Every finding on record at Permian Residential Care Center

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 in 1 of 1 kitchen reviewed for dietary services.1. The facility failed to ensure cleaning supplies were stored in a separate area from food items.2. The facility failed to ensure the microwave was cleaned.3. The facility failed to ensure no expired food items were in the kitchen. 4. The facility failed to ensure all food items in the freezer were properly labeled or stored in airtight containers. These failures could place residents at risk for food contamination and foodborne illness. The findings include: Observations during the initial tour on 12/10/25 at 11:15 AM revealed dried food on the inside top of microwave, 6 cartons of Glucerna with carb steady 8 Fluid ounces with an expiration date of August 2025, 1 container of SuperSaniCloth germicidal wipes in the same cabinet as 2 pitchers used for drinking and 1 large silver food container. During an interview on 12/10/25 at 11:25 AM, the RD stated the dietary manager was currently out of the facility and was not available. The RD stated she did not know why the expired Glucerna cartons were in the kitchen, she stated I told them not to use these, but I should have removed them. The RD stated the microwave was cleaned daily and she did not know why there was dried food on the top. Observation of the dining room freezer on 12/10/25 at 11:55 AM revealed 1 small Styrofoam container of white solid frozen substance, unlabeled, 1 small Styrofoam container of brown solid frozen substance unlabeled and the lid was partially removed, and 1 medium sized Styrofoam container of what appears to be chocolate chips uncovered and unlabeled. During an interview on 12/10/25 at 12:04 PM, the RD stated the ambassadors refilled the refrigerators and freezers in the dining room, but she did not think they put unlabeled items in the freezer. During an interview on 12/12/25 at 9:32 AM, the RD stated the dietary staff went over training often regarding storage of food items and cleanliness, but she was unable to provide an exact date. The RD stated she expected all food items in the freezer to be labeled and covered. The RD stated several ice cream cups were prepared for meals and sometimes a resident may not want it and it could be covered and put in the freezer for later. The RD stated she thought that was why the items were not labeled or covered properly. The RD stated she was not sure how the SuperSaniCloth germicidal wipes got put in the cabinet with food items. The RD stated the cabinets were not used often and someone may have grabbed the wipes off the counter and just put in the cabinet, but the chemicals were usually stored under the sink. The RD stated a potential negative outcome with dried food on the top of the microwave was cross contamination. The RD stated potential negative outcomes to food items not being covered or labeled in the freezer were the food quality not being as good or a resident could get a supplement in the food if it was not labeled properly. The RD stated a potential negative outcome to expired Glucerna in the kitchen was it could make someone sick. The RD stated a potential negative outcome to the residents with chemicals being stored with food items was the food could be dangerous if ingested. During an interview on 12/12/25 at 10:05 AM, the ADM stated she expected the sanitation and food storage to be monitored daily for food compliance. The ADM stated she did not know why the SuperSaniCloth germicidal wipes were in the same cabinet as food equipment because they were usually kept under the sink. The ADM stated the expired Glucerna may have been overlooked because none of the residents used it at this time. The ADM stated she did not know why food items were not labeled in the freezer and stated they should have been labeled. The ADM stated the kitchen staff were trained on food storage and sanitation, but it was unknown exactly when. The ADM stated there was the potential for cross contamination with improper food storage. Record review of the facility policy titled, Cleaning and Sanitizing Equipment, with a revised date of 11/3/23 reflected the following: Policy Statement/Purpose - There will be standards to ensure proper cleaning and sanitizing of equipment to prevent bacterial growth and contamination of food.Responsibility: All F&N[Food and Nutrition] personnel are responsible for proper usage, cleaning and disinfecting of kitchen tools and equipment.Procedure: 1. Equipment and utensils are direct food contact surfaces; it is important that they be cleaned thoroughly and sanitized regularly. Record review of the facility's policy titled, Food Storage, with a revised date of 12/20 reflected the following: Purpose: To establish guidelines for storing, thawing, and preparing food.Policy: Food items will be stored, thawed, and prepared in accordance with good sanitary practice.Procedure:.II. Frozen Meat/Poultry and Food Guidelines.C. Storage: Store items promptly at 0 degrees Fahrenheit or below. Foods should be stored in their original containers if designed for freezing. Foods to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers.i. Label and date all food items.XIII. Dry Storage Guidelines:.K. Cleaning supplies must be stored in a separate area away from food.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice for 1 (Resident #39) of 5 residents reviewed for respiratory care. The facility failed to ensure Resident #39 had a physician order for oxygen therapy. This failure could place residents at risk for oxygen toxicity and respiratory compromise. Findings included: Record review of the admission record for Resident #39 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (decline in mental ability severe enough to interfere with daily life), pneumonia (lung infection), and hypoxemia (low oxygen in the blood). Record review of the comprehensive MDS assessment for Resident #39, dated 11/10/25, revealed Resident #39 received oxygen therapy while being a resident at the facility. The MDS further revealed Resident #39 had a BIMS score of 09, indicating moderately impaired cognition. Record review of the comprehensive care plan for Resident #39, undated, revealed Focus - The resident has PRN oxygen therapy r/t SOB. Interventions - Oxygen settings: O2 at 2L/min via NC as indicated with an initiation date of 11/21/25. Record review of the order summary report for Resident #39, dated 12/11/25, revealed no active orders for oxygen therapy. Observation on 12/10/25 at 1:45 PM revealed Resident #39 sitting in a recliner chair in her room with oxygen on via NC at 2LPM via NC. Interview on 12/10/25 at 1:47 PM, Resident #39 stated she used oxygen therapy at all times due to a recent respiratory infection. Observation on 12/11/25 at 3:58 PM revealed Resident #39 sitting in a recliner in her room with oxygen therapy on via NC at 2LPM. During an interview on 12/11/25 at 4:01 AM, LVN A stated Resident #39 was admitted to the facility on oxygen. LVN A stated she did not know why Resident #39 did not have a physician order for oxygen and stated she assumed one was in the chart. LVN A stated those orders were usually put in the chart when the resident was admitted to the facility. LVN A stated a potential negative outcome to the resident with not having a physician order for oxygen was the resident could not need the oxygen and she could get too much oxygen. During an interview on 12/12/25 at 10:00 AM, the DON stated residents should have orders in place for oxygen therapy. The DON stated the admitting nurse looked over the oxygen orders for Resident #39 and that was why it was missed. The DON stated she was responsible for ensuring residents who received oxygen therapy had physician orders. The DON stated the nurses were trained on admission orders and usually 2 nurses signed off on the orders. The DON stated a potential negative outcome to the resident with using oxygen with no physician order was the residents could have adverse effects. The DON also stated it could be a medication error if oxygen was given to the resident with no physician order. During an interview on 12/12/25 at 10:05 AM, the ADM stated she expected oxygen orders to be input in PCC as the prescribing physician details. The ADM stated the admitting nurse was responsible for ensuring Resident #39 had an order for oxygen therapy. The ADM stated the admitting nurse did not put in the order for oxygen due to oversight. The ADM stated a potential negative outcome to the residents was it could cause them harm. During a phone interview on 12/12/25 at 10:13 AM, RN C stated she was the admitting nurse for Resident #39. RN C stated as the admitting nurse, it was her or the DON's responsibility to ensure the orders for oxygen were put in. RN C stated it was her oversight and that was why the oxygen order for Resident #39 was missing. RN C stated the nurses were trained constantly by word of mouth. RN C stated a potential negative outcome to the resident was another nurse could remove the oxygen from Resident #39 because there was not a physician order for it. Record review of the facility policy titled, Oxygen Administration, with a revised date of 10/10 reflected the following: Purpose - The purpose of this procedure is to provide guidelines for safe oxygen administration.Preparation - Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 1 of 2 medication carts (Medication Cart 1) reviewed. 1. The facility failed to ensure three boxes of Ipratropium Bromide/Albuterol Sulfate (a combination bronchodilator medication used to treat bronchospasm) were not expired in Medication Cart 1. 2. The facility failed to ensure 1 loose pill in Medication Cart 1 was properly labeled or stored. These failures could place residents at risk for medication errors and adverse drug reactions. The findings include: During an observation on 12/11/2025 at 11:43AM with RN B on Medication Cart 1, 1 loose white pill was found in the second drawer, unlabeled. Subsequently, 3 boxes of Ipratropium Bromide/Albuterol Sulfate were found in the middle right drawer of Medication Cart 1. Box 1 had an expiration date of June 2025. Box 2 had an expiration date of April 2025. Box 3 had an expiration date of 10/31/2025. During an interview and observation with the DON on 12/11/2025 at 11:55AM, she stated the white loose pill was Spironolactone (used to treat a variety of conditions, including heart failure, high blood pressure, fluid retention). A total of 35 expired vials of Ipratropium Bromide/Albuterol Sulfate were identified between all three boxes. During an interview with RN B on 12/11/2025 3:35pm, she stated she had been trained upon hire on how to check the medications carts. She stated she was trained to check the carts at the beginning and end of each shift. She stated she checked the carts for expired medications, organization, cleanliness and any loose pills. She stated she had not noticed the expiration on the boxes as she was looking at the pharmacy's do not use by date which was different than the expiration date. She stated she would check the medication box for the manufacturer's expiration date in the future. She stated the potential negative outcome of expired medication being in the cart could be causing an adverse reaction to the resident. She stated the potential negative outcome of loose pills in the cart could be a medication error or possible drug diversion. She stated it would be everyone's responsibility to ensure the carts were being looked through and kept up to date. During an interview with the DON on 12/12/2025 at 9:38AM, she stated training on the medication carts had been weekly. She stated the last training was approximately a year ago. She stated the training included checking medication dates for expiration and open dates, cleanliness of the cart, and keeping the carts up to date. She stated she monitored compliance by observation and being on the floor addressing concerns as they arose. She stated there were monthly checks done on the carts to order medication and restock as needed. She stated the potential negative outcome of having expired medication in the cart could be residents having an adverse effect if the medication were to be administered. She stated the potential negative outcome of loose pills in the cart could be medication errors. She stated her expectations of staff are to count the narcotic medications, keep the carts clean, and ensure all medication are accounted for. She stated the DON was responsible for the overall care of the medication carts. During an interview with the ADM on 12/12/2025 at 9:51 AM, she stated staff were trained weekly on the medication carts. She stated staff were trained to check expiration dates, and discharged resident's medications. She stated she was unsure when the last in-service or training for the medication carts had been conducted. She stated a potential negative outcome of giving residents expired medication could be not providing the residents with the intended effects. She stated the potential negative outcome of having loose pills in the cart could be the resident's medication being off on the quantity. She stated the DON was responsible for ensuring the checks on the medication carts were being completed. Record review of the facility's policy titled Storage Medications last revised on April 2007 revealed; The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received.2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.

Based on observations, interviews, and record review, the facility failed to ensure each resident's bedside, toilet, and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff area for 1 of 24 residents (Resident #10 ) reviewed for resident call system.The facility failed to ensure Resident #10's call light was within reach while she was positioned in her recliner.This failure could place residents at risk of not being able to call for assistance in emergency situations, a delay in care and services, and increased risk of falls and/or injuries. Findings include:Record Review of Resident #10's face sheet, dated 12/11/2025, revealed an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction unspecified (blood flow to the brain is disrupted due to issues with the arteries that supply it), Confusion Arousals (when some parts of the brain stay asleep while others wake up due to interrupted sleep), Unqualified Vision Loss (both Eyes) (inability to see clearly without any specific reason or underlying cause), Chronic Pain, Dysphagia following Cerebral Infarction (swallowing disorder that may occur after a stroke), and Weakness.Record review of Resident #10's Annual MDS assessment, dated 02/12/2025, revealed under Section C, Cognitive Patterns, a BIMS score of 00 indicating the resident's cognition was severely impaired. The MDS assessment indicated under Section GG Functional abilities GG0170, Resident #10 was dependent in the following areas: roll left and right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and tub/shower transfer.Record Review of Resident #10's Care Plan dated 02/26/2025, revealed the following focus areas: The resident has an ADL self-care performance deficit r/t Limited Mobility, Cerebral Infarction. The intervention area revealed the following: TRANSFER: Total Dependance with Hoyer lift X 2 staff members; Encourage the resident to use bell to call for assistance and within reach. Focus area: The resident is at risk for falls r/t weakness, Unaware of safety needs. The intervention area revealed the following: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance Record Review of Resident #10's physician orders dated 12/11/2025 revealed the following diagnoses: CEREBRAL INFARCTION, UNSPECIFIED, WEAKNESS, DYSPHAGIA FOLLOWING CEREBRAL INFARCTION, UNQUALIFIED VISUAL LOSS, BOTH EYES, CONFUSIONAL AROUSALS, and OTHER CHRONIC PAIN.During an observation and interview on 12/10/2025 at 10:00 AM, revealed Resident #10 was lying in her recliner in her room, alone without staff, approximately 6 feet away from her call light. The call light was observed clipped to her privacy curtain, next to her bed. The call light was out of reach from the resident's bed as well as the resident's recliner. Resident #10 stated she was in pain and wanted the surveyor to obtain assistance for her from staff. Resident #10 stated she was unable to stand on her own for fear of falling. Resident #10 stated she was supposed to call for staff assistance for all of her needs, as the worst thing that could happen to her, would be to fall. Resident #10 was not aware of where her call light was. CNA B responded after the surveyor pressed the call light for assistance. CNA B stated the call light should have been within the resident's reach, and she repositioned the call light within Resident #10's reach. CNA B stated she was uncertain why Resident #10's call light would have been clipped to her privacy curtain and not within reach. CNA B stated Resident #10 was unable to stand or transfer herself. During an interview on 12/12/2025 at 10:20 AM, CNA A stated she worked with Resident #10 frequently. CNA A stated she was not in the facility on 12/10/2025, and she did not know why Resident #10 did not have her call light within reach that morning. CNA A stated Resident #10 depended on staff for all transfers and most activities of daily living. CNA A stated Resident #10 would not have been able to reach her call light if it was clipped to her privacy curtain and she was lying in her recliner. CNA A stated Resident #10's call light should have always been within reach while she was in her bedroom, but she stated Resident #10 would frequently call out for help when she needed assistance. CNA A stated Resident #10 was able to use her call light, but she became confused at times also and would call out for help if needed instead of using the call light. CNA A stated she received frequent training regarding call lights at their monthly meetings and upon hire. CNA A stated the expectation was for all residents to have their call light accessible to ensure they could call for assistance when needed. CNA A stated if a resident did not have access to their call light, the resident may have been at risk of not receiving assistance when needed. During an interview on 12/12/2025 at 10:41 AM, the ADM stated all nursing staff were responsible for ensuring residents' call lights were within reach of the resident while in bed or in other positions in their bedrooms. The ADM stated she was not aware Resident #10's call light was not within her reach while she was in her recliner on the morning of 12/10/2025. The ADM stated Resident #10 depended on staff for all transfers and most activities of daily living. The ADM stated Resident #10 became confused at times and had trouble using her call light, but she stated the call light should still have been within reach. The ADM stated it was her expectation that nursing staff made frequent rounds to check on Resident #10. The ADM stated it was her expectation that all residents had access to their call light, and it should be within their reach at all times when they were in their bedrooms. The ADM stated staff were trained frequently on call lights, upon hire and at least annually. The ADM stated the last training staff received was in October 2025. The ADM stated there was a risk to Resident #10 not being able to notify staff if she needed assistance if her call light was not within reach. During an interview on 12/12/2025 at 11:05 AM, the DON stated she was not aware Resident #10's call light was not within her reach on the morning of 12/10/2025. The DON stated Resident #10 was dependent on staff for most of her activities of daily living. The DON sated Resident #10's cognition was better some days, but she could become confused often. The DON stated staff received training often regarding call lights, and she recalled the last in-service was in October 2025. The DON stated all nursing staff received training upon hire regarding call lights as well as annually, but they also completed in-service training as needed throughout the year. The DON stated it was her expectation that all residents had access to their call lights if they were in bed or sitting in another area of their room, so they would have access to contact staff if they needed assistance. The DON stated whoever assisted with transferring the resident to her recliner, should have placed Resident #10's call light within reach. The DON was unsure which staff transferred Resident #10 to her recliner that morning (12/10/2025). The DON stated there was a risk to residents if their call light was not within their reach, as they may not be able to call for help if they needed assistance. Record review of the facility's document, In-Service Training Report, Dated 10/08/2025, revealed the following: Call Bell Policy:Residents rely on staff to respond to call bells promptly. Timely responses: Reassure residents that they are in a safe and attentive environment Ensure needs are met without unnecessary delay Demonstrate respect and professionalism in caregiving

