according to nim on 06/11/14 the normal amonia range is 15-45 micrograms per deciliter). R#1's admission orders [REDACTED]. R#1's [DIAGNOSES REDACTED]. According to [MEDICATION NAME].org retrieved 06/11/14 revealed [MEDICATION NAME] adverse reactions to [MEDICATION NAME] include nausea, vomiting, constipation, stomach aches, [MEDICAL CONDITION], chemical driven liver damage. R#1's Nursing assessment dated [DATE] had kidney and/or urinary problems and his color was jaundiced. R #1 was alert and oriented times three (aware of person, place, and time.) R#1 utilized a urinal and bedpan. The Nutritional/Fluid section of the Nursing Assessment was not completed. R#1's Interim Plan of Care dated 05/01/14 revealed R#1 required one staff person for assistance with mobility and utilized a cane. R #1's speech was normal and R#1 was alert. The fluid section was not completed on the Interim Plan of Care. R#1's Care Plan for [MEDICAL CONDITION] dated 05/02/14 revealed R#1 had a [MEDICAL CONDITION] and was at risk for increased pain and limited ambulation. The goal of the Care Plan was for R#1's pain to be controlled within one hour of intervention and be able to return to previous functioning when R#1's fracture was healed. The approaches to be utilized by licensed nursing staff were: -provide therapy and restorative care per order -monitor incision for signs and symptoms of infection-increased drainage, temperature, redness and report to the Physician. -keep the Physician and Responsible Party informed of resident's progress -assist with ADLs/repositioning every two hours/PRN-use positioning devices for proper body alignment. R#1's Care Plan dated 05/02/14 revealed there was not a Care Plan for R#1's use of a Diuretic-[MEDICATION NAME] or dehydration. According to Hospital "BB's" Discharge Records dated 05/01/14 identified R#1's Medical History and Physical lab test results for amonia level was 56 (according to nim on 06/11/14 the normal amonia range is 15-45 micrograms per deciliter). R#1's Comprehensive Metabolic Profile dated 05/02/14 revealed: -Sodium-134 Reference Range (136-145) -Potassium-3.5 Reference Range (3.5-5.1) -Chloride-106 Reference Range (98-107) -Creatinine-0.6 Reference Range (0.7-1.3) R#1's History and Physical dated 05/06/14 revealed R#1's was admitted from Hospital "BB" for rehabilitation of a Partial Hip Replacement. R#1's current [DIAGNOSES REDACTED]. R#1's past history/[DIAGNOSES REDACTED]. R#1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R#1 had clear speech; made himself understood; understood others; was not cognitively impaired (able to make decisions, no cues/supervision required); required extensive assistance from one staff person with bed mobility, transferring dressing, toileting and bathing. R#1 was totally dependent on one staff for locomotion/transfer on and off the unit. R#1 was on a scheduled pain medication regimen. R#1 was always continent of bowel and bladder; was not dehydrated; required surgical wound care and weighed 142 pounds (lbs). R#1 had active [DIAGNOSES REDACTED]. R#1 received a diuretic. R#1 was on a scheduled pain regimen. R#1's prognosis was not less than six months. R#1 participated in the MDS assessment and expected to be discharged back to the community. The MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision did not include Dehydration/Fluid Maintenance or Pain. R#1's Medication Administsration Record (MAR) dated 05/02/14 through 05/18/14 [MEDICATION NAME] 10/325 mg one tablet po every four hours was administered as ordered except for: 05/02/14 at 8 a.m., 05/04/14 at 8 p.m., 05/14/14 at 8 p.m., 05/14/14 at 12 a.m. and 4 a.m., and 05/15/14 at 12 a.m. and 8 p.m. Both Pain Administration Record dated May 2014 and the PAINAD Assessment (observational tool) "Pain Intensity Scores" indicated R#1 had not been assessed for pain from 05/01/14 through 05/19/14 by either method. On 05/22/14 at 12:45 p.m. the Medication Aide (MA) "I" stated R#1 was on scheduled pain medication-[MEDICATION NAME]. MA "I" stated when a resident was on scheduled pain medication a pain assessment was not competed each time the resident was given the pain medication. MA "I" stated only residents who received PRN pain medication were assessed for pain prior to the pain medication being administered. MA "I" stated on an unknown date R#1 refused his [MEDICATION NAME] stating, "I feel I am taking too much pain medication and I do not want to feel drowsy anymore." MA "I" stated she went and told the Charge Nurse (unknown) who administered the pain medication to R#1. MA "I" stated R#1 took the [MEDICATION NAME] from the Charge Nurse. MA "I" stated R#1 took the medication "guess a different face, different voice." On 05/22/14 at 7:30 p.m. the Director of Nurses stated residents on scheduled pain medications did not receive a pain assessment each time the pain medication was administered. The DON stated if there were no other pain assessments or Nurse's Notes in R#1's chart then she "can not say he (R#1) was assessed." R#1's 24 Hour Report/Change of Condition Report dated 05/11/14 completed by the Charge Nurse for the 10:00 p.m. to 6:00 a.m. shift revealed R#1 had complaints of "nausea and vomiting." R#1's 24 Hour Report/Change of Condition Report dated 05/11/14 completed by the Charge Nurse for the 6:00 a.m. to 2:00 p.m. shift revealed R#1 had "N/V (nausea and vomiting) last night." R#1's Skilled Daily Nurses Note dated 05/11/14 did not have documentation that indicated R#1 had experienced nausea and vomiting during the night. R#1's 24 Hour Report/Change of Condition Report dated 05/12/14 completed by the Charge Nurse for the 10:00 p.m. to 6:00 a.m. shift revealed R#1 had "N/V episode", [MEDICATION NAME] administered at night." R#1's Skilled Daily Nurse's Notes dated 05/12/14 revealed R#1 had an episode of "nausea and vomiting" at night. R#1 was given [MEDICATION NAME] (medication for nausea) for relief, tolerated well and effective. R#1's undated 24 Hour Report/Change of Condition Report completed by the evening Charge Nurse revealed R#1 "requests to see dr. (doctor) ASAP (as soon as possible) did not specify reason other than that change noted. ? ammonia levels need to be checked? Call Dr. for lab loratab PRN." R#1's Skilled Daily Nurses Notes revealed: 05/11/14 - alert on day and evening shift - skin color was jaundiced on evening shift. There was no documentation for skin color on day or night shift. Resident refused scheduled pain medications 4 p.m. dose. He states he feels drowsy and thinks it (pain medication) is causing it. Will continue to monitor. Resident refused 8 p.m. scheduled pain medicine. Will continue to monitor. 05/12/14 - alert on evening and night shift - evening shift-normal skin color. "Pt with NV episode at HS (night) and given [MEDICATION NAME] for relief-tolerated well and effective. Voices no hip pain at this time; taking [MEDICATION NAME]-scheduled every four hours. Somewhat distraught at times and requires assist for most ADLs; except eating due to mobility issues. Some distress noted at times." 05/13/14-alert on evening and night shift-evening and night shift-normal skin color. "Pt resting well this night and [MEDICATION NAME] help him sleep. Giving as ordered; tolerated well and effective. Deny's (sic) pain, but is on an every four hour [MEDICATION NAME] regimen. Hip fx (fracture) area appears to be getting better according to pt. Assist for most ADLs due to some mobility issues. Slight distress is seen at times." 05/13/14 was the last Skilled Daily Nurse's Notes for R#1. From 05/14/14 through 05/17/14 revealed no documentation of R#1's condition (skin color, mental status, skin turgor, mucous membranes, vital signs), approximately 4 days and 4 hours. Nurse's Notes dated 05/18/14 revealed R#1's Family Member (FM) "TT" was in the facility to check on him and also expressing R#1's pain medications needed to be changed to as needed (PRN). FM "TT" expressed that R#1 was "always dazed and lethargic attributed to Loratab administration every four hours." Physician's Telephone Order dated 05/18/14 at 6:00 a.m. stated "DC (discontinue) 10/325 one po every 4 hours. Start [MEDICATION NAME] 10/325 one po every four hours PRN (as needed) per family request." R#1's Nurses Notes dated 05/19/14 at 11:00 a.m. revealed R#1 "displayed confusion. Pt.(patient) not able to respond appropriately to questions when asked. Pt doesn't complain of pain." Physician "DD" paged times one. R#1's Nurses Notes dated 05/19/14 at 11:20 a.m. revealed "Pt. family in-house and was concerned of pt condition. Informed family (Physician "DD") has been paged to inform of pt condition. No answer. Pt cont (continues) with confusion. Pt c/o (complains) of lt (left) abdominal pain, increased. Medicated pt with [MEDICATION NAME] 10/325 mg one PO (by mouth). Pt family insisted on sending pt out to hospital. Via family request wanted pt sent out to (Hospital "BB") immediately." Physician's Telephone Order dated 05/19/14 without a time revealed an order for [REDACTED]. R#1's Emergency Medical Transportation (EMT) documentation dated 05/19/14 from the ambulance company revealed: - EMT arrived at 11:49 a.m. -R#1 had an Altered Mental Status with severe jaundice noted to the skin and eyes, lips chapped with sores to lips and tongue. The family stated to Emergency Medical Service Employee that a change in pt's. mental status was noted by them (Family Member "VV" and "UU") on the 12th of May. Nurse (Licensed Vocational Nurse (LVN) "B") at bedside stated a decrease noted today. Pt. was a total lift by two to stretcher. Bolus given 200 ml-during transport-slight increase in systolic pressure. Patient talked but did not make sense of words. -Pt was alert, confused, hallucinations -Symptoms-Change in responsiveness, pain, weakness -Impression-Altered level of consciousness/abdominal pain. -initial Patient Acuity: Critical -11:58 a.m.-Blood Pressure (BP)-104/56, Heart Rate-58, Respirations 18, -11:59 a.m.-Oxygen initiated at two liters per minute -11:59 a.m.-Peripheral Intravenous initiated. R#1's Physician Quality Reporting System dated 05/19/14 from Hospital "BB" revealed R#1 had decreased mental status, confusion, lethargy, speech/cognition abnormalities were slowed, dysarthria (slurred speech), dry mucous membranes (sign of dehydration), sclera icterus (yellowing of the eyes), decreased responsiveness and was disoriented. R#1 had abdominal pain, generalized weakness and increased jaundice. Labs: Complete Blood Count revealed: -WBC 14 - Reference range 4.0 - 11.0, -HGB-10.4 - Reference range 13.5 - 17.5, -HCT 29 - Reference range 36 - 46, Chemistries: -"BUN 32 H" Normal range 6-20, -"Potassium 1.6" Normal ranges 3.6 to 5.2, -"Sodium 129 L" Normal ranges 135 to 145, -"Chloride 89" Normal ranges 96-106" Clinical Impression-Dehydration, [MEDICAL CONDITION] (low sodium blood levels), Hyponkalemia (low potassium level in blood) and Hepatic [MEDICAL CONDITION] (liver damage). According to www.mayoclinic.org on 06/03/14, [MEDICAL CONDITION] is a condition that occurs when the level of sodium (electrolyte) in your blood is abnormally low. If you get dehydrated, your body loses fluids and electrolytes. Medications that increase your risk of [MEDICAL CONDITION] include thiazide diuretics as well as some antidepressants and pain medications. According to www.umm.edu on 06/03/14, Hepatic [MEDICAL CONDITION] is the loss of brain function that occurs when the liver is unable to remove toxins from the blood. Hepatic [MEDICAL CONDITION] may be triggered by: dehydration, abnormalities (especially a decrease in potassium) from vomiting, or from treatments such as or taking diuretics ("water pills"). Severe symptoms may include: ? Abnormal movements or shaking of hands or arms ? Disorientation ? Drowsiness or confusion ? Slurred speech ? Slowed or sluggish movement People with hepatic [MEDICAL CONDITION] can become unconscious, unresponsive, and possibly enter a coma. Hospital "BB's" Complete Emergency Department Record dated 05/20/14 page 5 revealed:[MEDICAL CONDITION] Screening result was "Positive [MEDICAL CONDITION]", and R#1's "tongue is cracked and dry. Lips are dry and cracked." R#1 is "lethargic. Speech is difficult to understand." Hospital "BB's" Chemistry Lab Results dated 05/21/14 for R#1 indicated his Amonia Levels were at 101. According to www.mayoclinic.org on 05/30/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." On 05/21/14 at 9:05 a.m., FM "TT" stated R#1's condition began to decline approximately 05/12/14. R#1 did not call FM "TT" or FM "UU" before going to bed as he normally did. On 05/13/14, R#1 did not call or answer his personal phone. On 05/15/14 FM "TT" said she called the facility and was told R#1 was asleep. FM "TT" said she was not able to get in touch with R#1 from 05/13/18 through 05/17/14. FM "TT" and FM "UU" visited R#1 on 05/17/14 at approximately 10:30 p.m. and observed R#1's hands shaking. FM "TT" said R#1's dinner tray was still on his bedside table and he had not eaten the food. R#1 told FM "TT" and