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 in 1 of 1 dining rooms reviewed for dietary services. LVN A failed to properly serve a beverage to Resident #39 during the noon meal service. LVN B failed to properly serve beverages to Resident #3 and Resident #61 during the noon meal service. LVN C failed to properly serve a beverage to Resident #8 during the noon meal service. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Observations were made on 09/25/24 during noon dining services and revealed the following: At 11:50 AM, LVN A picked up a glass of ice water from the serving area and took it to Resident #39 who was seated at the dining table. LVN A did not wear gloves or use hand sanitizer prior to serving the glass of water. LVN A's hand placement was over the top of the glass and her fingers touched the top of the glass where the resident would drink from. Resident #39 drank from the glass after it was placed in front of her. At 11:53 AM, LVN B picked up a glass of ice water from the serving area and took it to Resident #3 who was seated at the dining table. LVN B's hand placement was over the top of the glass and her fingers touched the top of the glass where the resident would drink from. Resident #3 drank from the glass after it was placed in front of her. At 12:15 PM, LVN B picked up a glass of ice water and took it to Resident #61 who was seated at the dining table. While serving Resident #61, LVN B did not wear gloves or use hand sanitizer prior to serving beverages. LVN B's hand placement was over the top of the glass and her fingers touched the top of the glass where the resident would drink from. Resident #61 drank from the glass after it was placed in front of him. At 12:09 PM, LVN C picked up a glass of ice water from the serving area and took it to Resident #8 who was seated at the dining table. LVN C did not wear gloves or use hand sanitizer prior to serving beverages. LVN C's hand placement was over the top of the glass and her fingers touched the top of the glass where the resident would drink from. Resident #8 drank from the glass after it was placed in front of him. In an interview on 09/25/24 at 4:21 PM with LVN C, she stated she was usually in the dining room during mealtime and helped pass beverages and trays. She stated she did handle Resident #8's glass improperly and that the glass should only be carried from the side. She stated she had not been trained specifically on food service, but she had been trained on cross-contamination by nursing administration. She stated a potential negative outcome of failure to properly serve food and beverages was the transfer of germs. In an interview on 09/25/24 at 4:27 PM with LVN B, she stated she was usually in the dining room during mealtime and helped pass beverages and trays. She stated she did handle Resident #3 and Resident #61's glasses improperly and that the glass should only be carried from the side. She stated she had been trained on proper passing of food and drinks during mealtimes. She stated she was trained approximately quarterly by nursing administration on avoiding cross-contamination. She stated a potential negative outcome of failure to properly serve food and beverages was the transferring of germs to residents. In an interview on 09/25/24 at 4:48 PM with LVN A, she stated she was usually in the dining room during mealtime and helped pass beverages and trays. She stated she did handle Resident #39's glass improperly and that the glass should only be carried from the bottom. She stated she had been trained on proper handling of drinking glasses through infection control training conducted quarterly by nursing administration. She stated a potential negative outcome of failure to properly serve food and beverages was infection, cross-contamination and getting someone sick. In an interview on 09/26/24 at 10:22 AM with the ADM, she stated the facility policy for serving foods and beverages was to follow proper infection control practices. She stated placing a bare hand over the glass while serving a beverage was incorrect hand placement and it should be carried from the side of the glass. The ADM stated staff had been trained on proper infection control practices during dining times through annual in servicing and proficiency checks. She stated anything that a staff member touched should not come in contact with the resident's mouth and hand sanitizing should be observed between residents. She stated a potential negative outcome of failure to properly serve food and beverages was the spread of infection. In an interview on 09/26/24 at 10:45 AM with the DON, she stated the proper delivery of beverages to a resident was to carry the glass from the side, not over the top. She stated staff had been trained on proper infection control practices to utilize during dining times through hand hygiene training and infection control competency checks. She stated nursing administration was responsible to conduct staff training annually and as needed. The DON stated her expectation of staff for proper food and beverage service during mealtimes was to observe hand hygiene and infection control practices. She stated a potential negative outcome of failure to properly serve food and beverages was the spread of infection. Record review of facility-provided policy titled, Dining Services Standards, revised 12/2020 revealed: Purpose Residents are provided a positive meal experience. Policy The facility staff will ensure the residents are provided with a positive meal experience Procedure 3. All staff involved with meal service is trained on the general server competencies, including safe food handling practices 4. Proper handwashing and glove usage are utilized when serving food to patients/residents. No bare hand contact is made with ready to eat food. 5. Dining service standards apply to all areas where patients/residents are served meals and are divided into dining room service and in-room service.

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 17 residents (Residents #41 and #44) reviewed for infection control. 1. The facility failed to display transmission-based precaution signs for Resident #44 who was Covid positive on 9/25/24. 2. Housekeeper D failed to utilize personal protective equipment (PPE) when entering Resident #44's room who was Covid positive on 9/25/24. 3. LVN A staff failed to utilize hand hygiene practices during medication administration on 9/25/2024 for Resident #41. These failures could place residents at risk for infection and cross contamination. The finding included: Resident #44 Record review of undated face sheet revealed Resident #44 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #44 had a medical history of extraarticular fracture of lower end of right radius (bone fractures to the long bone of the arm), anemia (low iron in the blood), hypotension (low blood pressure), retention of urine and heart failure. Resident #44 had a diagnosis of Covid-19 (an acute disease in humans caused by a coronaviru) on 9/17/2024. Record review of Resident #44's care plan dated 9/17/2024 revealed, The resident has a Respiratory Infection Covid 19. Interventions for respiratory infection included, Emphasize good hand washing techniques to all direct care staff. Encourage fluid intake. Resident remains on contact and droplet isolation d/t COVID + status per CDC guidelines. Care plan revealed Resident #44 had a foley catheter and was placed on enhanced barrier precautions dated 7/19/2024. Resident #44 care plan reflected an intervention stating, ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Record review of Resident #44's admission MDS dated [DATE], Section C- Cognitive Patterns revealed she had a BIMS score of 14, which indicated Resident #44 was cognitively intact. Record review of Resident #44's physician orders revealed an order dated 9/17/2024, resident in contact/droplet contact isolation r/t COVID + status per CDC guidelines. Physician order dated 7/19/2024 revealed an order for enhanced barrier precautions. Record review of Resident #44's progress notes dated 9/17/2024 revealed, Resident Complains of sore throat, runny nose, malaise. Test was positive for Covid. Precautions initiated. During an observation of Resident #44's bedroom door on 9/25/2024 at 11:04 AM revealed there was an enhanced barrier precaution sign taped to the door. The sign reflected information on what to do prior to entering the room, Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high contact resident care activities. Dressing, bathing/showering, transferring, changing linen, providing hygiene, changing briefs, or assisting with toileting device care or use, wound care. A red sign with the word hot was noticed taped to the door below the EBP sign. Gowns, gloves, and N95 mask were available outside of Resident #44's room. No face shields were noted. No contact precautions or droplet precautions signs were noted on the door. During an observation of Resident #44's room on 9/25/2024 at 1:48pm, Housekeeper D was observed exiting Resident #44's room with an N95 mask in place. Housekeeper D, returned into the room with the N95 mask and no other PPE, to grab her cleaning supplies. Resident #41 Record review of undated face sheet revealed Resident #41 was a [AGE] year-old male, admitted to the facility on [DATE]. Resident #41 had a medical history of heart failure, chronic pain, hypertension (high blood pressure), and contractures (hardening or tightening of the muscles or tendons) of the right forearm and right lower leg. Record review of annual MDS dated [DATE] revealed Resident #41 had a BIMS score of 11 which indicated Resident #41 had moderate cognitive impairment. Record review of Resident #41's physician orders revealed an order for Voltaren External Gel 1% to be applied to the right ankle. During an observation on 9/25/2024 at 8:32 AM, LVN A grabbed Resident #41's Voltaren Gel medication and a pair of clean gloves. LVN A entered Resident #41's room, donned the clean gloves, removed residents' protective pad from the right leg, removed his sock, and applied the cream to the right foot. LVN A put Resident #41's sock back on, readjusted his pants leg, and the soft pad. LVN A doffed dirty gloves and exited resident #41's room with trash bag. LVN A walked down the hall to the biohazard room to discard trash bag and returned to the medication cart. LVN A failed to utilize hand hygiene prior to entering the room, before donning gloves, after doffing gloves, when exiting room and after discarding trash in the biohazard room. During an interview with LVN A on 9/25/2024 at 4:48pm, she stated she had been trained on handwashing. She stated the DON and ADON were responsible for handwashing training. LVN A stated the potential negative outcome from failure to properly sanitize hands could be spreading illness and germs. She stated she should have washed her hands after applying the medication. During an interview with Housekeeper D on 9/26/2024 at 9:26 AM, she stated she had been trained on infection control but did not remember when. She stated the DON had showed her how to use the CAPR system (air-purifying respirator) on 9/26/2024 but prior to that she had not been trained to use it. She stated the housekeeping supervisor was responsible for her training on infection control. She stated the housekeeping supervisor would let the housekeeping staff know if there was a resident who was on transmission-based precautions. Housekeeper D stated she had donned the gown, gloves and an N95 mask prior to entering Resident #44's room and before she exited, she removed the gown and gloves but not the N95 mask. She stated she forgot to grab one of her cleaning supplies and reentered the room with only the N95 mask. She stated she did see the red signs on the door that said hot, and it indicates to staff that the resident was covid positive. She stated she did not wear the face shield when she went in, and no one had told her that she needed a face shield. She stated it was not until 9/25/24 that she was told she had to wear the CAPR system. She stated she followed the sign on the door on what all to wear, and if there had been a sign stating to wear a face shield, she would have followed those steps. She stated the potential negative outcomes of not utilizing the proper PPE could be spreading the infection to another resident or another person in the facility. She stated she had not had any training on PPE prior to 9/25/24. She stated she had training upon hire, approximately 3 years ago, but nothing since. She stated the DON had taught her about the CAPR system today (9/26/2024) and was told that would be the only system to use for face shield and then the gown and gloves. She stated she did see the red hot sign and how to dress on the EBP signs. She stated she followed what was posted on the door for PPE usage. During an interview with the Housekeeping Supervisor on 9/26/2024 at 9:26 AM, she stated her staff only go by what they know, and they had not had anyone training them on infection control. She stated they are given a piece of paper that shows them what they must do but they are not trained on how to do it. She stated the papers for example will state to take off the gloves, but they do not know if there was a proper way to take the gloves off. She stated she had spoken to the infection preventionist at the hospital for guidance on 9/26/24. She stated her goal is to have her staff trained correctly. She stated they had not been trained on how to don and doff PPE. She stated there is not one person designated to calling her and notifying her if a resident was on TBP and she will get calls from different people, but it was not always the DON. She stated she did not know what the red signs with the word hot meant. She stated they had been told the signs on the doors would show what they needed to wear or what PPE they needed. She stated the potential negative outcome could be the housekeepers spreading whatever that resident had and spreading it to the facility. The Housekeeping Supervisor stated prior to 9/26/2024, her staff had not been trained on the CAPR system. She stated back in 2019, they had been trained on the CAPR system at the hospital but have not had any training since. During an interview with the DON on 9/26/2024 at 10:21 AM, she stated she is the infection preventionist. She stated she and the ADON do most of the handwashing training and treatment nurses can help as needed. She stated staff are trained to wash their hands after removing their gloves but sometimes they get nervous when they are being observed. She stated staff are expected to wash their hands or use hand sanitizer between residents' medication administration and between residents. She stated the potential negative outcome of not utilizing proper hand hygiene could be infections. The DON stated for residents who are covid positive, staff are trained to use the CAPR system, gowns, and gloves and if the CAPR system is not available the N95 mask and a face shield. She stated the housekeeping staff are trained to use PPE for TBP upon hire and annually for the hospital. She stated she did not train housekeeping staff this last time that there was a covid positive on 9/17/2024 and the potential negative outcome could be spreading the infection. The DON stated the facility had a mock survey conducted, unsure of date, and there had been a suggestion to take the TBP signs off the door because the signs needed to be clear for visitors to talk to the nurse and the signs could be a violation of HIPPA. She stated they could not find any documentation regarding that recommendation. The DON stated when there is a new covid positive resident, all departments are notified such as the kitchen, laundry, and housekeeping. She stated sometimes she will call, or she will have the business administrator make those notification. She stated the potential negative outcomes of not having the proper signage on the door could be people not understanding or spreading infection unintentionally. She stated the hot sign indicates when a resident is covid positive. She stated compliance was monitored by having the nurse managers go up and down the halls frequently and correct anything that is not being done correctly immediately and retrain as needed. She stated training was done with the staff's yearly competency . The DON stated handwashing monitoring and training was done the same, yearly with competencies and as needed. During an interview with the ADM on 9/26/2024 at 10:46 AM, she stated the DON was responsible for handwashing training . She stated staff are trained annually and upon hire and as needed. She stated staff are expected to wash their hands between medication administration and after removing gloves with either soap and water or alcohol-based hand sanitizer. She stated the potential negative outcomes of not utilizing proper hand hygiene could be spreading infection. The ADM stated staff are trained to use gown gloves and the CAPR system for Covid Positive residents. She stated if the CAPR system was not available, they would use the N05 mask and face shield. She stated housekeeping is trained by the staff development coordinator at the hospital and the infection preventionist at the hospital. She stated the potential negative outcome of not utilizing the proper PPE could be spreading infection. The ADM stated they had an organization (TMF iCare), that did a mock survey and they recommended to do zones for Covid. She stated they had been told that isolations signs could be a HIPPA violation. The ADM stated they tried to go back and find something in writing, but they had not been able to find it. She stated this had been within the last year. She stated they would be going back to the visual signs for what PPE to use for those rooms. She stated the potential negative outcomes of not having the proper signage on the door could be spreading infection. The ADM stated audits for PPE and handwashing are done by shift and staff are observed going into and exiting out of those rooms. She stated training on handwashing and PPE was done annually and upon hire. Record review of facility policy titled Handwashing/Hand Hygiene last revised August 2015 revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; c. Before preparing or handling medications; . .m. After removing gloves; n. Before and after entering isolation precaution settings. Record review of facility undated policy titled Covid + Resident revealed: .Nurse to ensure signage on door, ISO cart within area. Record review of facility policy titled Resident Isolation - Categories of Transmission-Based Precautions last revised 6/2020 revealed: I. Transmission-based precautions are used whenever measures more stringent than standard. precautions are needed to prevent or control the spread of infection . III. Contact Precautions . G. Notice i. The Facility alerts staff to the type of precaution a resident requires. ii. The Facility also ensures that the resident's care plan indicates the type of precautions implemented for the resident. iii. The Facility may utilize a sign requesting visitors to check in at the nursing station before entering a resident's room . IV. Droplet Precautions i. The Facility alerts staff to the type of precaution a resident requires. ii. The Facility also ensures that the resident's care plan indicates the type of precautions implemented for the resident. iii. The Facility may utilize a sign requesting visitors to check in at the nursing station before entering a resident's room. Record review of facility policy titled Administering Medications last revised December 2012 revealed, 22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 49305