FM "UU" he was being forced to take his pain medications. FM "TT" said she gave R#1 a strawberry soda and he spilled the soda on the bed. FM "UU" told LVN "A" he no longer wanted R#1 on scheduled pain medication every four hours. LVN "A" stated he would write an order for [REDACTED]. FM "TT" said she called the facility on 05/18/14 and LVN "B" would not give her information if the pain medication had been discontinued. FM "TT" stated she called the Director of Nurses (DON) and told the DON R#1 was not eating or drinking and R#1 was very disoriented. FM "TT" said she shared her concerns about R#1's ammonia levels being high due to his [MEDICAL CONDITION] of the Liver. The DON told FM "TT" she would have lab work completed on 05/19/14. FM "TT" said she and FM "UU" went to the facility on [DATE] and found R#1 in a fetal position and R#1 would not respond to her or FM "UU." FM "TT" said R#1 was jaundiced prior to being admitted to nursing facility but on 05/19/14 R#1's eyes were lemon yellow and sunken, his lips were cracked and dried blood was around his mouth. FM "TT" said there was no water pitcher or cups in the room. FM "TT" said she went out of the room to find a nurse and LVN "B" was in the hall. FM "TT" said she asked LVN "B" about R#1's lab results and LVN "B" asked, "What are you talking about? He (R#1) did not have orders for labs." FM "TT" said she want R#1 taken to the hospital. LVN "B" told her (FM "TT"), 'they will just take levels and send him back with lactalose." FM "TT" said she went back into R#1's bedroom and FM "UU" had given R#1 had three small glasses's of water. LVN "B" went back into the room and said he had paged the doctor and was waiting for a return call. LVN "B" said he had spoken to the DON and was told to get an order for [REDACTED].#1's room and assessed him prior to calling the ambulance. FM "TT" said when the Paramedics arrived they asked how long R#1 had been in this condition? LVN "B" said since this morning. FM "TT" said she and FM "UU" told the EMT they had noticed a change in R#1 around 05/12/14. EMT "M" stated, "that's more like it." The EMTs placed R #1 in the ambulance and told FM "TT" and FM "UU" to give them a few minutes to stabilize R #1. On 05/21/14 at 1:20 p.m., at Hospital "BB" R#1 was observed lying in bed and unresponsive to surveyor's questions. R#1 stared at surveyor with his mouth open. R#1's lips were cracked and R#1 had scabs on his bottom lip and the corner of the left side of his mouth. R#1 had an ulcer along the right side of his tongue. The skin on R#1's right and left arms was dry and flaky. R#1's eyes were sunken and yellow. On 05/21/14 at 1:25 p.m. , FM "TT" said she and FM "UU" arrived at nursing home on 05/19/14 at approximately 10:00 a.m. and observed R#1 lying in a fetal position. FM "TT" said, "I thought he (R#1) was dead." On 05/22/14 at 2:20 p.m. FM "TT" stated R#1's Physician at Hospital "BB" stated R#1 "may not make it through this." On 05/22/14 at 3:25 p.m. LVN "A" stated he had started working with R#1 on 05/12/14. LVN "A" said when he started working with R#1 he looked lethargic and dazed. LVN "A" stated R#1 "was a very sick man and everyone knew from the beginning he (R#1) was not doing good." R#1 had an episode of nausea and vomiting during one of LVN "C's" shifts and LVN "A" gave R#1 [MEDICATION NAME] (nausea medication). LVN "A" said on 05/17/14 FM "TT" and FM "UU" visited R#1. FM "UU" asked LVN A" about R#1's labs and LVN "A" told FM "UU" R#1 did not have any labs in his chart. FM "UU" stated FM "UU" wanted R#1's scheduled pain medication changed to as needed. LVN "A" stated he wrote the order and told the oncoming nurse during shift change that R#1's FM "UU" wanted R#1's pain medication/Loratab changed to as needed. LVN "A" stated he did not notify the physician R#1's family was concerned about R#1's condition or about the order for the change for the pain medication. LVN "A" stated he was not aware of any orders for R#1 to have labs drawn. On 05/22/14 at 4:05 p.m. the Director of Nurses (DON) stated after a resident is taken off of skilled services the nurses do not have to chart every day, they only have to chart if there is a change. On 05/22/14 at 6:10 p.m. Certified Nurse Aide (CNA) "G" stated CNAs had to ask the Charge Nurse which residents were at risk for dehydration or the the Charge Injures told them who to watch for dehydration. CNA "G" stated CNAs did not write anything down on a resident's ADL sheet regarding intake and output. CNAs let the Charge Nurses know if a resident did not urinate. CNA "G" said she would tell a nurse if a residents urine was dark or smelly, if a resident was not drinking fluid, if a resident was pale, clammy, or his/her lips were cracking. CNA "G" stated on 05/18/14 R#1 told her he needed the nurse. CNA "G" stated she told LVN "H" but did not know if LVN "H" went into R#1's room. CNA "G" stated the next time she went into R#1's room he asked to talk to a doctor. CNA "G" stated on 05/18/14 R#1 was moaning in pain the whole day. CNA "G" stated R#1 said for her to leave his food in his room but he did not eat. CNA "G" said on 05/18/14 R#1 drank half a glass of tea and half a glass of water but she did not know the exact amount. CNA "G" said residents who were dehydrated could go into shock and their body could shut down. On 05/22/14 at 6:35 p.m. LVN "H" stated she did not document intake or output on residents unless there was a physician's orders [REDACTED]. LVN "H" stated residents needed hydration for their heart and lungs to work. Dehydration would affect a resident by the resident's body shutting down. LVN "H" stated on 05/17/14 and 05/18/14 a CNA told her R#1 was complaining. LVN "H" went into R#1's room and he stated he needed his medication. LVN "H" said on 05/18/14 the CNA told her R#1 said he had vomited. LVN "H" stated she went into R#1's room and R#1 was forcing himself to throw up. LVN "H" stated their was red flim on the bed from the red soda R#1 had drank. LVN "H" stated she did not notify the Physician because she thought R#1 "was pretending to throw up." LVN "H" stated she did not document the episode on the 24 Hour Report or in the Nurse's Notes. On 05/22/14 at 7:10 p.m. LVN "C" stated the nurses did not document intakes and output on residents at risk for dehydration. LVN "C" said the "CNAs may, but she does not." LVN "C" stated she did not know which residents were at risk for dehydration nor was there a list of residents at risk for dehydration at the nurse's station. LVN "C" stated