Based on observation, interview, record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 resident (Resident #1) reviewed for accidents. The facility failed to use the appropriate transfer for Resident #1 which resulted in a positive fracture to the lower left extremity (ankle). The noncompliance was identified as past non compliance. The Immediate Jeopardy began on 02/21/24 and ended on 02/27/24. This failure could place residents at risk for harm and further injuries. The findings included: Review of Resident #1's face sheet (dated 03/01/24) indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had a diagnoses of hemiplegia (paralysis of one side of the body), osteoarthritis (degenerative joint disease) and a history of falling. Review of Resident #1's comprehensive MDS dated [DATE] revealed Resident #1 had a BIMS score of 10 which indicated Resident #1 cognition was moderately impaired. The MDS Assessment for Resident #1 revealed in section I8000 that the Resident #1 had an active diagnoses of history of falling. Section J1700 revealed that Resident #1 had not had a fall within the past 6 months before admission. Section V 0200 revealed that Resident #1 did trigger for the CAA: Falls and ADL functional/Rehabilitation. Section GG revealed that upon admission that the resident did none of the effort to completed the following ADL: chair/bed transfer, tub/shower transfer and car transfer. Review of Resident #1's care plan, dated 03/01/24, revealed the following: Date initiated: 01/03/24 Date revised: 03/01/24 Focus: The resident has an ADL self-care performance deficit r/t stroke left side hemiplegia. Goal: The resident will improve current level of function in ADLs through the review date. The resident will maintain current level of function through the review date. Interventions: The resident requires total liftx2 staff assistance for transfers non-weight bearing status related to left ankle fracture Date initiated: 02/27/24 Date revised: 02/29/24 Focus: The resident had an actual fall with serious injury. Resident had poor balance, unsteady gait, and left side deficits due to history of stroke. Goal: The resident fracture to lower leg will continue to heal without complication. Intervention: CAM boot to be removed each shift for skin check, then replaced. Evaluate for pain as needed. Resident to wear CAM boot at all time for fracture healing. Date initiated: 03/01/24 Date revised: 03/01/24 Focus: The resident is high risk for falls related to hemiplegia (paralysis of one side) Goal: The resident will not sustain serious injury through the review date. Interventions: Anticipate the resident's needs. Be sure the call light is within reach and encourage the resident to use it. Provide floor mats when in bed. PT evaluate and treat as ordered or PRN. Review of Resident #1's progress notes, from 02/21/24-02/27/24 revealed the following: On O2/21/24 at 1:50 PM Called to room by CNA, resident laying on floor on back with legs stretched out, mat behind her head. CNA states 'had to lower resident to floor due to she started sliding down during transfer from W/C to bed'. Assessed resident, no apparent injuries observed, resident denies any pain or discomfort, able to move extremities as prior and is able to function as did prior to being lowered to floor. CNA states 'the resident did not hit her head'. Notified residents Family Member at 3:17 PM, ADM and DON notified. Provider present at this time and was aware Author: RN A On O2/21/24 at 3:17 PM Received results of labs and provider reviewed. New order for Amoxicillin X 5 days for laryngitis. Notified residents family member of new orders and of resident being lowered to floor during transfer from wheelchair to bed, stated 'okay, thank you'. Will continue to monitor. Author: RN A On O2/22/24 at 2:31 PM IDT reviewed fall interventions. Continue current plan of care. Author: ADM On O2/23/24 at 9:39 AM Resident with complained of pain at a rate of 9 to the lower left extremity (LLE) this morning, upon assessment edema noted from left foot up to the left hip. Orders received for x-ray of the LLE and Venous Doppler, nurse to notify provider upon receive of results. Resident did not eat breakfast this morning and was assisted back to bed. Author: LVN G On O2/23/24 at 5:30 PM Venous Doppler results received, new order noted for Lovenox 40mg SQ BID x 7days, to start Eliquis 5mg 1 PO BID, Family Member in facility, verbalized understanding for new orders. Author: LVN G On O2/23/24 (Time not indicated) Resident continues on active charting due to assisted fall to the floor with no injuries. Also on active charting due to new order for Amoxicillin for DX: Laryngitis. Resident was resting in bed with eyes closed. Respirations are even and non labored. No signs and symptoms of distress noted. Call light and fluids are within reach. Bed is in lowest locked position for residents safety. Staff will continue to monitor for changes or needs this shift. Plan of care ongoing. Author: LVN F On O2/25/24 at 3:03 AM Give 1 tablet by mouth every 6 hours as needed for Pain - Moderate. Author: LVN E On O2/26/24 at 9:52 AM IDT reviewed Resident #1's fall. Resident #1 was lowered to the ground while being transferred by CNA. Transfer status reviewed, will continue plan of care to transfer x2 staff Author: ADM On O2/26/24 at 6:50 PM New order for X-Ray to left ankle d/t tenderness and redness to area. Family notified. Results pending. Author: LVN D On O2/26/24 at 7:56 PM FNP in facility visiting and assessing the resident. The resident continued to have edema to left lower leg with increased tenderness to left ankle area. X-ray ordered and provider reviewed images, it appears for resident to have a fracture to left ankle. New order for resident to be NPO after midnight. Physician C contacted family. Author: RN B O2/27/24 at 12:49 PM Resident went to the Podiatrist by staff via gerichair for fracture. Returned with the orders to keep CAM Boot to Left Lower Extremity, Re-xray in 3 weeks. There was no apparent distress at this time. Staff will continue to monitor. Author: RN A Record review of the provider investigator report (3613) dated 03/01/24 revealed the following: Allegation: CNA A was assisting Resident #1 in transfer and had to lower her to the floor when Resident #1 started to slide down during the transfer. Provider Response: Swelling and tenderness started 2/23, resident positive for DVT. Symptoms continued, x-ray showed positive fracture 2/26. CNA transferring at time of fall was suspended. Parties notified: family, physician, DON, administrator Investigation Findings: Confirmed Provider Action Taken Post-Investigation: Re-education, mentor assignment, minimal 3 week transfer observations, 100% audit of transfer status Investigative Summary: 2/21/24 - NA H was assisting Resident #1 in transfer and had to lower her to the floor when NA H started to slide down during the transfer. RN A assessed and found resident was able to move extremities as prior level of function and resident denied pain or discomfort. Notification was made to DON, Administrator and provider and family. RN A gave immediate re-education to NA H on transfer status as Resident #1 should have been transferred with the assistance of 2 people. Formal re-education was given by RN Q and LVN R to aides working with Resident #1. 2/23/24 - Resident #1 complained of pain (9) to the left lower extremity, upon assessment edema noted from left foot up to the left hip. Orders received from, X-Ray of the left lower extremity and Venous Doppler. Venous Doppler results received positive for DVT, new order noted for Lovenox 40mg SQ BID x 7days, to start Eliquis 5mg 1 PO BID, D/C ASA per provider, Son notified. Provider stated X-ray to left lower leg cancelled due to positive DVT. [family member]in facility and verbalized understanding of new orders. Resident #1 is to remain on bedrest and use lift for transfers. 2/26/24 - Provider ordered x-ray to left ankle due to tenderness and redness to the area. XRay result was positive for ankle fracture. Order received for NPO after midnight and arrangements made to see podiatrist in the morning. Upon discovery of fracture, aide was suspended pending investigation. 2/27/24 - Podiatrist diagnosed a bimalleolar fracture to the left ankle. Resident has been bound with CAM boot in place to left lower extremity. Podiatrist and Provider indicated the resident was not a candidate for surgery, [family member] agrees. Resident has been medicated for pain with Tramadol and Tylenol prn. 1:1 counseling was completed by DON before NA H provided patient care. ADM and DON reviewed the incident. On 1/24/2024 all staff including aide involved were educated on fall prevention, care plan and Kardex use. 2/27/24 a complete audit of transfer status was completed by DON. A in-service started re-educating all CNAs on Kardex transfer status and compliance. Transfer competencies completed by nurse managers on all CNAs. In order to achieve/maintain compliance, nurse managers will observe 3 transfers per day Monday through Friday for 3 weeks and floor nurses will complete 3 transfer observations twice daily for 3 weeks or until substantial compliance is achieved. Upon discovery of fracture, aide was suspended pending investigation. 1:1 counseling was completed by DON before NA H provided patient care. The administrator and DON acknowledge the transfer status was not followed appropriately. NA H acknowledges she made a mistake and failure to read the Kardex caused the fall. While injury did occur, it was not intentional rather a mistake was made and therefore, abuse is unsubstantiated. A review of NA H performance, attitude and aptitude have been considered by the management team. NA H has demonstrated compassion, care, and willingness to learn. She will be paired with a mentor for 4 weeks with a weekly nurse manager review. NA H was advised that any further failure to follow a resident's Kardex will result in termination. An interview on 03/07/24 at 3:55 PM with Resident #1 revealed that she did not know how she fractured her ankle. She said that she was not in any pain at the time of the interview. She said the staff at the facility were nice to her, and she had no concerns. She said staff usually clip her call light or lay it near her. She said the only downside was now having to wear a brief and be changed because she could go to the restroom on her own before. She said she had COVID and wanted to rest. Observation on 03/07/24 at 3:55 PM, Resident #1 was observed lying in bed. Her bed was in the lowest position, and a floor mat was on the side of the bed. She had a CAM boot on her left ankle. An interview with NA H on 03/13/24 at 10:30 AM revealed that she no longer worked at the facility. She said that due to the incident, she was no longer confident in her ability to transfer residents safely. She said this was a decision that she made on her own. She said that she was bringing Resident #1 back from labs. She said she got her as close to the bed and locked her wheelchair. She said it slipped her mind that she was weak on her left side, and that was the side that she transferred on. She said she used the gait belt. She said she thought she was a one-person transfer at the time. She said that when Resident #1 first arrived, she was a two-person with the Hoyer, then went to a two-person without the Hoyer. She said she thought she was a one-person transfer with the gait belt. She said that after she saw that Resident #1 was sliding down, she eased her to the floor and placed the floor mat behind her to make her comfortable. She said she looked out of the room and asked her coworkers for help. She said they told her to get a nurse. She said she did, and after Resident #1 was assessed, they were permitted to transfer her to the bed. She said that she was immediately counseled that she was a two-person transfer. She said that during the nurse assessment and transfer into the bed, the resident did not indicate that she was in pain at the time of the incident. She said she was counseled and retrained at least twice and had to demonstrate that she knew where to find resident transfers and that she could safely transfer using the gate belt, a second person, and the Hoyer lift. An interview on 03/07/24 at 2:36 PM with CNA J revealed she had worked with Resident #1 but does not have any firsthand information about the incident that occurred with NA H. She said she was working with another patient when NA H asked her for assistance. She said she walked into the room and observed Resident #1 on the floor. She said she advised NA H to get the nurse. NA H explained that she had to sit Resident #1 down. She said the nurse conducted her assessment and then had them transfer Resident #1 to the bed. She said Resident #1 did not appear to be in any pain when she arrived in the room. She said Resident #1 looked at her and smiled when she walked into the room. She said that Resident #1 did not appear to be in pain during the transfer. She said NA H did not express why she transferred Resident #1 alone. She said she had never transferred Resident #1 alone because she required two people. She said she had been trained and had to demonstrate her knowledge and use of the gait belt and where to find the transfer in the computer and the Hoyer lift. An interview with the ADM on 03/07/24 at 12:37 PM revealed that she investigated the incident involving Resident #1 and NA H. She said she found that on 02/21/24, NA H was assisting Resident #1 in a transfer when she had to assist her down to the floor. She stated that a nurse assessed Resident #1. She stated that Resident #1 did not exhibit any signs of pain at the time of the incident. She stated the family, and the physician were notified of the incident. She stated that NA H was counseled immediately due to the incident because there should have been two staff to complete the transfer for Resident #1. She stated that two additional superior nursing staff later counseled NA H about transfer status. She stated the staff continued to monitor Resident #1. She stated on 02/23/24, Resident #1 was complaining of pain at a 9. She stated that the staff noticed that she had edema from her left foot up to her left hip. She stated that this information was reported to the provider, and an X-ray and Doppler were ordered. She stated because of the findings of a DVT then, they held off on the X-ray because I believed the issue had been found. She stated that Resident #1 had been notified of the finding. She said Resident #1 was to remain on bed rest, and the transfer had been upgraded to using the Hoyer lift. She said 02/26/24 an X-ray was conducted, and an X-ray was found. She stated the provider was notified and ordered that she be NPO on this date to see the podiatrist the next day (02/27/24). She said the podiatrist confirmed the fracture on 02/27/24. The podiatrist stated that Resident #1 was not a candidate for surgery. She said once the fracture was confirmed NA H was suspended. She said the DON provided one-on-one training before they allowed NA H to return. NA H was brought back to the facility on [DATE]. As a result of the incident, she said that education was provided to 100 percent of all certified nurse aides. She stated that 6 transfers are monitored per shift moving forward. She said that during the training of all NAs, they had to demonstrate back their ability to do a proper transfer. She stated that the wrong transfer was used, but they unsubstantiated their investigation for abuse because it was unintentional. She said NA H was an aide who had shown much promise and had no issues before the incident with Resident #1 or other residents. She said that in addition to the training provided, they partnered NA H with a mentor. NA H ultimately decided she no longer wanted to be an aide and resigned. She said when she asked NA H why she chose to transfer Resident #1 on her own, she was told by NA H that she had seen other staff transfer that way. The ADM said Resident #1 was a fall risk before the incident. The ADM indicated that NA H had completed the certified nurse aide course and was waiting to take her test and was able to provide services to the residents in the facility. An interview with the DON on 03/07/24 at 12:38 PM agreed with what the ADM said happened between NA H and Resident #1. She said that due to the incident, nurses are rounding more frequently and observing transfers throughout the day. She said the nurses had to sign off and verify that the CNAs were using the proper lift. She said before the incident, she required two people to assist her in transferring, but now she still needed two people, and the staff should be using the Hoyer lift. She said when the Doppler picked up the DVT (blood clot), they thought they had found the problem. When they observed the redness and swelling, they got an X-ray. She said at the time of the incident, the X-ray and Doppler were not done because the resident did not show any signs of pain, and there was no swelling. An interview with RN A on 03/15/24 at 12:18 PM revealed that she was the nurse on duty on the day when Resident #1 fell . She said she was unsure of the exact date because she was PRN. She said she did know that it was in February of 2024. She said she got called to Resident #1's room by staff. She said she did not know the name of the staff. She said Resident #1 was propped up on the closet door when she arrived with a cushion behind her. She said she assessed the resident and found nothing indicating that Resident #1 was in pain or had injuries. She said the assessment included taking her vital signs, asking her if she was in pain, and if she could move her upper and lower extremities. She said Resident #1 was not in pain and that she and another staff member had transferred her to bed. She said she rechecked her for bruises and swelling and saw nothing. She said she notified the ADM, DON, provider, and family of the incident. She said she spoke with the staff member who initially transferred her and asked what happened. She said the staff told her she was attempting to transfer her, but Resident #1 started going down. She said that when Resident #1 started falling, she eased Resident #1 to the floor. RN A said she was told that Resident #1 did not hit her head. She said that she asked if the staff knew where to go to find the residents' transfers and that the staff told her no. She said that she reported this information to management. She said that she (RN A) did not specifically know what Resident #1's transfer was but that based on her weak left side and history of a stroke, she would have assumed that she required two staff. She said she was familiar with the facility's paper version to indicate transfers, but the electronic version was new. She said that in-servicing on transfers started the day she worked when Resident #1 fell . She said that she was unaware that Resident #1 had a fracture until the day Resident #1 went to the podiatrist because that was the next time she worked. Record review of the facility in-service, ANE, Fall Prevention, Care Plan and Kardex interventions, dated 01/24/24 17 staff had been in serviced. Record review of the facility in-service, dignity, transfers/gait belts/ lift, dated 01/26/24 57 staff had been in serviced. This inservice did include NA H. Record review of NA H Nurse Aide Performance Record, dated 12/13/23-1/05/23 revealed that she had satisfactory performance for all procedural guidelines to include basic restoration services (assisting resident to transfer to chair or wheelchair) Record review of one-to one in-service for NA H, dated 02/21/24, revealed the following: Reviewed resident transfer status and Kardex location/utilization. Staff educated were able to state they do know location of Kardex information and where to find transfer status. Return demonstration of finding Kardex provided by staff. Education provided to refer to Kardex prior to transferring to ensure proper transfer status is used. (signed by NA H). Record review of Employee Counseling Report dated 02/27/24 revealed NA H was suspended until reeducation with transfers and where to find transfers status and that this decision was a result to the incident that occurred on 02/21/24 when she assisted Resident #1 to the floor. It stated the expectation was for NA H to use the Kardex to ensure proper transfer status is being used and she should follow the plan of care. It explained the next action would be termination. Record review of transfer audit dated 3/02/24-03/07/24 revealed a total of 96 audits had been observed, verified by a licensed nurse and completed appropriately. An interview on 03/07/24 at 4:28 PM with the ADM revealed there was no specific policy for incident and accident prevention but that they used the fall prevention policy. Review of the facility policy and procedure, Fall Evaluation and Prevention, dated 08/2020, reflected: Purpose To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. Policy The facility will evaluate residents for their fall risk and develop interventions for prevention. Upon Admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. The staff should not utilize a restraint to prevent falls unless they receive written documentation to support the use of the restraint. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed. INTERVENTION SUGGESTIONS FOR FALL PREVENTION Encourage resident to request assistance with transfers and ambulation. Position bed so that the exit is toward the resident strong side.

Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 1 of 18 residents (Resident #43) reviewed for care plans as follows: Resident #43 did not have a care plan for urinary incontinence, risk for fall and risk for pressure ulcers. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include: Resident #43 Record review of Resident #43's face sheet, dated 07/25/23, revealed an [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Alzheimer's disease (cognitive loss), anxiety, major depression, hypertension (high blood pressure), muscle weakness, generalized arthritis (joint pain) and pain in left hip. Record review of Resident #43's Comprehensive Minimum Data Set, dated dated [DATE], revealed Resident #43 had a BIMS score of 15 which indicated Resident #43's cognition was not impaired. The Care Area Assessment (problem areas) revealed urinary incontinence, falls and pressure ulcer was a care area that will be addressed in the care plan and was marked on the care area assessment to be care planned. Resident #43's functional status revealed he required one-person limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. If further revealed Resident #43 was not steady during transfers and required staff assistance. Resident #43 also required a wheelchair for mobility and had limited range of motion on both sides of lower extremities. Section H - Bladder and Bowel revealed Resident #43 was always continent of bowel and bladder. Section J - Health Conditions revealed Resident #43 had no history of falls in the last 6 months. Section M - Skin Conditions revealed resident was not at risk of developing pressure ulcers, but had moisture associated skin damage. It further revealed skin treatment was pressure reducing device for bed, turning/repositioning program, and applications of ointments or medications. Record review of Resident #43's care plan, dated 06/21/23, revealed no care plan for urinary incontinence, fall risk or pressure ulcer risk. During an interview on 07/27/23 at 10:15 AM with Resident #43, he stated he is occasionally incontinent of urine. He stated he required staff to assist him to the toilet at time and in/out of bed. He stated he does not move much when he is in bed and liked to lay on his back most of the time. He stated it had been a while since his last fall but that he is unsteady at times. During an interview on 07/27/23 at 10:30 AM with the MDS Coordinator, she stated everyone had a section to complete on the care plan. She stated she was responsible for section V and care planning. She stated she pulled section V sheet and made sure all triggered care areas were care planned. She stated she made a mistake and the missing care areas for Resident #43 were not care planned. She stated section V was used to form the care plan along with assessments and resident interviews. She stated there was no reason a triggered care area would not be care planned. She stated the care plan was used to inform staff on how to care for residents and meet their needs the best they can. She stated nursing and CNA's used the care plan. She stated the potential negative outcome could be proper care would be missed. She stated she does not know why the triggered care areas were missed, maybe just an oversight. She stated there were no systems in place to ensure triggered care areas were not missed. She stated her expectations were all triggered care areas were care planned. She stated she had training on how to do care plans. During an interview on 07/27/23 at 10:45 AM with the DON, she stated the IDT was responsible for the care plan. She stated her main role in the care plan process was falls, nutrition, weights, dehydration, and feeding tubes. She stated all tasks were divided up between the team. She stated Sec V and assessments were used to form the care plan. She stated there should not be any reason a triggered care area was not care planned. She stated the care plan was used to take care of resident's needs and so everyone was on the same page for the best care for the resident. She stated everyone used the care plans. She stated the CNA's use the care plan related to activities of daily living. She stated the potential negative outcome could be resident would not get their needs met. She stated the triggered care areas that were missed was an oversight and human error. She stated the IDT all have sections to complete. She stated her expectations were all triggered care areas, medications, and anything the staff needed to know for that resident to be care planned. She stated she had training on care plans. During an interview on 07/23/23 at 11:00 AM with the ADM, she stated the MDS Coordinator was specifically responsible for care planning triggered care areas on section V. She stated Section V was used to form the CP. She stated there might be some triggered care areas that were not care planned depending on the resident. She stated the care plan was used to deliver care and a comprehensive view of the resident, on how to care for the resident. She stated nurses and CNA's used care plan . She stated missed care areas that were not care planned could cause the resident to not receive care that was needed. She stated missed triggered care areas was due to human error. She stated the care plan should include relevant variances outside residents' baseline. During an interview on 07/27/2023 at 11:11 AM with RN B, she stated she was familiar with Resident #43 and stated that he was a mild fall risk. She stated she was not sure if he was at risk for pressure ulcer development or UTI development. She stated he was able to urinate on his own using the toilet and he does spend a lot of time in bed. She stated they do not necessarily pull up the care plan and go through it when planning care for a resident. She stated the risk of not having care plan focus areas and appropriate interventions for areas like risk for UTI, fall risk, or risk for PU development, was that staff may be unaware of care areas or appropriate preventative interventions. During an interview on 07/27/23 at 11:15 AM with RN A, she stated IDT was responsible for care plans. She stated her specific role was infection control. She stated the process in forming a care plan was section V, diagnosis and building care plan to be individualized. She stated there was no reason why a triggered care area should not be care planned. She stated the care plan was used for individual treatment. She stated everyone used the care plan. She stated missing care areas that were not care planned could cause the resident to be treated wrong and cause injury/ harm . She stated the triggered care areas were missed because she did not verify, they were done before signing the MDS complete. She stated they have a system in place. She stated the system will alert if triggered areas were not care planned and each IDT member was responsible for specific care areas. She stated her expectations of what should be care planned was anything that keeps the resident safe, abilities/disabilities, medications, infection and mental/physical health. She stated she has had training on care plans. During an interview on 07/27/23 at 11:22 AM with CNA A, she stated, she had worked at facility for about a year. She stated she does not use care plans for her day to day care but said care plans were in place for the wellness of the residents. She stated she would expect risk for pressure ulcer development, risk for falls, and risk for UTI to all be care planned. She stated if focus care areas like these were not included in a care plan the risk was that the resident may develop the condition if interventions are not known of by staff. She stated Resident #43 required staff assistance to transfer to wheelchair or the toilet. She stated he had incontinence episodes in his brief. Record review of the provided facility's policy titled Care Planning, revised June 2020, revealed: Purpose - to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Policy: I. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with MDS guidelines. II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. III. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed bases. Procedure: . IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; B. Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment; .

Based on interview and record review the facility failed to ensure an encoded, accurate, and complete MDS quarterly assessment was electronically transmitted to the CMS System for 8 of 8 residents records reviewed for MDS assessments. (Resident #1, #2, #3, #4, #5, #6, #10 and #47) The facility did not ensure the Quarterly MDS assessment were transmitted as required for Resident #1, #2, #3, #4, #5, #6, #10 and #47. This failure could place the residents at risk for MDS assessments not being transmitted and not receiving care and services as needed. Findings included: Resident #1 Record review of admission record for Resident #1 dated 06/15/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS for Resident #1 dated 04/26/22 revealed Section Z: Z0500 Signature of RN Assessment Coordinator Verifying Assessment Completion. B. Date RN Assessment Coordinator signed assessment as complete: 05/06/22 Record review of the CMS Submission Report dated 06/10/22 revealed Resident #1's MDS assessment dated [DATE] was transmitted on 06/10/22. Resident #2 Record review of admission record for Resident #2 dated 06/15/22 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS for Resident #2 dated 04/27/22 revealed Section Z: Z0500 Signature of RN Assessment Coordinator Verifying Assessment Completion B. Date RN Assessment Coordinator signed assessment as complete: 05/04/22 Record review of the CMS Submission Report dated 06/10/22 revealed Resident #2's MDS assessment dated [DATE] was transmitted on 06/10/22. Resident #3 Record review of admission record for Resident #3 dated 06/15/22 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS for Resident #3 dated 04/26/22 revealed Section Z: Z0500 Signature of RN Assessment Coordinator Verifying Assessment Completion B. Date RN Assessment Coordinator signed assessment as complete: 05/06/22 Record review of the CMS Submission Report dated 06/10/22 revealed Resident #3's MDS assessment dated [DATE] was transmitted on 06/10/22. Resident #4 Record review of admission record for Resident #4 dated 06/15/22 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS for Resident #4 dated 05/09/22 revealed Section Z: Z0500 Signature of RN Assessment Coordinator Verifying Assessment Completion B. Date RN Assessment Coordinator signed assessment as complete: 05/18/22 Record review of the CMS Submission Report dated 06/10/22 revealed Resident #4's MDS assessment dated [DATE] was transmitted on 06/10/22. Resident #5 Record review of admission record for Resident #5 dated 06/15/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS for Resident #5 dated 05/09/22 revealed Section Z: Z0500 Signature of RN Assessment Coordinator Verifying Assessment Completion B. Date RN Assessment Coordinator signed assessment as complete: 05/18/22 Record review of the CMS Submission Report dated 06/10/22 revealed Resident #5's MDS assessment dated [DATE] was transmitted on 06/10/22. Resident #6 Record review of admission record for Resident #6 dated 06/15/22 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS for Resident #6 dated 05/09/22 revealed Section Z: Z0500 Signature of RN Assessment Coordinator Verifying Assessment Completion B. Date RN Assessment Coordinator signed assessment as complete: 05/18/22 Record review of the CMS Submission Report dated 06/10/22 revealed Resident #6's MDS assessment dated [DATE] was transmitted on 06/10/22. Resident #10 Record review of admission record for Resident #10 dated 06/15/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS for Resident #10 dated 04/26/22 revealed Section Z: Z0500 Signature of RN Assessment Coordinator Verifying Assessment Completion B. Date RN Assessment Coordinator signed assessment as complete: 05/06/22 Record review of the CMS Submission Report dated 06/10/22 revealed Resident #10's MDS assessment dated [DATE] was transmitted on 06/10/22. Resident #47 Record review of admission record for Resident #47 dated 06/15/22 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS for Resident #47 dated 05/09/22 revealed Section Z: Z0500 Signature of RN Assessment Coordinator Verifying Assessment Completion B. Date RN Assessment Coordinator signed assessment as complete: 05/18/22 Record review of the CMS Submission Report dated 06/10/22 revealed Resident #47's MDS assessment dated [DATE] was transmitted on 06/10/22. During an interview on 06/15/22 at 09:05 AM, MDS Coordinator stated she was responsible for transmitting completed MDS to CMS. She stated the quarterly MDS assessments should be transmitted 14 days after completion. She stated the quarterly MDS assessments for Resident #1, #2, #3, #4, #5, #6, #10 and #47 were submitted late and verified all quarterly MDS were submitted on 06/10/22. MDS Coordinator stated they were submitted late because it sometimes gets chaotic with people out of the office and not being able to get the MDS assessment completed. She stated the negative outcome for late submissions could be a rejected MDS assessment. During an interview on 06/15/22 at 09:40 AM, RN Nurse Manager stated she was responsible for signing MDS assessments once they have been completed. She stated she signs MDS on Thursday and Fridays each week. She stated the MDS Coordinator was responsible for transmissions. During an interview on 06/15/22 at 10:01 AM, Administrator stated the MDS Coordinator was responsible for transmitting MDS assessments timely. She stated the negative outcome could reflect negative quality measures and wrong payment. Record review of the CMS's RAI Version 3.0 Manual CH: 5 Submission and correction of the MDS Assessments dated October 2019 provided by the facility revealed: Transmitting Data: Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 2 of 20 residents (Residents #25 and 103) reviewed for care plans as follows: Resident #25 did not have a care plan for behavior. Resident #103 did not have a care plan for cognitive loss and communication. These failures could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Resident #25 Record Review of Resident 25's face sheet dated 06/14/2022 documented an [AGE] year-old male admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] Record Review of Resident #25's comprehensive annual MDS (Minimum Data Set) dated 12/27/2021 documented the following: Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 04 severely cognitively impaired (Alert and Oriented x time, place, person). Section E Behavior- E0900. Wandering- Presence & Frequency 1. Behavior of this type occurred 1 to 3 days Section V - Care Area Assessment Summary (9) behavior Record Review of Resident #25's Care Plan dated 12/27/2021 did not reveal a care plan for behaviors. During an interview with the MDS Coordinator on 06/07/2022 at 3:30 PM, She stated after reviewing the care plan for Resident #25 that, she did not see a care plan for behavior. She said initially that she did not know why the care plan was not done and that she attributes this missing care plan to the facility not having a social worker. She stated that she was focused on her responsibilities with the care plan. She said initially that she was unsure what the negative outcome would be for Resident #25. She later stated that the negative effect on the resident could leave the facility. She said there had been care plan meetings, and this should have been caught, and she cannot explain why this was not caught before. During an interview with the DON on 06/15/2022 at 8:58 AM, she stated everyone in the facility uses the care plan. She stated the care plan was a plan that was used for the resident to maintain or improve in important areas of their life. She said she does not have a reason why the missing care plans were not done but should have been done. She stated that the facility has been busy with the COVID outbreak. She stated the MDS coordinator was responsible and knows that the MDS coordinator tries to keep them done. She said she expects the care plan to meet the resident's needs and include all needs. She stated as it relates to Resident #25 and the missing behavior care plan, a negative outcome would be that the resident could wander off. She stated the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said that behaviors, as it relates to dementia, are subject to worsen or decline. She stated she was not concerned about the resident because he has a wander guard. During an interview with the Administrator on 06/15/2022 at 9:09 AM, she stated that they were all responsible for the care plan, but the MDS coordinator was assigned, but anyone from admissions, social worker, and or admission nurse can contribute to it. She stated that as the Administrator, she does not create the care plan as she was nonclinical. However, she said she was available to assist with assessments if needed. She stated that in the absence of her social worker, she divided the social worker's duties; specifically, the care plan was assigned to the MDS coordinator. She stated that she felt the care plans were missed because they did not have a social worker dealing with the COVID outbreak. She said she did not have concerns because they have a nurse practitioner and the staff at the facility was very familiar with the residents. She stated that she agreed that COVID was unpredictable and could affect the staff as it did the residents, and the accuracy of the care plan could help continue the care for the residents. She stated she has a high-level view of MDS and care plans. She said that she expects the triggered care areas from the MDS to be included in the care plan. She stated a care plan was a tool used to care for the residents. She stated this care plan was used to meet the resident's specific needs. She said she was not concerned with Resident #25 having a negative outcome from the missing behavior care plan because although he has dementia, he was very intentional with his wandering. She stated around 3 or 4 PM, they know where he was going to be every day. When asked about the purpose of the wander guard and if the wandering was intentional, the Administrator stated that this tool (wander guard) might need to be reassessed. During an interview with the MD on 06/15/2022 at 9:35 AM, he stated that it was difficult to definitively say that a person with cognitive impairment such as dementia was making intentional or unintentional decisions or displaying deliberate or unintentional actions. He stated there was no way to confirm this. However, he said that after talking with staff that his wandering was not intentional, and the resident had attempted to go to the front door. He stated he supports the resident by having the wandering guard for his safety. During an interview with LVN A on 06/15/2022 at 9:45 AM, she stated that the resident wanders out of his room and he comes to the desk typically, but when his family comes and visits, he will attempt to go out of the door and has to be redirected. She stated she feels the resident needs the wander guard and would not feel comfortable if he did not have the wander guard. She stated the resident was at risk of leaving the facility. During an interview with RN B on 06/15/2022 at 9:50 AM, she stated the resident can remember his room but does not know where he was as he repeatedly asks about his stay at the facility and if it was paid for. She stated when the resident's family member comes to visit; he will go to the door and make sure his wife made it to the car. She said his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #103 Record Review of Resident #103's face sheet dated 06/14/2022 documented a [AGE] year-old female admitted [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #103's comprehensive annual MDS (Minimum Data Set) dated 05/28/2022 documented the following: Section B- Hearing, Speech, and Vision B0700. Makes Self Understood 1. Usually understood- difficulty communicating some words or finishing thoughts but is able if prompted or given time. B0800. Ability to Understand Others 1. Usually Understands- misses some part/intent of message but comprehends most conversation Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 10 moderately impaired cognitively (Alert and Oriented x time, place, person). Section V - Care Area Assessment Summary (2) cognitive loss (4) communication Record Review of Resident #103's Care Plan dated 05/28/2022 did not reveal a care plan for cognitive loss and communication. During an interview with the MDS Coordinator on 06/14/2022 at 4:02 PM, she stated after reviewing the care plan for Resident #103 that, she did not see a care plan for cognitive loss and communication. She stated the care plan was not done and that she attributes this missing care plan to the facility not having a social worker. She said that she was focused on her responsibilities of the care plan. She stated the negative outcome for Resident #103 would be that the proper interventions would not be in place to address the triggered areas. She said not managing a person's cognitive loss and communication could deprive the resident of being taken care of in a language they understand and miss out on them communicating important factors such as pain. She stated that she was concerned that the MDS was inaccurate because when the resident came in, she was sick. She said she completed the MDS and has been trained to complete MDSs. She stated that although she was concerned about the MDS's accuracy, she had not redone the care plan or addressed those concerns. She said this would have been caught at the next care plan meeting on the 16th of June. She agreed that this meant that the resident's needs for those care areas would not have been met from admission until that time. During an interview with the DON on 06/15/2022 at 8:58 AM, she stated as it relates to Resident #103 and the missing cognitive loos and communication care plan, a negative outcome would be that the resident could continue to decline or get hurt because staff may need to know that need to pay extra attention. She stated she is unsure if the MDS was completed correctly or done from the appropriate angle for Resident #103. During an interview with the Administrator on 06/15/2022 at 9:09 AM, she stated as it relates to Resident #103 the missing communication care plan could affect the resident negatively because the resident may not be able to express her needs. She stated the nurses would ask questions such as pain, and the lack of this care plan would cause needs not to be met. She said this information not getting to paper was their fault. She said she felt her staff does well about catching cognitive concerns. She did not express any negative outcome of the cognitive care plan not being completed. Record review of the facility policy Care Plans, Comprehensive Person-Centered, (undated), revealed the following documentation: Purpose: To ensure that a comprehensive person- centered Care Plan is developed for each resident based on their individual assessed needs. Procedure: VIII. A comprehensive person-centered care plan will be developed for each resident. The care plan will include measurable objectives and timetables to meet the residents medical, nursing, mental and psychosocial needs. IX. Each resident comprehensive care plan will describe the following: A. services that are to be furnished to attain or maintain the residence highest practicable physical, mental and psychosocial well-being;

Based on observation, interview, and record review, the facility failed to provide care and services to prevent complications for one of one (Resident #28) resident reviewed with a gastrostomy tube (feeding tube) ([DEVICE]). 1. LVN B did not flush the [DEVICE] with water prior to medication administration. 2. LVN B did not allow the medication to flow by gravity and instead plunged the medication into the [DEVICE] via syringe. This failure to provide care and services could affect residents with [DEVICE]s at risk for complications including aspiration, and pneumonia. Findings included: Resident #28 Record review on 03/10/2021 of Resident #28's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with some of the following Diagnoses: [REDACTED]. Observation on 03/10/21 at 8:33 AM of [DEVICE] medication administration to Resident #28, LVN B crushed or poured the following medications in a cup and diluted with 50 mL's of water. [MEDICATION NAME] 500mg 1- tablet [MEDICATION NAME] 5 mg 1-tablet [MEDICATION NAME] 50mg 1- tablet aspirin 81mg 1- tablet [MEDICATION NAME] 1- capsule [MEDICATION NAME] blend 1- capsule [MEDICATION NAME] 2 tablets vitamin D3 50 mg 1 tablet [MEDICATION NAME] liquid 5ml LVN B then checked for [DEVICE] placement and checked for residual -(remainder). LVN B then drew up the diluted medication into the syringe and plunged it via [DEVICE]. LVN B then drew up 50 mL's of water into the syringe and plunged it via [DEVICE]. During an interview with LVN B on 03/10/21 at 8:54 AM, LVN B said it was okay to plunge the medication and water via [DEVICE] as Resident #28's [DEVICE] has a lot of pressure in it and that was she was supposed to do that. During an interview with DON on 03/10/21 at 9:05 AM regarding not flushing [DEVICE] with water before medication administration and plunging with the medication and water in with a syringe, DON stated water and medication should be done by gravity and the [DEVICE] should have been flushed prior to medication administration. Record review on 03/10/21 of Resident #28's active orders dated 03/10/21 documented the following: ~ Regular diet Mechanical soft meat texture as tolerated. Start date 3/24/20. ~ [MEDICATION NAME] 1 Cal Liquid (Nutritional Supplements) Give 40 ml/hr via [DEVICE] every night shift for Nutritional Supplements from 8pm-6am. ~ Check residual while [MEDICATION NAME] 1 cal running. Stop feeding and report if over 35ml to ACNS-BC on time a day. Start date 11/01/21. ~ Clean [DEVICE] site with DWC, pat dry with gauze, apply [MEDICATION NAME] to site daily and cover with inner dry dressing daily, every day shift. Start date 03/02/21. ~ Flush [DEVICE] (per pump) with 50ml of H2O q 4 hours every shift. Start date 03/25/20. Start date 03/25/20. ~ Flush [DEVICE] with 30-60ml of water before and after medication administration every shift. Start date 03/25/20. ~ May crush and cocktail- (mixture) meds via [DEVICE] for med pass times related [MEDICAL CONDITION] shift. Start date 03/24/20. ~ May crush meds. Order date 11/01/2004. ~ May take medications PO (by mouth) as desired per resident request. Order date 03/09/21. ~ May use lopez valve due to tube pressure. Order date 03/09/20. Record review of Resident #28's significant change comprehensive MDS (Minimum Data Set) dated 03/09/21. Section G - Functional Status - G0110 Activities of Daily Living (ADL) Assistance H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g. tube feeding, total [MEDICATION NAME] nutrition, IV fluids administered for nutrition or hydration.) = Self performance 2 - limited assistance, and Support 2 one-person physical assist. Section K - Swallowing/Nutritional Status K0100 Swallowing Disorder C. Coughing or choking during meals or when swallowing medications. D. Complaints of difficulty or pain with swallowing. K0510. Nutrition approach B. Feeding tube (while a resident). K0710. Percent Intake by Artificial Route A. Proportion of total calories the resident received through [MEDICATION NAME] or tube feeding. 2. 26-50% while a resident. V0200. CAAs and Care Planning 12. Nutritional Status = A. Care Area Triggered: yes B. Addressed in Care Plan: yes Record review for Care Plan dated 03/09/21 for Resident #28 revealed the following: Focus: ~ The resident requires [DEVICE] feeding r/t (related to) swallowing problem (revised 03/09/21) Goal: ~ The resident will be free of aspiration- (foreign matter into lungs) through the review date next 90 days. (revised 03/09/21) ~ The resident will remain free of side effects or complications related to tube feeding through review date (revised 03/09/21) ~ The resident will maintain adequate nutritional and hydration status abe (as evidenced by) weight stable, no s/sx (signs/symptoms) of malnutrition or dehydration through review date next 90 days. (revised 03/09/21) Interventions: ~The resident needs the HOB (head of bed) elevated 45 degrees during tube feeding. ~ The resident requires assistance with tube feeding, abnormal breath/lung sounds, abnormal lab values, abnormal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration.ng and water flushes via pump. ~ Change syringe and pump set tubing daily as ordered. ~ Check for tube placement and gastric contents/residual volume per facility protocol/per orders and record. ~ Monitor/report PRN (as needed) an s/sx of aspiration -fever, SOB (shortness of breath), tube dislodged, infection of tube site, self-extubation, tube dysfunction or malfunction. ~ Obtain and monitor lab/diagnostic work as ordered. ~ Provide local care to [DEVICE] site as ordered and monitor for s/sx of infection. ~ RD (Registered Dietician) to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed to maintain wt. (weight). Weigh as ordered per doctor. Record review on 03/10/21 documented the facility's policy and procedure titled Gastrostomy Tube Medication Administration with an effective date of March 9, 2007 revealed the following: Purpose: To provide guidelines for the safe administration of medication through a gastrostomy tube. Procedure: .8. Check placement in the stomach and residual gastric contents: a. Attach to 60mL syringe containing approximately 10cc of air b. Auscultate the abdomen (approximately 3 inches below the sternum) while injecting air from the syringe into the tubing. c. Listen for whooshing sound to check placement of the tube in the stomach. d. Pull back gently on the syringe to aspirate stomach content. e. If the stomach contents cannot be aspirated, pull back slightly on the tube to reposition. If the tube is still not patent, withhold medication and notify the physician. f. Return gastric contents to the stomach. g. Flush tubing with 30-60mL of water. h. Remove the syringe and clamp tubing. Place the end of the tubing on a clean gauze pad or clean towel positioned on the abdomen or chest of the resident. 9. Dilute the crushed or split medication with 15-30 mL of water. 10. Reattach syringe to the end of the tubing. 11. Administer medication. Clamp tubing (or begin flush) before the tube drains completely. 12. When the last of the medication begins to drain from the tubing, flush the tubing with 30-60mL of water. 13. Clamp the tubing or restart the tube feeding per physician's orders [REDACTED].

Based on observation, interview, record review, the facility failed to ensure a medication error rate of less than 5%. The medication error rate was 5.41% with two errors in thirty-seven opportunities involving one of three staff (LVN B) and one of six residents (Residents #28) reviewed for medication pass. The facility's failure could affect all residents who receive medications administered by the facility. Findings Include: Observation on 03/10/21 at 8:33 AM of medication pass with LVN B revealed Resident #28 did not have the Gastrostomy tube ([DEVICE]) flushed with water prior to medication administration and was administered [MEDICATION NAME] 5mg one tab via [DEVICE]. Record review of Resident #28's March 2021 physician orders [REDACTED]. Interview on 3/10/21 at 8:53 AM with LVN B confirmed she did not flush with water prior to medication administration and I forgot to do that. Interview on 3/10/21 at 10:16 AM with DON revealed the [MEDICATION NAME] was given by wrong route per physician orders. DON stated, I'll get it fixed. DON stated the [DEVICE] should have been flushed with water prior to medication administration. Record review of the facility's policy and procedure titled Administering Medications with revised date of December 2012 documented the following: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: .3. Medications must be administered in accordance with the orders, including and required time frames

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, in that: a) Two of four medication carts were observed unlocked and unattended. b) Four of four medication carts contained expired medications and/or supplies. c) One of four medication carts contained improperly labeled medications. d) One of one medication rooms contained expired supplies. These failures could affect all residents who have medications stored within the facility. The findings include: Observation on 3/8/21 at 3:33 PM of med cart 1 of 2 in south hallway revealed [MEDICATION NAME] 600mg tabs 1 box expired on 01/2021. Interview on 3/8/21 at 3:34 PM with LVN C confirmed the medication was expired. LVN C stated, It shouldn't be in the med cart. Observation on 3/8/21 at 3:52 PM of med cart 1 of 2 in north hallway revealed 3 loose and unidentified pills in the bottom of the drawer and expired medications to include: [MEDICATION NAME] 325mg 1 bottle expired 02/21, [MEDICATION NAME] sulfate 90mcg expired 02/21, [MEDICATION NAME] 2mg expired 02/21, [MEDICATION NAME] 10mg 1 box expired 03/19, [MEDICATION NAME] 600mg 1 box expired 10/20, antacid extra strength liquid 1 bottle expired 08/20, [MEDICATION NAME] Alcohol 50% 1 bottle expired 08/2019, [MEDICATION NAME] cream 2% 1 tube expired 01/26/21, artificial tears 1 bottle unlabeled expired on 11/1/2009. Interview on 3/8/21 at 4:05 PM LVN E confirmed expired meds and loose pills. LVN E stated the expired medications shouldn't be in the med cart. LVN E stated the night shift and pharmacy consultants help keep expired medications out of the cart, but all of the nurses who use the cart are responsible. Observation on 3/8/21 at 4:15 PM of 2 of 2 medication carts in the South Hallways revealed 2 loose and unidentified pills. Interview on 3/8/21 at 4:16 PM with LVN D confirmed the loose and unidentified pills. Observation on 3/8/21 at 4:19 PM of 2 of 2 med carts in north hallway revealed 5 loose and unidentified pills and expired medications to include: [MEDICATION NAME] 325mg 1 bottle expired 02/21, [MEDICATION NAME] gel 1% 1 tube expired 01/21, [MEDICATION NAME] 20mg 1 bottle expired 01/21, antacid liquid 1 bottle expired on 02/21, Glucerna 1 bottle expired 3/1/21, Vitamin A&D ointment 1 tube expired on 08/18, Lubricant eye drops 1 bottle expired on 01/21. Interview on 3/8/21 at 4:31 PM with LVN F confirmed expired medications and loose pills. LVN F stated the night shift usually checks for expired meds, but it is all the nurse's responsibility to check. LVN F state the expired medications should not be in the med cart. Observation on 3/9/21 at 6:47 AM revealed an unlocked and unattended medication cart in the south hallway. One resident in a wheelchair observed in the hallway. Interview on 3/9/21 at 6:50 AM with LVN D stated she just received the keys for the medication cart from the night nurse. LVN D stated the medication cart is never supposed to be unlocked without staff present. LVN D opened the drawers and confirmed medications in the cart. Observation on 3/9/21 at 2:46 PM of the only medication room revealed expired supplies to include: (2)male/female luer lock system (for IV medication administration) expired on 01/2019, (1)male/female luer lock system expired on 04/2019, (2)blue top vacuette expired 01-04-2021, (1)12inch extension set expired 07-2020, (1)lemon [MEDICATION NAME] swab sticks pack of 3 expired 10-2016, (1)BD safety glide needle 25g 5/8 expired 01-2013, (2)[MEDICATION NAME] expired 12-2020, (17)swab sticks expired on 03-01-2021 and (1)swab stick expired on 07/01/2020. Interview on 3/9/21 03:01 PM with DON regarding expired supplies. DON stated the supplies should not have been in the medication room and she would dispose of them. DON stated the night shift usually checks for expired supplies and medications but all the nurses are responsible. Observation on 3/10/21 at 10:28 AM in the South Hallway lobby area revealed an unlocked and unattended medication cart. Interview on 3/10/21 at 10:30 AM with DON revealed medication stored in the cart. DON stated the cart was used for the COVID unit and was forgotten back there. DON stated it should have been locked. Review of facilities policy and procedure titled Storage of Medications with a revised date of April 2007 revealed the following: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others

Based on observation, interview and record review, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for three of eight residents observed for medication administration and wound care in that: The facility staff failed to use proper infection control precautions when administering medications to a resident with a gastrostomy tube([DEVICE]). The facility staff failed to use proper infection control precautions when providing wound care for Resident #9 and #20. These failures could affect any resident with risk for infection. Findings include: Observation on 3-9-21 at 12:42 pm, LVN A was observed wiping and re-wiping four times on the same area of the wound with the gauze that had wound cleanser on it for Resident #9. She wiped and re-wiped four times with the same side if the Q-tip while applying an ointment to the wound. LVN A put a section of tape to the side of the table then used the same section of tape to secure the wound dressing to the skin. LVN A then started to clean the wound on resident #9's right ear. She wiped and re-wiped with same side five times. She wiped and re-wiped with the same side of the Q-tip four times while applying an ointment to the wound. She used hand sanitizer to clean her hands in between glove changes but never used soap and water to clean her hands. Observation on 3-9-21 at 1:07pm of LVN A performing wound care on resident #20's wound on her buttocks. While preparing for wound care, LVN A- laid a small wooden spoon on top of the medication cart surface without a barrier then used the spoon to apply ointment on for wound care. LVN A wiped and re-wiped with the same side of the gauze four times. She wiped and re-wiped with the same side if the Q-tip four times while applying an ointment to the wound. In an interview on 3-9-10 at 2:40pm with LVN A about observed wound care. When asked what she should do before and after completing wound care, she answered she should have washed her hands with soap and water. When asked why she didn't wash her hands before and after wound care, she replied she just forgot. When pointing out how she wiped and re-wiped with the same side of the cleansing gauze for resident #20 and resident #9, Surveyor asked her if she had any training for wound care and she replied she had not had any training. When asked if she knew she needed to wipe just once per swipe or to only touch 1 side at a time on the Q-tip, she replied no. When reminded of the instance where she put the wooden spoon on the medication cart surface, she stated she should have put it on a barrier. When asked why she didn't, she replied she didn't know why. In an interview on 3-9-21 at 2:00pm the DON stated the she expected her staff to wash their hands with soap and water before and after completing wound care. Observation on 3-10-21 at 8:33 AM of LVN B performing medication administration for Resident #28 via gastrostomy tube([DEVICE]) revealed the following: LVN B dropped a medication card in the hallway floor while prepping the medication and picked it up and placed it back in the med cart. LVN B did not wash hands or use hand sanitizer and began opening the capsules into a cup. LVN B then walked into the room and washed hands with soap and water. LVN B didn't put on gloves to grab the piston syringe and placed the piston syringe on a bedside table that wasn't cleaned prior. LVN B then grabbed Resident #28's [DEVICE] and pulled it out from her shirt. In an interview on 3-10-21 at 8:53 AM, LVN B confirmed placing piston syringe on the dirty bedside table and touching the [DEVICE] without gloves. In an interview on 3-10-21 at 9:05 AM, DON stated she expects a barrier between the piston syringe and the bedside table and gloves to be worn when touching the [DEVICE]. Record review on 03/10/21 at 9:29 AM of the facility policy dated 10-2010 and titled Wound Care reflected the following, Steps in the Procedure: 2. Wash and dry your hands thoroughly. 14. Be certain all clean items are on clean field. 23. Wash and dry your hands thoroughly. Record review of the following website documented the following: https://www.cdc.gov/handwashing/when-how-handwashing.html) Key Times to Wash Hands You can help yourself and your loved ones stay healthy by washing your hands often, especially during these key times when you are likely to get and spread germs: Before, during, and after preparing food Before and after eating food Before and after caring for someone at home who is sick with vomiting or diarrhea Before and after treating a cut or wound After using the toilet After changing diapers or cleaning up a child who has used the toilet After blowing your nose, coughing, or sneezing After touching an animal, animal feed, or animal waste After handling pet food or pet treats After touching garbage The guidance for the list of key times to wash hands was developed based on data from a number of studies. There can also be other times when it is important to wash hands. Record review on 03/10/21 at 4:00 pm documented the facility's policy and procedure titled Gastrostomy Tube Medication Administration with an effective date of March 9, 2007 revealed the following: Purpose: To provide guidelines for the safe administration of medication through a gastrostomy tube. Procedure: .8. Check placement in the stomach and residual gastric contents: a. Attach to 60mL syringe containing approximately 10cc of air b. Auscultate the abdomen (approximately 3 inches below the sternum) while injecting air from the syringe into the tubing. c. Listen for whooshing sound to check placement of the tube in the stomach. d. Pull back gently on the syringe to aspirate stomach content. e. If the stomach contents cannot be aspirated, pull back slightly on the tube to reposition. If the tube is still not patent, withhold medication and notify the physician. f. Return gastric contents to the stomach. g. Flush tubing with 30-60mL of water. h. Remove the syringe and clamp tubing. Place the end of the tubing on a clean gauze pad or clean towel positioned on the abdomen or chest of the resident. 9. Dilute the crushed or split medication with 15-30 mL of water. 10. Reattach syringe to the end of the tubing. 11. Administer medication. Clamp tubing (or begin flush) before the tube drains completely. 12. When the last of the medication begins to drain from the tubing, flush the tubing with 30-60mL of water. 13. Clamp the tubing

Based on observation, interview and record review, the facility failed to ensure one Resident (Resident #30) of two reviewed for Percutaneous Endoscopic Gastrostomy (PEG-a tube inserted through the abdomen into the stomach for the purpose of administering liquid nutrition and medications) received the appropriate treatment and services to prevent complications and aspiration. · RN (Registered Nurse) C failed to check PEG tube residual prior to administering Resident #30's medication as ordered by the physician. This failure could place residents receiving tube feedings at risk for aspiration pneumonia, dehydration, and metabolic abnormalities which could result in additional medical treatment and a decline in the resident's health. Findings include. Record review of Resident #30's admission record dated 04/16/19 indicated she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #30's order summary report dated 04/16/2019 indicated in part: · Check for gastric residual per [DEVICE] with each medication administration, Call (Nurse Practioner) if greater than 40cc of residual. (cc = cubic centimeters) Record review of Resident #30's care plan indicated in part: · Focus: the resident requires tube feeding r/t dysphagia, swallowing problem - date initiated 12/17/15, revised 02/07/19. · Goal: The resident will remain free of side effects or complications related to tube feedings through review date. · Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record. During an observation on 04/15/19 at 3:40 p.m. RN C administered Resident #30's medication by PEG administration. RN C proceeded to administer the medications without first checking for residual. During an interview on 04/15/19 at 3:52 p.m. RN C said she had forgotten to check for residual prior to administering the medication. During an interview on 04/16/19 at 9:52 a.m. the Director of Nurses (DON) said RN C should have checked for residual prior to the medication administration. During an interview on 04/16/19 at 10:36 a.m. the Administrator said he understood that RN C should have checked for residual prior to administering the medication. Record review of the facility's policy Gastrostomy tube medication administration dated 03/09/2007 indicated in part: · To provide guidelines for safe administration of medication through a gastrostomy tube. 8. Check placement in the stomach and residual gastric contents: d) Pull back gently on the syringe to aspirate stomach content.