a dehydrated resident would "shrivel up" and their organs would begin to shut down if the resident did not get enough fluids. LVN "C" stated she did not know if a resident on fluid restrictions was getting too much fluid other than the [MEDICAL TREATMENT] company told how much fluid was taken out of the resident. On 05/22/14 at 7:30 p.m. the DON stated she "expected the nurse to monitor dehydration." The DON said "it was important to monitor intake and output so a resident did not end up in kidney failure, dehydration could lead to kidney failure." The DON stated she did not do an assessment on R#1 on 05/19/14 prior to him leaving the facility. The DON stated she had not notified the Physician on 05/18/14 after she told R#1's family she would get labs drawn. On 05/23/14 at 2:30 p.m. LVN "B" stated there was one episode of R#1 having nausea and vomiting but LVN "B" did not remember the day nor did he document the episode of nausea and vomiting in R#1's Nurse's Notes or on the 24 Hour Nursing Report. LVN "B" stated he had been told R#1 was not on skilled services therefore he did not have to document unless their was a change of condition. LVN "B" stated R#1 never wanted water, R#1 asked for ice for his sodas and water he kept in his room. LVN "B" stated the morning of 05/18/14, LVN "A" told him (LVN "B") about the change regarding the scheduled pain medications not being administered every four hours to only as needed. LVN "B" stated the morning of 05/19/14 he was in R#1's room and R#1 appeared confused. LVN "B" stated he did not notify the physician. LVN "B" stated at approximately 10:00 a.m. to 10:45 a.m. he was in the hall and FM "TT" asked him if R#1's labs had been drawn? LVN "B" stated he did not know anything about labs and would speak to the DON. LVN "B" stated FM "TT" wanted R#1 sent to the hospital. LVN "B" stated he told FM "TT" the facility could get immediate orders (STAT) and do the same services as the hospital. LVN "B" stated he attempted to call Physician "DD" but Physician "DDs" voice mail was not set up to take messages. LVN "B" stated he never did speak with Physician "DD" regarding R#1. LVN "B" stated he went and spoke with the DON who told him she was writing the order for the labs. LVN "C" stated he took R#1's vital signs but he wrote them on a piece of paper and did not document the vital signs in R#1's medical chart. LVN "B" stated R#1 was confused but his vital signs were normal. LVN "B" stated he did not observe R#1's lips cracked or bloody. On 05/27/14 at 3:30 p.m. Physician "DD" stated he had not been made aware of any concerns regarding R#1. Physician "DD" stated no one notified him of R#1's nausea and vomiting or of R#1's FM "TT" and FM "UU's" concerns of R#1 receiving too much pain medication. Physician "DD" stated it could have taken R#1 several days to get dehydrated or a day. Physician "DD" stated "the staff are not medically trained to know symptoms." On 06/02/14 at 4:30 p.m. Hospital Nurse (HN) "NN" stated when R#1 arrived at Hospital "BB" on 05/19/14 R#1 was skin and bones he was so emaciated, his skin was "glow in the dark orange he was so jaundiced, his lips were dry and cracked and his tongue had an ulcer." HS "NN" said R#1 was alert but confused. His potassium level was 1.6. HS "NN" stated the emergency room Doctor stated R#1 "looks like a Zombie." Review of the facility's 24 Hour Reports dated 05/01/14 through 05/19/14 revealed no documentation regarding R#1's hydration status. The undated Statement of Patient's Rights indicated the "Patient has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside facility. Facility must protect and promote the rights of each Patient, including the following rights: A. Exercise of Rights (5)(b) has the right to be free from abuse, neglect, and exploitation." F. Change in Patient's Condition (1) Facility shall immediately inform Patient; consult with Patient's physician; and if known, notify Patient's Responsible Party when there is- (b) A significant change in Patient's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (c) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment)." The facility's undated Patient Bill of Rights; L. Care Involvement" "1. The facility will provide appropriate care, treatment and services." On 05/22/14 at 9:35 p.m., an IJ was identified and the DON and the Administrator were informed of the IJ due to the above failures. On 05/23/14 at 2:25 a.m. the facility's 4th Plan of Removal was accepted and contained the following: All nursing personnel (CNAs, CMAs, LVNs, RNs) are being inserviced on the following topics related to Signs and Systems of Dehydration and monitoring tools: 1. Causes of Dehydration 2. Risk Factors of Dehydration 3. Advanced Signs and Symptoms of Dehydration 4. Documentation of S/S of Dehydration 5. Flow Record added Foley Output Empty Q (every) Shift 6. Hydration Flow Record 6 a.m., 2 p.m. & 8 p.m. for water pitcher 7. Physician order [REDACTED]. 8. Flow Record for brief distribution for incontinent residents The in-service has been initiated by the Director of Nurses and Assistant Director of Nurses. Validation of understanding is being accomplished by administering a post test on the subject's in-serviced. The in-service will continue each shift to ensure all staff has the training and validation testing. Any employee not passing the test will be inserviced 1:1 by the DON and will be allowed to re-test. Initiated 05/22/14 Completion 05/24/14. The DON has been in-serviced on the topics of S/S of Dehydration by the Regional Nurse Consultant and has passed the test for validation of materials. The Administrator, DON, ADON, and Regional Nurse Consultant, thoroughly assessed each patient that is receiving [DEVICE] feedings, has a Foley catheter, is on fluid restriction, hospice, [MEDICAL TREATMENT], cognitive loss and decrease in ADL functions. A skin identification form was completed with the findings. Not patients were identified with S/S; any signs or symptoms will be addressed immediately with notification to the physician related to change of condition. The DON also conducted a complete audit of Registered Dietitian recommendations and there were not any discrepancies identified. Initiated 05/22/14 Completion 05/24/14. It is the responsibility of the DON/ADON to conduct audits utilizing the 24 hour report communication tool through the morning routine daily meeting (M-F) to validate assessment findings and physician and family notification has been carried out as required. The will prompt the DON/ADON to follow up in the resident chart for proper hydration interventions, effectiveness and/or signs or symptoms of dehydration. The RN Weekend Supervisor will follow the same practice to monitor compliance on the weekends. Initiated 05/22/14 Completion date on going. For employees who are unable to come to the facility on [DATE] or 05/24/14 for the in-service listeed on this Plan of Removal, the DON/ADON, Unit Manager or Weekend RN Supervisor will conduct the in-service with employees prior to patient care. This in-service will be documented on the in-service record and the employee will be required to complete the Post Test prior to their schedule shift. This test will be administered by either the DON/ADON/UM or RN Weekend Supervisor; failure to pass the test will result in the employee not working until receiving 1:1 in-service on materials the next business day the the DON/ADON/UM or RN Sprvr. All newly hired staff nursing staff will receive the aforementioned in-services prior to working their shift. This test will be administered by either the DON/ADON; failure to pass the test will result in the employee not working until receiving 1:1 in-service on materials the next business day by the DON. Initiated 05/22/14 Completion date on-going. A QA Meeting was held via telephone; the QA Committee, which includes the Medical Director, will monitor for the next 90 days to ensure the system is effective. The QA committee will review 24 hour reports, prn documentation, and morning start up and review Post Tests for new hires. Inititated 05/22/14 Completion date on-going (90 days). Through observation, interviews and record reviews, the survey team determined that the inservicing was initiated and staff followed the residents at risk for dehydration monitoring that was documented in the facility's Plan of Removal were implemented. The facility's list of residents at risk of dehydration dated 05/22/14 identified two residents on fluid restrictions, five residents receiving [MEDICAL TREATMENT], three residents receiving Hospice, two r

Surveyor: Sheppard, Luci Ann Based on interview and record review the facility failed to ensure resident's drug regimen was free from unnecessary drugs for one Resident (R #1) of two Residents reviewed for scheduled pain medications. The facility was aware R #1 received scheduled pain medication every four hours and did not monitor the pain medication for excessive dose, excessive duration, without adequate indications or monitoring for its use or for the presence of adverse consequences even though R#1 voiced his concerns. This failure placed R#1 who received scheduled medications at risk for a decline in Activities of Daily Living, loss of appetite, weight loss, drowsiness, confusion, dizziness, and risk of falls and fractures. The findings were: R #1's Face Sheet dated 05/02/14 revealed a [AGE] year old male admitted on [DATE]. R#1's admission orders [REDACTED]. R#1's [DIAGNOSES REDACTED]. According to [MEDICATION NAME].org retrieved 06/11/14 revealed [MEDICATION NAME] adverse reactions to [MEDICATION NAME] include nausea, vomiting, constipation, stomach aches, [MEDICAL CONDITION], chemical driven liver damage. R#1's Nursing assessment dated [DATE] had kidney and/or urinary problems and his color was jaundiced. R #1 was alert and oriented times three (aware of person, place, and time.) R#1 utilized a urinal and bedpan. R#1's Pain assessment dated [DATE] indicated R#1 had pain from a Right [MEDICAL CONDITION]. R#1's "acceptable level of pain" was a "5." There was no indication of the pain rating scale. R#1's pain rating at the time of the pain assessment on a scale of one to 10 was a two (hurts a little bit). R#1's breathing-normal, negative vocalizations-none, facilal expressions-smiling or inexpressive, body language-relaxed and consaolability-no need to console was scored a zero. R#1's nonverbal/non-cognitve signs of pain were cursing if in pain. R#1's MAR indicated [REDACTED] Both Pain Administration Record dated May 2014 and the PAINAD Assessment (observational tool) "Pain Intensity Scores" indicated R#1 had not been assessed for pain from 05/01/14 through 05/19/14 by either method. R#1's Interim Plan of Care dated 05/01/14 revealed R#1 required one staff person for assistance with mobility and utilized a cane. R #1's speech was normal and R#1 was alert. The fluid section was not completed on the Interim Plan of Care. R#1's Care Plan for [MEDICAL CONDITION] dated 05/02/14 revealed R#1 had a [MEDICAL CONDITION] and was at risk for increased pain and limited ambulation. The goal of the Care Plan was for R#1's pain to be controlled within one hour of intervention and be able to return to previous functioning when R#1's fracture was healed. The approaches to be utilized by licensed nursing staff were: -provide therapy and restorative care per order -monitor incision for signs and symptoms of infection-increased drainage, temperature, redness and report to the Physician. -keep the Physician and Responsible Party informed of resident's progress -assist with ADLs/repositioning every two hours/PRN-use positioning devices for proper body alignment. R#1's Care Plan dated 05/02/14 revealed there was not a Care Plan for R#1's use of a Diuretic-[MEDICATION NAME] or dehydration. R#1's History and Physical dated 05/06/14 revealed R#1's was admitted from Hospital "BB" for rehabilitation of a Partial Hip Replacement. R#1's current [DIAGNOSES REDACTED]. R#1's past history/[DIAGNOSES REDACTED]. According to Hospital "BB's" Discharge Records dated 05/01/14 identified R#1's Medical History and Physical lab test results for amonia level was 56 (according to nim on 06/11/14 the normal amonia range is 15-45 micrograms per deciliter). R#1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R#1 had clear speech; made himself understood; understood others; was not cognitively impaired (able to make decisions, no cues/supervision required); required extensive assistance from one staff person with bed mobility, transferring dressing, toileting and bathing. R#1 was totally dependent on one staff for locomotion/transfer on and off the unit. R#1 was on a scheduled pain medication regimen. R#1 was always continent of bowel and bladder; was not dehydrated; required surgical wound care and weighed 142 pounds (lbs). R#1 had active [DIAGNOSES REDACTED]. R#1 received a diuretic. R#1 was on a scheduled pain regimen. R#1's prognosis was not less than six months. R#1 participated in the MDS assessment