Based on observation, interview and record review the facility failed to ensure personal privacy by securing signed consents for the use of video cameras and postings of electronic monitoring for 2 of 4 residents reviewed for privacy (#15 and #16). · The facility had video cameras in Resident #15's and #16's with double occupancy without obtaining written consents forms from the roommates representative. · The facility did not have postings that electronic monitoring was being conducted in Resident #15's and #16's rooms. These failures would place residents at risk of embarrassment, and reduction of the self-esteem and self-worth by not being provided desired privacy during personal care or meetings with family or physicians. Findings included: Record review of Resident #15's Admission Record dated 04/16/19 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Review of Resident #15's MDS dated [DATE] indicated in part: BIMS summary score = 05 indicating resident had severe impairment. Record review of Resident #15's care plan revealed there was no documentation of a care plan to alert staff to ensure resident privacy due to cameras placed in the room during care. Record review of Resident #57's Admission Record dated 04/16/19 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Review of Resident #57's MDS dated [DATE] indicated in part: BIMS summary score = 13 indicating resident was cognitively intact. Record review of Resident #57's care plan indicated in part: Focus: Mrs._____ family placed a webcam for electronic monitoring of resident in her room. Date initiated: 01/08/2018. Interventions: Consent for electronic monitoring will be obtained from roomates family, if applicable. Date initiated: 01/08/2018. Revision 03/21/19. During an observation on 04/13/19 at 3:22 p.m. revealed a video camera in Resident #7's room. There was no posting seen that indicated there was electronic monitoring taking place in that room. There was another resident in the room, Resident #16. During an observation on 04/13/19 at 3:24 p.m. revealed a video camera in Resident #57's room. There was no posting seen that indicated there was electronic monitoring taking place in that room. There was another resident in the room, Resident #15. During an interview on 04/15/19 at 1:40 p.m. the Administrator said they did not have postings outside the door of the resident's room with video camera monitoring conducted by their family member. He said they did not use the postings here. He said the resident's roommate's representative for Resident's #15 and #16 knew about the cameras but did not think there were consents on file. He said he believed the video cameras also recorded audio. During an interview on 04/15/19 at 1:52 p.m. the Administrator said there were no consent forms found indicating the Resident #15's and #16's representatives had consented. Record review of Resident #7's Admission Record dated 04/16/19 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Review of Resident #7's Minimum Data Set ((MDS) dated [DATE] indicated in part: Brief Interview Mental Status (BIMS) summary score = 03 indicating resident had severe impairment. Record review of Resident #7's care plan indicated in part: Focus: Mrs._____ family placed a webcam for electronic monitoring of resident in her room. Date initiated: 04/19/2018. Interventions: Consent for electronic monitoring will be obtained from roomates family, if applicable. Date initiated: 04/19/2018. Revision 04/11/19. Record review of Resident #16's Admission Record dated 04/16/19 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Review of Resident #16's MDS dated [DATE] indicated in part: Cognitive skills for daily decision making = Severely impaired. Record review of Resident #16's care plan revealed there was no documentation of a care plan to alert staff to ensure resident privacy due to cameras placed in the room during care. Record review of the facility's undated information regarding authorized electronic monitoring located in the facility admission agreement indicated in part: · A resident or the resident's guardian or legal representative is entitled to conduct authorized electronic monitoring (AEM) under subchapter R, Chapter 242, Health and Safety code. To request AEM, you, your guardian or your legal representative must: 2) obtain the consent of other residents, if any, in your room, using the consent to authorized electronic monitoring form; and 3) give the form(s) to the facility administrator or designee. · Is notice of AEM required? Anyone conducting AEM must post and maintain a conspicuous notice at the entrance to the resident's room. The notice must state that an electronic monitoring device is monitoring the room. Record review of the facility's policy Electronic monitoring and photographic/audio devices dated 04/15/2019 indicated in part: · The resident has the right to privacy, confidential care and protection of health information. In order to safeguard resident privacy, the facility does not permit photographing of any kind of use of electronic monitoring or audio recording devices, unless prior written permission obtained from the resident and facility management. · Obtain a signed request and informed consent form from residents or if deemed incompetent from an authorized family member or legal guardian, requesting to install a surveillance camera. If other residents (roomates) may be captured in surveillance, obtain their written informed consent/permission. · Post conspicuous signage throughput the facility and on the residents door informing residents, staff and families/visitors of the presence of video cameras.

Based on observation, interview and record review, the facility failed to prepare, distribute and serve food under sanitary conditions in 1 of 1 kitchen. - The 3 compartment sink was not filled with the recommended amount of sanitizer Parts Per Million (PPM). - The ice machine filter had lint build up and the floor fan had lint and grease build up. This failure could place 70 residents who consumed food prepared in the kitchen at risk of food-borne illness. Findings included: During an observation on 03/05/18 at 9:10 a.m. there was a floor fan which had lint and grease build up on it. The fan was located on the floor by the stove and food preparation area. The ice machine filter had lint build up on the entire filter. During an observation on 03/06/18 at 11:18 a.m. Dietary Aide (DA) A was washing some pots in the 3 compartment sink. During an interview on 03/06/18 at 11:19 a.m. DA A said she would first scrub the pot in the first sink then rinse it on the second one and then sanitize it in the third one. DA A said she would sanitize the pot by soaking it in the third sink for like 3 minutes or so. DA A said she did not know how much chemical sanitizer was in the third sink and that she was a new employee and usually did not wash the pots. DA A said she did not know how to check for the amount of chemical sanitizer in the sink. DA A said she would first fill up the 3rd sink with water from the faucet and then she would push the button on the chemical pump dispenser and that was it. During an interview on 03/06/18 at 11:26 a.m. The Director of Dining Services (DDS) said the PPMs on the 3 compartment sink should be at 200. The DDS said that DA A knew how to check the amount of PPMs in the sink. The DDS was made aware of the observations of the fan and the ice machine filter. The DDS said the fan should have not been there and had been removed since then. The DDS said they would clean the ice machine filter. During an observation on 03/06/18 at 11:28 a.m. The DDS was asked to demonstrate how to check the PPM's in the 3 compartment sink. The DDS took a test strip and dipped it in the sink water. The DDS compared the test strip results with the color on the test strip bottle and said the strip indicated the PPM was at 50. The DDS said it had to be at 200 PPMs and proceeded to tell DA A to empty the sink and refill it with the correct amount of PPMs. During an interview on 03/07/18 at 04:23 p.m. the Administrator was made aware of the kitchen findings. The Administrator said he understood how it was an issue. Record review of the facility's policy dated 09/2013 and titled safety and sanitation-sanitizing food contact surfaces and work areas indicated, in part: · Description: Sanitizer buckets and cleaning towels are in the kitchen, available and in use. Proper food contact surface sanitizing procedures are practiced. · Why/value: Reducing the potential food borne illness and maintain a clean, sanitary work environment are fundamental to a quality food service operation. Management is responsible for ensuring that team members have the equipment and skills needed to perform their responsibilities. · Proper sanitizer dilution rates and applications can be sourced from our chemical supplier. For our sanitizer the proper dilution is 200 ppm. Record Review of the POS [REDACTED] · Oasis 146 Multi-Quat Sanitizer. (Quat = Quaternary which is a type of ammonium chloride compound used for sanitizing surfaces). · Sanitation range testing. 1. Testing solution should be at room temperature. 2. Withdraw and tear off approximately 2 inches of test paper from dispenser. Dip test paper for 10 seconds in test solution. Don't shake. 3. Compare colors immediately with colors on the test paper package to determine ppm. Always compare against package scale. 4. Testing solution should be between 150 - 400 ppm. Record review of the 3 compartment sink sanitizer gallon label dated (YEAR) indicated in part: · To Sanitize Food Contact Surfaces, Food Processing Equipment and Other Hard Surfaces in (Food Processing Locations): Use Oasis 146 Multi-Quat Sanitizer to sanitize pre-cleaned hard non-porous surfaces of food processing equipment, food utensils, dishes, refrigerated storage areas and display equipment and other hard non-porous surfaces in federally inspected meat and poultry plants or restaurants. Prior to application, remove gross food particles and soil by a pre-flush, pre-scrape or when necessary, a pre-soak. Then thoroughly wash or flush objects. With a good detergent or compatible cleaner followed by a potable water rinse before application of the sanitizing solution. Apply a use-solution of 1 oz. to 2.67 oz. of Oasis 146 Multi-Quat Sanitizer per 4 gallons of 400 ppm hard water (150 - 400 ppm active quat) or 1.25 oz. to 2.67 oz. of Oasis 146 Multi-Quat Sanitizer per 4 gallons of 500 ppm hard water (200 - 400 ppm active quat). Expose all surfaces to the sanitizing solution for a period of not less than 1 minute. Allow equipment to drain thoroughly and air dry. (oz. = ounces). Record review of the facility's resident roster dated 03/08/18 indicated there were 71 total residents and 1 that was Nothing By Mouth (NPO).

Based on interview and record review, the facility failed to ensure the quality assessment and assurance committee (QAA) met at least quarterly. The facility's last QAA committee meeting was 07/14/17. This failure could place the census of 71 residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings included: During an interview on 3/05/18 at 9:05 a.m. the Administrator said the facility had quarterly QAA meetings and all department heads and the Medical Director attended. During an interview and record review on 03/07/18 at 02:59 PM the Director of Nurses (DON) provided the Sign-in sheet for the (MONTH) 11, (YEAR) QAA meeting. The DON acknowledged the facility had one meeting for two quarters because we got behind, time just flies. She said the facility had not had a meeting since then. During an interview on 03/07/18 at 03:22 PM the DON said she did not know how not having a meeting happened. She acknowledged it had been nine months since the facility had a QAA meeting. She said it was just a busy, rough 3 months, we had bouts of the flu, and all the (abuse) allegations we had. She said the Medical Director was in the facility all the time. During an interview on 3/7/18 at 4:31 PM the Administrator said he thought they had QAA meeting since July. (Surveyor requested a QAA sign-in sheet to verify). During an interview on 03/08/18 at 09:43 AM the Administrator said everyone had a QAA meeting scheduled on their day planner but no one could find a sign in sheet for the meeting. During an interview on 03/08/18 at 10:43 AM the Medical Director said he did not remember when last QAA meeting was. He said maybe January? We're in here every day so . He was informed last sign-in sheet was (MONTH) and said that might be right. Review of the facility's undated policy and procedure on Quality Assurance & Performance Improvement Plan (QAPI)for Permian Resident Care Center documented, in part: the governing body and/or administration of the nursing home will develop a culture that involves leadership seeking input from facility staff, residents, and their families and/or representatives. The governing body assures adequate resources exist to conduct QAPI efforts. This includes designating one or more persons to to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment, and technical training as needed. PRCC governing body is ultimately responsible for overseeing the QAPI committee. The owner/president has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. Review of the form CMS 671 Resident Census and Condition of Residents dated 03/05/18, completed by the MDS (Minimum Data Set) Coordinator documented there were 71 residents in the facility.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures regarding allegations of abuse for 1 of 11 residents reviewed for abuse and neglect (Resident #38). The Administrator, who was the facility's Abuse Coordinator, failed to follow the facility's abuse policy by not suspending Certified Nurse Aide (CNA) B after receiving an allegation of abuse. This failure could place 36 residents living on Hall 2 by placing them at increased risk for abuse and neglect. Findings included: Review of the facility's undated policy and procedure on Abuse Prevention documented, in part: The facility will not tolerate abuse or neglect in any form. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain. It is also defined as mental anguish or deprivation by an individual, including a care taker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Residents are protected against abuse by the following: Investigation: All allegations of abuse will be handled in the following manner: - The staff member who receives the allegations of abuse will contact the Administrator and or the DON immediately. - The staff will take immediate action to protect the resident population from further allegations of abuse. This action can include suspension of employees, monitored visits by families, and prohibited access to the facility for other individuals. Reporting/Response: All allegations of abuse are reported to the proper authorities. Any employee against whom allegations are alleged is suspended pending the outcome of the investigation. RESIDENT #38 Review of Resident #38's 3/5/18 Admission Record documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's 12/20/17 quarterly Minimum Data Set (MDS) Assessment documented: - She scored a 13 of 15 on her mental status exam (13-15 = cognitively intact) and showed no signs of [MEDICAL CONDITION]. - She had 2 of 27 indicators of depression (indicating possible mild depression). - She needed extensive assistance of one staff for transfers. - She was on a scheduled pain medication, which was occasionally experienced and it was coded as mild. - She was on an anti-anxiety medication for 7 of 7 days during the assessment timeframe. Review of Resident #38's Care Plan updated 1/4/18 documented, in part: Focus: Resident #38 has frequent complaints about staff, food, and has had frequent physical complaints. Review of Resident #38's Incident Report date 3/4/18 documented, in part: Nursing Description: was summoned to resident's room by CNA (Certified Nurse Aide). This nurse accompanied by another nurse arrived to room. CNA x 2 noted at resident's side. Resident noted to be agitated and yelling at CNA's about not getting up in chair before supper. Self transferred from commode to bed without assist, was physically abusive towards CNA when they attempted to assist her, reported by CNA. This is when resident accused CNA of tugging her shoulder and hitting her shoulder. As conversation continued she continued to voice concerns on past problems and then was unable to remember the CNA that hit her shoulder earlier. Spoke with resident on concerns, Resident stated she tugged my shoulder, she then proceeded to say she hit my shoulder. Immediate Action Taken: Both shoulders assessed, able to move extremity without discomfort, no bruising or redness noted. Spoke with CNA's. Attempted several times to talk and comfort resident with no success. Administrator, DON (Director of Nurses), and family notified. Review of CNA B's undated statement documented at about 3:30 I, (CNA B) answered a call light for (Resident #38). She was sitting on the bedside commode. I let her know it was about time to start getting ready for supper since she was already up from her bed. She never answered me, nothing. She just started being combative towards me and self transferred herself to the edge of the bed. During that time she didn't even give me time to get gait belt, so I guided her to her bed to avoid fall by that time I had already told a coworker walking by to call my charge nurse. As soon as my charge nurse walked in room she told him that I had tugged her shoulder and before he walked out she said I had hit her shoulder. She never gave me time to even help her other than me guiding her safely to bed. She said it was not her problem what time the round started, she is always given the choice to eat in her room or dining room. I don't understand why she was so upset. Review of Restorative Aide (RA) C's undated statement documented on the day of (MONTH) 4, (YEAR) I was walking by the nurse's station and I heard (CNA B) asking for the nurse so I notified the nurse and went to see if I could help. (CNA B) wanted to let the nurse know that (Resident #38) transferred herself from the bedside commode to the bed. (Resident #38) was sitting on the bed when I walked in . I asked (Resident #38) what the problem was and she replied I'm not getting in that chair and sitting for an hour before my tray comes that's stupid. I explained that she was our last resident to get up and it was time. She was saying we need to hire more people and we should get together and not show to work then (the facility) would have to hire more people. (Licensed Vocational Nurse (LVN D)) walked in and she had different complaints about different stuff, her gum, the staff not caring for her and then she said (CNA B) hit her on her shoulder. (LVN E) and (LVN D) tried talking to her but she got mad and asked to talk to her daughter. Review of Resident #38's Social Service notes documented, in part: - dated 1/4/18: resident continues to have frequent complaints about staff. - dated 3/5/18: Social Worker visited with (Resident #38) about an incident she reported to nursing. She stated that yesterday about 4:00 (she didn't know if it was morning or afternoon), a big old smart alec came into her room to get her up. She stated that the girl grabbed her by the shoulder and scratched her. She stated that she told the girl that she scratched her, and the girl denied it. (Resident #38) told her that she was lying. During an interview and observation on 03/05/18 at 02:42 PM Resident #38 was observed in bed. She had full range of motion of her arms. She said she was not given a choice about when to get up and some of the girls are not very respectful and some do not want to work. When asked for clarification, she repeated the statement. Resident #38 said it hurt when she lay in one place for too long and the staff take too long when she used her call light for help with repositioning. At no point during the interview did Resident #38 say the staff hurt her or were rough. During an interview on 03/08/18 at 11:08 AM CNA B said she worked at the facility for 1 year and 3 month. She said on 3/4/18 around 3:30-ish she was in another room. When she came out of the room Resident #38's call light was on so she answered it. CNA B said she knocked and entered the room. CNA B said Resident #38 was sitting on the bedside commode. CNA B said she got Resident #38's geri-chair closer to her. CNA B said she told Resident #38 it was almost supper time. CNA B said Resident #38 never really answered and just started getting up by herself. CNA B said when she started getting up I put hands on her waist to get to her to sit down, I was afraid she'd fall. CNA B explained she guided Resident #38 by waist and she sat on edge of bed. CNA B said she did not have a chance to get the gait belt. CNA B said she called RA C who walking down hall to call the charge nurse and then RA C came in to help. CNA B said the main thing was we did not want her to fall. CNA B said Resident #38 elbowed me the entire time. CNA B denied touching Resident #38's arm. CNA B said Resident #38 was upset. CNA B said Resident #38 never said 'I don't want to', and never gave CNA B the chance to ask about dinner. CNA B described Resident #38 as very fragile. CNA B said she did not know how long Resident #38 was on the call light. CNA B added she did not know how long she was sitting on the bedside commode, so she may have been in pain. CNA B added Resident #38 was very demanding and things have to be just so with her. CNA B said she never had problems with Resident #38 before. CNA B said most of time Resident #38 was a one person assist with transfers and she stood up pretty well. CNA B said occasionally Resident #38 would need 2 people to help with transfers. CNA B said Resident #38 never said she was hurting her, not even when charge nurse or RA C came in. CNA B said Resident #38 mentioned to (Restorative Aide) RA C that she tugged her arm. She said Resident #38 said CNA B hit her when charge nurse came in and Resident #38 said she pulled her arm. CNA B repeated I never touched her other than guiding her by the waist. CNA B said she let LVN D know real quick. CNA B said as soon as LVN D came in she reported Resident #38 changed her words between 'tug' and 'hit'. CNA B said LVN D told her to write an incident report. CNA B said LVN D did not send her home. CNA B said she told LVN D when RA C was in the room. During an interview on 03/08/18 at 11:33 AM RA C said she had been at the facility for 3 years. RA C said she was passing by and CNA B was by the door and asking for nurse assist. RA C said LVN D was on phone or writing something. RA C said she went down to Resident #38's room to help. RA C said Resident #38 was on the bed and you could tell she was already mad. RA C said Resident #38 transferred by herself. RA C explained in past the resident transferred by herself and fell . RA C said she asked Resident #38 if she wanted to eat in room and Resident #38 said no. RA C said Resident #38 kept repeating the facility needed more help. RA C said she told her we could not get people up at the last minute. RA C said Resident #38 kept going from one thing to another - her gum was missing; we weren't fast enough. RA C said LVN D came in and told Resident #38 to calm down. RA C said when the aides got her situated, Resident #38 said CNA B hit her. RA C said she asked Resident #38 why she did not mention it sooner and she said she forgot. RA C said she asked if we could look at her arm and she said no. RA C said Resident #38 was not tearful - just mad and trying to get her way. RA C said Resident #38 was not acting afraid. RA C said she was thinking 'why didn't she say anything when I came into the room?' RA C said Resident #38 was sitting on the bed and calmed down when RA C came in. RA C said she thought Resident #38 got upset because the aides did not agree with Resident #38 about not coming to work. She said LVN D went into Resident #38's room and then LVN E went in there to try to calm her down. They go in as two's just for safety too. RA C described Resident #38 as takes forever to get her ready, and she was really picky. RA C said the staff take a lot of time with Resident #38. RA C said she felt like one is just for her and everyone else is doing everything else. RA C added Resident #38 was not that hard to take care of, she was not heavy and she transferred well - she was just demanding. RA C said Resident #38 had thrown fits - its just a whole ball of complaints but had never accused anyone of hitting her before. RA C said the only thing Resident #38 says is the care is slow; and never said anyone was mean. RA C said Resident #38 was a one person assist with all activities of daily living and the staff had two staff in there for witness sake because the staff never know what kind of mood Resident #38 was going to be in. During an interview on 03/08/18 at 11:50 AM LVN D said he worked at the facility for four years. He said when he went into Resident #38's room Resident #38 was upset and on the bed. He said Resident #38 said CNA B hit her in shoulder or tugged on left shoulder. He said she was specific to the location. LVN D said Resident #38 was frustrated and was not crying or acting afraid. LVN D said after he assessed her, the aides got her in the geri chair and once she got into her geri-chair she was fine. LVN D said Resident #38 never said anyone hit her before. Not told anyone she's been hit before. LVN D said he left room called the DON, the Administrator and Resident #38's daughter. LVN D said the daughter asked what was happening and what caused it and then said she said understood. LVN D reported the daughter said Resident #38 was 'a handful' but did not understand why Resident #38 was up in the geri-chair for so long. LVN D said the Administrator told him to move CNA B away and put another CNA in there. LVN D said he was not instructed to send CNA B home. During an interview on 03/08/18 at 11:53 AM LVN E said she followed LVN D down to Resident #38's room. LVN D said RA C reported Resident #38 was screaming at CNA B. She said she was not sure when RA C went into the room. LVN E said Resident #38 was sitting on the bed. LVN E said Resident #38 never held her shoulder and never complained of pain in shoulder. LVN E said CNA B tried to explain that Resident #38 was upset and hitting her (CNA B) because Resident #38 did not want to get up. LVN E said at that point, (Resident #38) said no you hit me and then immediately said tugged on shoulder. LVN E said Resident #38 went to dinner and never said another word. LVN E said Resident #38 spoke to her daughter and did not say a word to her daughter. LVN E said she knew in the past Resident #38 gave CNA B a hard time. LVN E said right after CNA B said Resident #38 was combative, Resident #38 accused CNA B. LVN E said she thought Resident #38 was trying to put the blame on CNA B. LVN E said Resident #38 was very difficult - she's not respectful to aides or nursing staff or other residents. She's very demanding, if you're not doing what she wants then and there she will snap at you, she yells a lot. She wants one on one care. LVN E said it all boiled down to: (CNA B) said lets get up for dinner and (Resident #38) just snapped. LVN E said Resident #38 picked a few staff and goes out of her way to be difficult for them. During an interview on 03/08/18 at 01:44 PM the Administrator said the staff called and reported CNA B hit Resident #38 on the shoulder. He said LVN D reported when he when down to Resident #38's room, Resident #38 said CNA B rustled her on the draw sheet. He said LVN D did not find any bruising or redness. The Administrator said the next day he had the skin nurse do an assessment and she did not notice any bruising or redness. He said when the social worker interviewed Resident #38, she said CNA B scratched her on shoulder. The Administrator said LVN D reported Resident #38's story changed. The Administrator said Resident #38 was demanding and difficult. He said while transferring Resident #38, CNA B grabbed her to guide her to the bed. The Administrator said he thought it was a bad day. I knew based on the time they were disturbing her normal routine and that would upset her. The Administrator said LVN D called and reported Resident #38 accused CNA B of hitting her (Resident #38) in the shoulder. The Administrator said he told LVN D to tell CNA B to have no contact with Resident #38 and paired CNA B off with someone the rest of the shift. The Administrator acknowledged the policy said he should suspend her. He said the policy says can and then later says have to. He said the policy needed to be rewritten. He acknowledged he did not follow the facility policy. He said CNA B only worked on the 200 hall. Review of the 3/5/18 census documented there were 36 residents residing on the 200 hall where CNA B worked.