and expected to be discharged back to the community. The MDS dated [DATE] revealed Care Area Triggered and Care Planning Decision did not include Dehydration/Fluid Maintenance or Pain. R#1's 24 Hour Report/Change of Condition Report dated 05/11/14 completed by the Charge Nurse for the 10:00 p.m. to 6:00 a.m. shift revealed R#1 had complaints of "nausea and vomiting." R#1's 24 Hour Report/Change of Condition Report dated 05/11/14 completed by the Charge Nurse for the 6:00 a.m. to 2:00 p.m. shift revealed R#1 had "N/V (nausea and vomiting) last night." R#1's Skilled Daily Nurses Note dated 05/11/14 did not have documentation that indicated R#1 had experienced nausea and vomiting during the night. R#1's 24 Hour Report/Change of Condition Report dated 05/12/14 completed by the Charge Nurse for the 10:00 p.m. to 6:00 a.m. shift revealed R#1 had "N/V episode", [MEDICATION NAME] administered at night." R#1's Skilled Daily Nurse's Notes dated 05/12/14 revealed R#1 had an episode of "nausea and vomiting" at night. R#1 was given [MEDICATION NAME] (medication for nausea) for relief, tolerated well and effective. R#1's undated 24 Hour Report/Change of Condition Report completed by the evening Charge Nurse revealed R#1 "requests to see dr. (doctor) ASAP (as soon as possible) did not specify reason other than that change noted. ? ammonia levels need to be checked? Call Dr. for lab [MEDICATION NAME] PRN." R#1's Skilled Daily Nurses Notes revealed: 05/11/14 - alert on day and evening shift - skin color was jaundiced on evening shift. There was no documentation for skin color on day or night shift. Resident refused scheduled pain medications 4 p.m. dose. He states he feels drowsy and thinks it (pain medication) is causing it. Will continue to monitor. Resident refused 8 p.m. scheduled pain medicine. Will continue to monitor. 05/12/14 - alert on evening and night shift - evening shift-normal skin color. "Pt with NV episode at HS (night) and given [MEDICATION NAME] for relief-tolerated well and effective. Voices no hip pain at this time; taking [MEDICATION NAME]-scheduled every four hours. Somewhat distraught at times and requires assist for most ADLs; except eating due to mobility issues. Some distress noted at times." 05/13/14-alert on evening and night shift-evening and night shift-normal skin color. "Pt resting well this night and [MEDICATION NAME] help him sleep. Giving as ordered; tolerated well and effective. Deny's (sic) pain, but is on an every four hour Loratab regimen. Hip fx (fracture) area appears to be getting better according to pt. Assist for most ADLs due to some mobility issues. Slight distress is seen at times." 05/13/14 was the last Skilled Daily Nurse's Notes for R#1. From 05/14/14 through 05/17/14 revealed no documentation of R#1's condition (skin color, mental status, skin turgor, mucous membranes, vital signs), approximately 4 days and 4 hours. Nurse's Notes dated 05/18/14 revealed R#1's Family Member (FM) "TT" was in the facility to check on him and also expressing R#1's pain medications needed to be changed to as needed (PRN). FM "TT" expressed that R#1 was "always dazed and lethargic attributed to Loratab administration every four hours." Physician's Telephone Order dated 05/18/14 at 6:00 a.m. stated"DC (discontinue) 10/325 one po every 4 hours. Start [MEDICATION NAME] 10/325 one po every four hours PRN (as needed) per family request." R#1's Nurses Notes dated 05/19/14 at 11:00 a.m. revealed R#1 "displayed confusion. Pt.(patient) not able to respond appropriately to questions when asked. Pt doesn't complain of pain." Physician "DD" paged times one. R#1's Nurses Notes dated 05/19/14 at 11:20 a.m. revealed "Pt. family in-house and was concerned of pt condition. Informed family (Physician "DD") has been paged to inform of pt condition. No answer. Pt cont (continues) with confusion. Pt c/o (complains) of lt (left) abdominal pain, increased. Medicated pt with [MEDICATION NAME] 10/325 mg one PO (by mouth). Pt family insisted on sending pt out to hospital. Via family request wanted pt sent out to (Hospital "BB") immediately." Physician's Telephone Order dated 05/19/14 without a time revealed an order for [REDACTED]. R#1's Emergency Medical Transportation (EMT) documentation dated 05/19/14 from the ambulance company revealed: - EMT arrived at 11:49 a.m. -R#1 had an Altered Mental Status with severe jaundice noted to the skin and eyes, lips chapped with sores to lips and tongue. The family stated to Emergency Medical Service Employee that a change in pt's. mental status was noted by them (Family Member "VV" and "UU") on the 12th of May. Nurse (Licensed Vocational Nurse (LVN) "B") at bedside stated a decrease noted today. Pt. was a total lift by two to stretcher. Bolus given 200 ml-during transport-slight increase in systolic pressure. Patient talked but did not make sense of words. -Pt was alert, confused, hallucinations -Symptoms-Change in responsiveness, pain, weakness -Impression-Altered level of consciousness/abdominal pain. -initial Patient Acuity: Critical -11:58 a.m.-Blood Pressure (BP)-104/56, Heart Rate-58, Respirations 18, -11:59 a.m.-Oxygen initiated at two liters per minute -11:59 a.m.-Peripheral Intravenous initiated. R#1's Physician Quality Reporting System dated 05/19/14 from Hospital "BB" revealed R#1 had decreased mental status, confusion, lethargy, speech/cognition abnormalities were slowed, dysarthria (slurred speech), dry mucous membranes (sign of dehydration), sclera icterus (yellowing of the eyes), decreased responsiveness and was disoriented. R#1 had abdominal pain, generalized weakness and increased jaundice. Labs: Complete Blood Count revealed: -WBC 14 - Reference range 4.0 - 11.0, -HGB-10.4 - Reference range 13.5 - 17.5, -HCT 29 - Reference range 36 - 46, Chemistries: -"BUN 32 H" Normal range 6-20, -"Potassium 1.6" Normal ranges 3.6 to 5.2, -"Sodium 129 L" Normal ranges 135 to 145, -"Chloride 89" Normal ranges 96-106" Clinical Impression-Dehydration, [MEDICAL CONDITION] (low sodium blood levels), Hyponkalemia (low potassium level in blood) and Hepatic [MEDICAL CONDITION] (liver damage). According to www.mayoclinic.org on 06/03/14, [MEDICAL CONDITION] is a condition that occurs when the level of sodium (electrolyte) in your blood is abnormally low. If you get dehydrated, your body loses fluids and electrolytes. Medications that increase your risk of [MEDICAL CONDITION] include thiazide diuretics as well as some antidepressants and pain medications. According to www.umm.edu on 06/03/14, Hepatic [MEDICAL CONDITION] is the loss of brain function that occurs when the liver is unable to remove toxins from the blood. Hepatic [MEDICAL CONDITION] may be triggered by: dehydration, abnormalities (especially a decrease in potassium) from vomiting, or from treatments such as or taking diuretics ("water pills"). Severe symptoms may include: Abnormal movements or shaking of hands or arms Disorientation Drowsiness or confusion Slurred speech Slowed or sluggish movement People with hepatic [MEDICAL CONDITION] can become unconscious, unresponsive, and possibly enter a coma. Hospital "BB's" Complete Emergency Department Record dated 05/20/14 page 5 revealed:[MEDICAL CONDITION] Screening result was "Positive [MEDICAL CONDITION]", and R#1's "tongue is cracked and dry. Lips are dry and cracked." R#1 is "lethargic. Speech is difficult to understand." Hospital "BB's" Chemistry Lab Results dated 05/21/14 for R#1 indicated his Amonia Levels were at 101. According to www.mayoclinic.org on 05/30/14, "Sepsis is a potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. [MEDICAL CONDITION] progresses to septic shock, blood pressure drops dramatically, which may lead to death. Anyone can [MEDICAL CONDITION], but it's most common and most dangerous in elderly people or those with weakened immune systems. Early treatment of [REDACTED]." On 05/21/14 at 9:05 a.m., FM "TT" stated R#1's condition began to decline approximately 05/12/14. R#1 did not call FM "TT" or FM "UU" before going to bed as he normally did. On 05/13/14, R#1 did not call or answer his personal phone. On 05/15/14 FM "TT" said she called the facility and was told R#1 was asleep. FM "TT" said she was not able to get in touch with R#1 from 05/13/18 through 05/17/14. FM "TT" and FM "UU" visited R#1 on 05/17/14 at approximately 10:30 p.m. and observed R#1's hands shaking. FM "TT" said R#1's dinner tray was still on his bedside table and he had not eaten the food. R#1 told FM "TT" and FM "UU" he was being forced to take his pain medications. FM "TT" said she gave R#1 a strawberry soda and he spilled the soda on the bed. FM "UU" told LVN "A" he no longer wanted R#1 on scheduled pain medication every four hours. LVN "A" stated he would write an order for [REDACTED]. FM "TT" said she called the facility on 05/18/14 and LVN "B" would not give her information if the pain medication had been discontinued. FM "TT" stated she called the Director of Nurses (DON) and told the DON R#1 was not eating or drinking and R#1 was very disoriented. FM "TT" said she shared her concerns about R#1's ammonia levels being high due to his [MEDICAL CONDITION] of the Liver. The DON told FM "TT" she would have lab work completed on 05/19/14. FM "TT" said she and FM "UU" went to the facility on [DATE] and found R#1 in a fetal position and R#1 would not respond to her or FM "UU." FM "TT" said R#1 was jaundiced prior to being admitted to nursing facility but on 05/19/14 R#1's eyes were lemon yellow and sunken, his lips were cracked and dried blood was around his mouth. FM "TT" said there was no water pitcher or cups in the room. FM "TT" said she went out of the room to find a nurse and LVN "B" was in the hall. FM "TT" said she asked LVN "B" about R#1's lab results and LVN "B" asked, "What are you talking about? He (R#1) did not have orders for labs." FM "TT" said she want R#1 taken to the hospital. LVN "B" told her (FM "TT"), 'they will just take levels and send him back with lactalose." FM "TT" said she went back into R#1's bedroom and FM "UU" had given R#1 had three small glasses's of water. LVN "B" went back into the room and said he had paged the doctor and was waiting for a return call. LVN "B" said he had spoken to the DON and was told to get an order for [REDACTED].#1's room and assessed him prior to calling the ambulance. FM "TT" said when the Paramedics arrived they asked how long R#1 had been in this condition? LVN "B" said since this morning. FM "TT" said she and FM "UU" told the EMT they had noticed a change in R#1 around 05/12/14. EMT "M" stated, "that's more like it." The EMTs placed R #1 in the ambulance and told FM "TT" and FM "UU" to give them a few minutes to stabilize R #1. On 05/21/14 at 1:20 p.m. , at Hospital "BB" R#1 was observed lying in bed and unresponsive to surveyor's questions. R#1 stared at surveyor with his mouth open. R#1's lips were cracked and R#1 had scabs on his bottom lip and the corner of the left side of his mouth. R#1 had an ulcer along the right side of his tongue. The skin on R#1's right and left arms was dry and flaky. R#1's eyes were sunken and yellow. On 05/21/14 at 1:25 p.m. , FM "TT" said she and FM "UU" arrived at nursing home on 05/19/14 at approximately 10:00 a.m. and observed R#1 lying in a fetal position. FM "TT" said, "I thought he (R#1) was dead." On 05/21/14 at 9:05 a.m. , FM "TT" stated on 05/07/14 the DON told her R #1's insurance had not approved R #1 for skilled PT but R #1 was being offered restorative PT but he was refusing. FM "TT" stated she told the DON that R #1 had told her (FM "TT") he was being forced to take [MEDICATION NAME] and it was making him drowsy. On 05/22/14 at 2:20 p.m. FM "TT" stated R#1's Physician at Hospital "BB" stated R#1 "may not make it through this." On 05/22/14 at 3:25 p.m. LVN "A" stated he had started working with R#1 on 05/12/14. LVN "A" said when he started working with R#1 he looked lethargic and dazed. LVN "A" stated R#1 "was a very sick man and everyone knew from the beginning he (R#1) was not doing good." R#1 had an episode of nausea and vomiting during one of LVN "C's" shifts and LVN "A" gave R#1 [MEDICATION NAME] (nausea medication). LVN "A" said on 05/17/14 FM "TT" and FM "UU" visited R#1. FM "UU" asked LVN A" about R#1's labs and LVN "A" told FM "UU" R#1 did not have any labs in his chart. FM "UU" stated FM "UU" wanted R#1's scheduled pain medication changed to as needed. LVN "A" stated he wrote the order and told the oncoming nurse during shift change that R#1's FM "UU" wanted R#1's pain medication/Loratab changed to as needed. LVN "A" stated he did not notify the physician R#1's family was concerned about R#1's condition or about the order for the change for the pain medication. LVN "A" stated he was not aware of any orders for R#1 to have labs drawn. On 05/22/14 at 4:05 p.m. the Director of Nurses (DON) stated after a resident is taken off of skilled services the nurses do not have to chart every day, they only have to chart if there is a change. On 05/22/14 at 6:10 p.m. Certified Nurse Aide (CNA) "G" stated CNAs had to ask the Charge Nurse which residents were at risk for dehydration or the the Charge Injures told them who to watch for dehydration. CNA "G" stated CNAs did not write anything down on a resident's ADL sheet regarding intake and output. CNAs let the Charge Nurses know if a resident did not urinate. CNA "G" said she would tell a nurse if a residents urine was dark or smelly, if a resident was not drinking fluid, if a resident was pale, clammy, or his/her lips were cracking. CNA "G" stated on 05/18/14 R#1 told her he needed the nurse. CNA "G" stated she told LVN "H" but did not know if LVN "H" went into R#1's room. CNA "G" stated the next time she went into R#1's room he asked to talk to a doctor. CNA "G" stated on 05/18/14 R#1 was moaning in pain the whole day. CNA "G" stated R#1 said for her to leave his food in his room but he did not eat. CNA "G" said on 05/18/14 R#1 drank half a glass of tea and half a glass of water but she did not know the exact amount. CNA "G" said residents who were dehydrated could go into shock and their body could shut down. On 05/22/14 at 6:35 p.m. LVN "H" stated she did not document intake or output on residents unless there was a physician's orders [REDACTED]. LVN "H" stated residents needed hydration for their heart and lungs to work. Dehydration would affect a resident by the resident's body shutting down. LVN "H" stated on 05/17/14 and 05/18/14 a CNA told her R#1 was complaining. LVN "H" went into R#1's room and he stated he needed his medication. LVN "H" said on 05/18/14 the CNA told her R#1 said he had vomited. LVN "H" stated she went into R#1's room and R#1 was forcing himself to throw up. LVN "H" stated their was red flim on the bed from the red soda R#1 had drank. LVN "H" stated she did not notify the Physician because she thought R#1 "was pretending to throw up." LVN "H" stated she did not document the episode on the 24 Hour Report or in the Nurse's Notes. On 05/22/14 at 7:10 p.m. LVN "C" stated the nurses did not document intakes and output on residents at risk for dehydration. LVN "C" said the "CNAs may, but she does not." LVN "C" stated she did not know which residents were at risk for dehydration nor was there a list of residents at risk for dehydration at the nurse's station. LVN "C" stated a dehydrated resident would "shrivel up" and their organs would begin to shut down if the resident did not get enough fluids. LVN "C" stated she did not know if a resident on fluid restrictions was getting too much fluid other than the [MEDICAL TREATMENT] company told how much fluid was taken out of the resident. On 05/22/14 at 7:30 p.m. the DON stated she "expected the nurse to monitor dehydration." The DON said "it was important to monitor intake and output so a resident did not end up in kidney failure, dehydration could lead to kidney failure." The DON stated she did not do an assessment on R#1 on 05/19/14 prior to him leaving the facility. The DON stated she had not notified the Physician on 05/18/14 after she told R#1's family she would get labs drawn. On 05/23/14 at 2:30 p.m. LVN "B" stated there was one episode of R#1 having nausea and vomiting but LVN "B" did not remember the day nor did he document the episode of nausea and vomiting in R#1's Nurse's Notes or on the 24 Hour Nursing Report. LVN "B" stated he had been told R#1 was not on skilled services therefore he did not have to document unless their was a change of condition. LVN "B" stated R#1 never wanted water, R#1 asked for ice for his sodas and water he kept in his room. LVN "B" stated the morning of 05/18/14, LVN "A" told him (LVN "B") about the change regarding the scheduled pain medications not being administered every four hours to only as needed. LVN "B" stated the morning of 05/19/14 he was in R#1's room and R#1 appeared confused. LVN "B" stated he did not notify the physician. LVN "B" stated at approximately 10:00 a.m. to 10:45 a.m. he was in the hall and FM "TT" asked him if R#1's labs had been drawn? LVN "B" stated he did not know anything about labs and would speak to the DON. LVN "B" stated FM "TT" wanted R#1 sent to the hospital. LVN "B" stated he told FM "TT" the facility could get immediate orders (STAT) and do the same services as the hospital. LVN "B" stated he attempted to call Physician "DD" but Physician "DDs" voice mail was not set up to take messages. LVN "B" stated he never did speak with Physician "DD" regarding R#1. LVN "B" stated he went and spoke with the DON who told him she was writing the order for the labs. LVN "C" stated he took R#1's vital signs but he wrote them on a piece of paper and did not document the vital signs in R#1's medical chart. LVN "B" stated R#1 was confused but his vital signs were normal. LVN "B" stated he did not observe R#1's lips cracked or bloody. On 05/27/14 at 1:05 p.m., Director of the EMT (DEMT) "O" stated she received a phone call from EMT "M" on 05/19/14 during transport of R #1 to Hospital "BB." DEMT "O" said EMT "M" told her R #1 was "severely dehydrated and appeared doped up." On 05/27/14 at 3:30 p.m. Physician "DD" stated he had not been made aware of any concerns regarding R#1. Physician "DD" stated no one notified him of R#1's nausea and vomiting or of R#1's FM "TT" and FM "UU's" concerns of R#1 receiving too much pain medication. Physician "DD" stated it could have taken R#1 several days to get dehydrated or a day. Physician "DD" stated "the staff are not medically trained to know symptoms." On 06/02/14 at 4:30 p.m. Hospital Nurse (HN) "NN" stated when R#1 arrived at Hospital "BB" on 05/19/14 R#1 was skin and bones he was so emaciated, his skin was "glow in the dark orange he was so jaundiced, his lips were dry and cracked and his tongue had an ulcer." HS "NN" said R#1 was alert but confused. His potassium level was 1.6. HS "NN" stated the emergency room Doctor stated R#1 "looks like a Zombie." HN "NN" stated R #1 had been taking a large amount of [MEDICATION NAME] and had received a [MEDICATION NAME] before leaving the facility. Review of the facility's 24 Hour Reports dated 05/01/14 through 05/19/14 revealed no documentation regarding R#1's hydration status. The facility's Physician Order's List for Scheduled Pain Medication-[MEDICATION NAME] dated 05/25/14 indicated there was one resident who received Scheduled Pain Medication-[MEDICATION NAME]. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to monitoring scheduled pain medications. As of exit on 05/29/14 at 12:05 p.m., the facility provided no further information.