Based on observation, interview and record review, the facility failed to provide protection after an allegation of abuse for 1 of 11 residents (Resident #38) reviewed for abuse. The facility did not provide protection after an allegation of abuse from Resident #38. This failure could place the 36 residents who reside on Hall 2 at risk of not being protected from staff who have alleged abuse accusations. Findings included: Review of Resident #38's 3/5/18 Admission Record documented she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's 12/20/17 quarterly Minimum Data Set (MDS) Assessment documented: - She scored a 13 of 15 on her mental status exam (13-15 = cognitively intact) and showed no signs of [MEDICAL CONDITION]. - She had 2 of 27 indicators of depression (indicating possible mild depression). - She needed extensive assistance of one staff to transfer. - She was on scheduled pain medication, which was coded as occasionally experienced and was mild. - She was on an anti-anxiety medication for 7 of 7 days during the MDS assessment timeframe. Review of Resident #38's Care Plan updated 1/4/18 documented, in part: Focus: Resident #38 has frequent complaints about staff, food, and has had frequent physical complaints. Review of Resident #38's Incident Report date 3/4/18 documented, in part: Nursing Description: was summoned to resident's room by CNA (Certified Nurse Aide). This nurse accompanied by another nurse arrived to room . CNA x 2 noted at resident's side. Resident noted to be agitated and yelling at CNA's about not getting up in chair before supper. Self transferred from commode to bed without assist, was physically abusive towards CNA when they attempted to assist her, reported by CNA. This is when resident accused CNA of tugging her shoulder and hitting her shoulder. As conversation continued she continued to voice concerns on past problems and then was unable to remember the CNA that hit her shoulder earlier. Spoke with resident on concerns, Resident stated she tugged my shoulder, she then proceeded to say she hit my shoulder. Immediate Action Taken: Both shoulders assessed, able to move extremity without discomfort, no bruising or redness noted. Spoke with CNA's. Attempted several times to talk and comfort resident with no success. Administrator, DON (Director of Nurses), and family notified. Review of CNA B's undated statement documented at about 3:30 I, (CNA B) answered a call light for (Resident #38). She was sitting on the bedside commode. I let her know it was about time to start getting ready for supper since she was already up from her bed. She never answered me, nothing. She just started being combative towards me and self transferred herself to the edge of the bed. During that time she didn't even give me time to get gait belt, so I guided her to her bed to avoid fall by that time I had already told a coworker walking by to call my charge nurse. As soon as my charge nurse walked in room she told him that I had tugged her shoulder and before he walked out she said I had hit her shoulder. She never gave me time to even help her other than me guiding her safely to bed. She said it was not her problem what time the round started, she is always given the choice to eat in her room or dining room. I don't understand why she was so upset. Review of Restorative Aide (RA) C's undated statement documented on the day of (MONTH) 4, (YEAR) I was walking by the nurse's station and I heard (CNA B) asking for the nurse so I notified the nurse and went to see if I could help. (CNA B) wanted to let the nurse know that (Resident #38) transferred herself from the pot to the bed. (Resident #38) was sitting on the bed when I walked in . I asked (Resident #38) what the problem was and she replied I'm not getting in that chair and sitting for an hour before my tray comes that's stupid. I explained that she was our last resident to get up and it was time. She was saying we need to hire more people and we should get together and not show to work then (the facility) would have to hire more people. (Licensed Vocational Nurse (LVN D)) walked in and she had different complaints about different stuff, her gum, the staff not caring for her and then she said (CNA B) hit her on her shoulder. (LVN E) and (LVN D) tried talking to her but she got mad and asked to talk to her daughter. Review of Resident #38's Social Service notes documented, in part: - dated 1/4/18: resident continues to have frequent complaints about staff. - dated 3/5/18: Social Worker visited with (Resident #38) about an incident she reported to nursing. She stated that yesterday about 4:00 (she didn't know if it was morning or afternoon), a big old smart alec came into her room to get her up. She stated that the girl grabbed her by the shoulder and scratched her. She stated that she told the girl that she scratched her, and the girl denied it. (Resident #38) told her that she was lying. During an interview and observation on 03/05/18 at 02:42 PM Resident #38 was observed in bed. She had full range of motion of her arms. She said she was not given a choice about when to get up and some of the girls are not very respectful and some do not want to work. When asked for clarification, she repeated the statement. Resident #38 said it hurt when she lay in one place for too long and the staff take too long when she used her call light for help with repositioning. At no point during the interview did Resident #38 say the staff hurt her or were rough. During an interview on 03/08/18 at 11:08 AM CNA B said she worked at the facility for 1 year and 3 month. She said on 3/4/18 around 3:30-ish she was in another room. When she came out of the room Resident #38's call light was on so she answered it. CNA B said she knocked and entered the room. CNA B said Resident #38 was sitting on the bedside commode. CNA B said she got Resident #38's geri-chair closer to her. CNA B said she told Resident #38 it was almost supper time. CNA B said Resident #38 never really answered and just started getting up by herself. CNA B said when she started getting up I put hands on her waist to get to her to sit down, I was afraid she'd fall. CNA B explained she guided Resident #38 by waist and she sat on edge of bed. CNA B said she did not have a chance to get the gait belt. CNA B said she called RA C who walking down hall to call the charge nurse and then RA C came in to help. CNA B said the main thing was we did not want her to fall. CNA B said Resident #38 elbowed me the entire time. CNA B denied touching Resident #38's arm. CNA B said Resident #38 was upset. CNA B said Resident #38 never said 'I don't want to', and never gave CNA B the chance to ask about dinner. CNA B described Resident #38 as very fragile. CNA B said she did not know how long Resident #38 was on the call light. CNA B added she did not know how long she was sitting on the bedside commode, so she may have been in pain. CNA B added Resident #38 was very demanding and things have to be just so with her. CNA B said she never had problems with Resident #38 before. CNA B said most of time Resident #38 was a one person assist with transfers and she stood up pretty well. CNA B said occasionally Resident #38 would need 2 people to help with transfers. CNA B said Resident #38 never said she was hurting her, not even when charge nurse or RA C came in. CNA B said Resident #38 mentioned to (Restorative Aide) RA C that she tugged her arm. She said Resident #38 said CNA B hit her when charge nurse came in and Resident #38 said she pulled her arm. CNA B repeated I never touched her other than guiding her by the waist. CNA B said she let LVN D know real quick. CNA B said as soon as LVN D came in she reported Resident #38 changed her words between 'tug' and 'hit'. CNA B said LVN D told her to write an incident report. CNA B said LVN D did not send her home. CNA B said she told LVN D when RA C was in the room. During an interview on 03/08/18 at 11:33 AM RA C said she had been at the facility for 3 years. RA C said she was passing by and CNA B was by the door and asking for nurse assist. RA C said LVN D was on phone or writing something. RA C said she went down to Resident #38's room to help. RA C said Resident #38 was on the bed and you could tell she was already mad. RA C said Resident #38 transferred by herself. RA C explained in past the resident transferred by herself and fell . RA C said she asked Resident #38 if she wanted to eat in room and Resident #38 said no. RA C said Resident #38 kept repeating the facility needed more help. RA C said she told her we could not get people up at the last minute. RA C said Resident #38 kept going from one thing to another - her gum was missing; we weren't fast enough. RA C said LVN D came in and told Resident #38 to calm down. RA C said when the aides got her situated, Resident #38 said CNA B hit her. RA C said she asked Resident #38 why she did not mention it sooner and she said she forgot. RA C said she asked if we could look at her arm and she said no. RA C said Resident #38 was not tearful - just mad and trying to get her way. RA C said Resident #38 was not acting afraid. RA C said she was thinking 'why didn't she say anything when I came into the room?' RA C said Resident #38 was sitting on the bed and calmed down when RA C came in. RA C said she thought Resident #38 got upset because the aides did not agree with Resident #38 about not coming to work. She said LVN D went into Resident #38's room and then LVN E went in there to try to calm her down. They go in as two's just for safety too. RA C described Resident #38 as takes forever to get her ready, and she was really picky. RA C said the staff take a lot of time with Resident #38. RA C said she felt like one is just for her and everyone else is doing everything else. RA C added Resident #38 was not that hard to take care of, she was not heavy and she transferred well - she was just demanding. RA C said Resident #38 had thrown fits - its just a whole ball of complaints but had never accused anyone of hitting her before. RA C said the only thing Resident #38 says is the care is slow; and never said anyone was mean. RA C said Resident #38 was a one person assist with all activities of daily living and the staff had two staff in there for witness sake because the staff never know what kind of mood Resident #38 was going to be in. During an interview on 03/08/18 at 11:50 AM LVN D said he worked at the facility for four years. He said when he went into Resident #38's room Resident #38 was upset and on the bed. He said Resident #38 said CNA B hit her in shoulder or tugged on left shoulder. He said she was specific to the location. LVN D said Resident #38 was frustrated and was not crying or acting afraid. LVN D said after he assessed her, the aides got her in the geri chair and once she got into her geri-chair she was fine. LVN D said Resident #38 never said anyone hit her before. Not told anyone she's been hit before. LVN D said he left room called the DON, the Administrator and Resident #38's daughter. LVN D said the daughter asked what was happening and what caused it and then said she said understood. LVN D reported the daughter said Resident #38 was 'a handful' but did not understand why Resident #38 was up in the geri-chair for so long. LVN D said the Administrator told him to move CNA B away and put another CNA in there. LVN D said he was not instructed to send CNA B home. During an interview on 03/08/18 at 11:53 AM LVN E said she followed LVN D down to Resident #38's room. LVN D said RA C reported Resident #38 was screaming at CNA B. She said she was not sure when RA C went into the room. LVN E said Resident #38 was sitting on the bed. LVN E said Resident #38 never held her shoulder and never complained of pain in shoulder. LVN E said CNA B tried to explain that Resident #38 was upset and hitting her (CNA B) because Resident #38 did not want to get up. LVN E said at that point, (Resident #38) said no you hit me and then immediately said tugged on shoulder. LVN E said Resident #38 went to dinner and never said another word. LVN E said Resident #38 spoke to her daughter and did not say a word to her daughter. LVN E said she knew in the past Resident #38 gave CNA B a hard time. LVN E said right after CNA B said Resident #38 was combative, Resident #38 accused CNA B. LVN E said she thought Resident #38 was trying to put the blame on CNA B. LVN E said Resident #38 was very difficult - she's not respectful to aides or nursing staff or other residents. She's very demanding, if you're not doing what she wants then and there she will snap at you, she yells a lot. She wants one on one care. LVN E said it all boiled down to: (CNA B) said lets get up for dinner and (Resident #38) just snapped. LVN E said Resident #38 picked a few staff and goes out of her way to be difficult for them. During an interview on 03/08/18 at 01:44 PM the Administrator said the staff called and reported CNA B hit Resident #38 on the shoulder. He said LVN D reported when he when down to Resident #38's room, Resident #38 said CNA B rustled her on the draw sheet. He said LVN D did not find any bruising or redness. The Administrator said the next day he had the skin nurse do an assessment and she did not notice any bruising or redness. He said when the social worker interviewed Resident #38, she said CNA B scratched her on shoulder. The Administrator said LVN D reported Resident #38's story changed. The Administrator said Resident #38 was demanding and difficult. He said while transferring Resident #38, CNA B grabbed her to guide her to the bed. The Administrator said he thought it was a bad day. I knew based on the time they were disturbing her normal routine and that would upset her. The Administrator said LVN D called and reported Resident #38 accused CNA B of hitting her (Resident #38) in the shoulder. The Administrator said he told LVN D to tell CNA B to have no contact with Resident #38 and paired CNA B off with someone the rest of the shift. The Administrator acknowledged the policy said he should suspend her. He said the policy says can and then later says have to. He said the policy needed to be rewritten. He acknowledged he did not follow the facility policy. He said CNA B only worked on the 200 hall. Review of the facility's undated policy and procedure on Abuse Prevention documented, in part: The facility will not tolerate abuse or neglect in any form. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain. It is also defined as mental anguish or deprivation by an individual, including a care taker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Residents are protected against abuse by the following: Investigation: All allegations of abuse will be handled in the following manner: - The staff member who receives the allegations of abuse will contact the Administrator and or the DON immediately. - The staff will take immediate action to protect the resident population from further allegations of abuse. This action can include suspension of employees, monitored visits by families, and prohibited access to the facility for other individuals. Reporting/Response: All allegations of abuse are reported to the proper authorities. Any employee against whom allegations are alleged is suspended pending the outcome of the investigation. Review of the 3/5/18 census documented there were 36 residents residing on the 200 hall where CNA B worked.

Based on interview and record review, the Administrator and the Director of Nurses (DON) failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for one (Resident #16) of three discharged residents. The Administrator failed to implement the facility's Neglect Prevention Program Policies and Procedures, Fall Prevention Policies and Procedures, or policies related to Identifying a Change in Condition. The Administrator failed to supervise the DON to ensure she was doing a thorough job of ensuring staff complied with their job responsibilities and systems were implemented for monitoring of Changes in Condition. The DON and Administrator failed to identify that Resident #16 had a significant changes in condition (vomiting, increased blood pressure, lethargy, no urine output, "jerky movements," and out of the normal weakness) The DON failed to supervise the facility's nurses to ensure: LVN A and RN B recognized and notified the physician of changes in condition for Resident #16. All nurses were trained and following the facility's policy/procedure for unwitnessed falls. Communication between the nurses and nurse aides was conducted between shift change. These deficient practices resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE] at 3:55 p.m. While the IJ was removed on [DATE] at 4:21 p.m., the facility remained out of compliance at a level of Actual Harm at a Pattern that was not IJ because the facility had not had time to implement and monitor policies and procedures. These failures resulted in the physician not being involved in the diagnosing and/or management of critical medical conditions/crises for Residents #16. This failure could place 40 residents residing on Hall One at risk for delay in treatment, serious complications and/or death. Findings included: The Health survey was re-opened on [DATE]. An Extended Health Survey was conducted with an exit of [DATE]. 1. Review of Resident #16's Admission Record documented she was admitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Resident #16 had a Do Not Resuscitate (DNR) order. Review of the facility's Physician Discharge Summary signed by the physician on [DATE] documented Resident #16's final [DIAGNOSES REDACTED]. Review of Resident #16's [DATE] quarterly MDS (Minimum Data Set) assessment documented in part: - Makes self understood: sometimes understood - ability is limited to making concrete requests. - Mental Status: 3 of 15 (,[DATE] is considered severe cognitive impairment.) - [MEDICAL CONDITION] (misconceptions or beliefs that are firmly held, contrary to reality) - Resident was occasionally incontinent of bladder. - Resident had two or more falls without any injury and two or more falls with injuries (skin tears, abrasions, superficial bruises, hematomas, and sprains). Resident #16 had no falls with a major injury. Review of Resident #16's care plan last updated [DATE] documented, in part: - Resident #16 was "at risk for falls, injury d/t (due to) unsteady gait and cognitive impairment, [MEDICATION NAME] PRN (as needed), [MEDICATION NAME] q (every) d (day), and hx (history) of fall at home." The facility identified the following approaches: "w/c (wheelchair) used primarily self-propel short distance and without direction must be redirected." "monitor for s/sx (signs and symptoms) of med and report significant to doctor." "Personal safety alarm in bed and wheelchair pressure alarm." - Cognitive loss or alternation in thought processes related to dx of [MEDICAL CONDITION], as evidenced by moderately impaired decision making and short term and/or long term memory loss. - Resident has episodes of combative behavior with staff. Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [DATE] ,[DATE] (with morning medications) - [DATE] ,[DATE] (with morning medications) - [DATE] ,[DATE] (with morning medications) - [DATE] No Blood Pressure was documented - [DATE] ,[DATE] (with morning medications) Nurses notes dated [DATE] at 2215 (10:15 p.m.) documented: Called by north station nurse: observed resident laying on floor on L (left) side in front of w/c in TV (television) room, assessed resident, no apparent injuries observed. VS (vital signs) ,[DATE]-[DATE].5, assisted resident to w/c after 1 min (minute) VS ,[DATE]-[DATE].9, after 3 min in w/c - VS: ,[DATE]-[DATE].8 - no apparent distress, no c/o (complaints) voiced. Assisted resident to bed. At 2230 (10:30 p.m.) Notified resident's daughter. Notified Doctor per protocol (faxed to doctor's office). Encouraged resident to ask for assist. Personal alarm was on and sounding when found resident, WCTM (will continue to monitor). Signed by RN B. Review of the [DATE] Incident/Accident report completed by RN B documented Resident #16 had a fall at 2215 (10:15 p.m.) in the television room. RN B documented Resident #16 was confused. RN B documented Resident #16 did not have any apparent injuries at the time of the fall. Review of Resident #16's Post Fall Investigation for the [DATE] 10:15 p.m. fall documented: 1. Was the fall observed? No. 2. Resident's Vital Signs: 96.5 (temperature), 78 pulse, 18 respirations, ,[DATE] blood pressure, second blood pressure ,[DATE] sitting. 3. What was resident's response to "why do you think you fell ?" RN B documented: "Resident unable to tell why she thinks she fell . Resident delusional and responses are inappropriate for situation. Resident appeared to think she was in bed and was stating the bed not comfortable." Review of the second page of the Post Fall Investigation documented Resident #16 was Confused and Disoriented prior to and following the fall. Nurses notes dated [DATE] at 0400 (4:00 a.m.) documented: Resident in bed with eyes closed, no apparent distress observed. Alarms in place and on. WCTM. Signed by RN B. Review of Resident #16's ,[DATE] MAR indicated [REDACTED] Nurses notes dated [DATE] at 1540 (3:40 p.m.) documented: Resident in bed all day, unable to rouse resident sufficiently to administer 0800 (8 a.m.) or 1200 (noon) medications. Approximately 1430 (2:30 p.m.) dark emesis noted staining resident's face, bedding and clothing. VS - 96XXX,[DATE]-,[DATE]-22, O2 (oxygen saturation) 93 on RA (room air), occasional jerky movements, no intelligible conversation, responds to requests to open eyes, "squeeze fingers (very weakly)", HR (heart rate) apical vs (verses) radial is = (equal), no urine produced at this time on this shift, given water only to this time, will inform oncoming shift. Signed by LVN A. (No documentation the physician was notified). Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - LVN A circled as not given the following 7 a.m. through 7 p.m. medications on [DATE] - [MEDICATION NAME] 100mg (milligrams) for a stool softener. (8 a.m.) - [MEDICATION NAME] 7XXX,[DATE]mg for pain (8 a.m.) - Vitamin D3 2000 IU (units) for vitamin supplement (8 a.m.) - [MEDICATION NAME] 50 mg for dementia with behaviors (8 a.m.) - [MEDICATION NAME] 25mg (noon) - Artificial Tears for dry eyes (8 a.m.) - [MEDICATION NAME] 300mg for hypertension (8 a.m.) - [MEDICATION NAME] 100mg for osteoarthros (8 a.m.) - [MEDICATION NAME] XL 100 mg for hypertension (8 a.m.) - [MEDICATION NAME] 10mg for asthma (8 a.m.) LVN A documented "all 0800 meds held - resident sleeping could not rouse." and "1200 [MEDICATION NAME] held - Resident asleep could not rouse." Nurses notes dated [DATE] at 2030 (8:30 p.m.) documented: VS: ,[DATE]-[DATE]XXX,[DATE]% on RA. Assisted resident to bed, very lethargic at this time. Holding meds due to not waking enough to swallow. No apparent injuries observed from fall on [DATE]. Alarms in place, WCTM. Signed by RN B. (No documentation the physician was notified). Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - RN B circled as not given the following evening medications on [DATE]: - Klonopin 0.5 mg for [MEDICAL CONDITION] - [MEDICATION NAME] 7XXX,[DATE] (8 p.m.) - [MEDICATION NAME] 20mg for [MEDICAL CONDITION] (8 p.m.) Nurses notes dated [DATE] at 0230 (2:30 a.m.) documented: Vomited moderate amount of brown emesis, bowel sounds hyperactive, continues to be lethargic. Daughter had stated yesterday that her mom had been c/o stomach ache. CNA (Certified Nurse Aide) flowbook shows resident had large BM (bowel movement) on [DATE]. Will continue to monitor for further emesis or any other problems. Signed by RN B. (No documentation the physician was notified). Review of the ,[DATE] MAR indicated [REDACTED] Nurses notes dated [DATE] at 0950 (9:50 a.m.) documented: At approximately 0845 (8:45 a.m.) (CNA F) entered resident's room because she observed resident in bed and fluid on floor. At some time earlier another (CNA P) reported to this nurse resident was awake and (CNA G) had raised HOB (head of bed) and placed call light in reach. Resident was unresponsive when this nurse entered the room - no respirations, no blood pressure. At 0850 (8:50 a.m.) House Supervisor and Doctor were called. At 0915 (9:15 a.m.) Doctor arrived and pronounced death. Signed by LVN A. 2. During an interview on [DATE] at 11:55 a.m. the Director of Nurses (DON) said the nurse should call the physician due to abnormal symptoms such as heart rate, blood pressure or any change in condition. The DON said if residents have no apparent injuries then they only have to do vital signs after the fall. During a follow-up interview on [DATE] at 2:05 p.m. with the Administrator and DON present. The DON said the physician should be notified when there was an "abnormal change," not something the resident did all the time. The DON said an abnormal change would be breath sounds, heart rate, blood pressure right off the top of her head. The DON said she could not put a time limit on when a nurse should notify the physician. The DON pointed out the witness statements said Resident #16 was okay. The DON said the physician should be notified if a resident missed a dose depending on the medication. The DON said Resident #16 had no signs or symptoms of injuries so she did not have anything to stimulate a neuro-check. She said there was no suspicion of Resident #16 having a head injury. The DON said Resident #16 could tell you sometimes what happened. The Administrator added Resident #16 could communicate "immediate" needs or happenings. The Administrator said Resident #16 would have been able to report if she hit her head during a fall. The Administrator asked what the change in condition was. Surveyor outlined the nurses notes of vomiting and lethargic at times. The Administrator said Resident #16 was up and about in her wheelchair and was doing normal stuff and there was no reason to do neuro checks. The DON acknowledged LVN A was written up for not notifying the doctor. The DON said after Resident #16's fall she had to take a licensed nurse's word there were no signs or symptoms of injury and she did not think of the situation as neglect. She acknowledged not all injuries from a fall were immediately apparent but said with a head injury there was usually a raised area, a red area, a blue area. She said a delayed injury usually showed up in an arm or a leg. She said with a head injury there was a bruise or a lump quick. The DON said Resident #16 fell at 10:15 p.m. on [DATE] and it was 1:30 p.m. the next day when the nurse charted Resident #16 was in bed all day. The DON said Resident #16's vital signs were within normal limits, her oxygen level was alright, she opened her eyes and squeezed fingers (surveyor had to point out the note read "squeezed fingers weakly") and her heart rate was good. The DON said when she wrote LVN A up all this "other stuff" (anything after [DATE] at 10:30 p.m.) had not happened yet (LVN A was not written up until [DATE]) . She said she had to take the other nurse's word. The DON said "I don't think there was any neglect, I think it was stupid" The DON said Resident #16's vital signs were still good and the charting that Resident #16 was "lethargic" happened at night when she was in bed. The DON acknowledged the doctor should have been called. A review of a calendar documented [DATE] was a Saturday. The DON said she read LVN A's notes on the Monday after it happened ([DATE]). The DON said she thought LVN A failed to call the doctor and she did not think LVN A neglected Resident #16. The DON said when she noticed LVN A did not call the doctor she wrote her up. The Administrator said the nurses "all knew to notify the family, the doctor, and the state if something went wrong." According to the Mayo Clinic website based off Mayo Clinic Family Health book 4th Edition documented on Traumatic Brain Injuries Signs and Symptoms included, in part: nausea or vomiting, fatigue or drowsiness, sleeping more than usual. Moderate to severe traumatic brain injuries had the following symptoms: inability to wake from sleep, repeated vomiting or nausea. 3. During an interview on [DATE] at 3:30 p.m. Resident #16's physician verified she was not notified that Resident #16 had the change in condition of dark emesis, no urine output, jerky movements, incoherent speech, not taking her medication and that the resident was lethargic. She said she should have been notified that day. She said the staff called her on the day the resident passed but no one called and notified her of the change in condition. 4. Review of LVN A's undated written statement documented on [DATE] at approximately 1800 (6 p.m.) LVN A saw Resident #16 "up in wheelchair in day room. Family visiting with young children. Resident acknowledges greetings. 1800 meds (medications) administered at this time." During an interview on [DATE] at 3:45 p.m. LVN A said "I had seen Resident #16 "stay up all night at times and thought that was the reason we could not arouse her. I should have checked on the fact that she had no urine output. There is no time line for my charting and that is a mistake and not calling the physician (with the change of condition) was a mistake. I took another nurse (LVN O) to Resident #16's room and she said the vomiting did not smell like blood." 5. During an interview on [DATE] at 1:35 p.m. RN B said she had worked the 7:00 p.m. to 7:00 a.m. shift for three months. RN B confirmed she worked the weekend of [DATE] through [DATE]. She described Resident #16 as "very out of it, confused, disoriented." RN B said Resident #16 would stay up for "hours and hours and days and days" and then would "be out of it, sleeping." RN B said the other night nurse called her into the television room when Resident #16 was on the floor. RN B said she assessed Resident #16 and did all the vital signs and there were no apparent injuries observed. RN B said the staff put Resident #16 to bed at that time and at 4 a.m. she was asleep, in no distress and the alarms were on. RN B acknowledged Resident #16 was unable to answer appropriately if she hit her head. RN B acknowledged Resident #16's blood pressure was high, but noted that the blood pressure was going down on the third check. RN B confirmed she did not start neuro-checks. RN B said on [DATE] (Saturday 7 p.m.) she saw Resident #16 up in her wheelchair at the beginning of her shift with her grandchildren. She said Resident #16 was "lethargic." RN B explained Resident #16 was "out of it, not talking, and not responding that much." RN B said she briefly talked with the family and told them the staff would put Resident #16 to bed. RN B said Resident #16 being lethargic "wasn't anything abnormal," since that was how Resident #16 was when she had been up for hours. RN B said she was told in report that Resident #16 had vomited. RN B said she remembered the daughter saying Resident #16's stomach hurt. RN B said she held Resident #16's 8:30 p.m. medications because of the lethargy. RN B said "I didn't want to put medications in her mouth, it was not the first time this was the case." RN B said she did not know the facility's policy and procedure about holding medications. She said she did not feel comfortable putting medications in Resident #16's mouth. She said the medication was Klonopin which she didn't need because it was something to make her more lethargic. RN B said Resident #16 did vomit some on her shift. RN B said the vomit was brown and not coffee ground colored. RN B said Resident #16 had not acted any different at that point. RN B said there was nothing to report to the physician. She said Resident #16 vomited "once, that was it, she was stable." RN B pointed out the facility had standing orders for nausea/ vomiting, "but it was just that one time." RN B said she did not want to give Resident #16 the [MEDICATION NAME] because "if it was not necessary it would knock her out even more." RN B said again there was nothing abnormal about Resident #16 being lethargic other than the one time vomiting. She said the vomit was not "dark or coffee grounds or smelled." RN B said the aides did not tell her Resident #16 was acting any different. RN B said the facility did not do neuro-checks if the resident said they did not hit their head. She said it seemed odd to her and it "made sense" to do them if it was an unwitnessed fall. She said in her orientation she was told to do neuro- checks only if there were signs or symptoms or if you saw the resident hit their head. RN B said "if there were no signs or symptoms if they hit their head you didn't do them." RN B said she was not in-serviced about the neuro-check policy and procedure. RN B said she knew to call the doctor with a change in condition. RN B said "other than" Resident #16 "vomiting, there was nothing out of her normal behavior or I definitely would have" called the doctor. RN B said vomiting after a fall was not a good thing. She said with Resident #16's daughter saying her stomach hurting prior to the fall she was thinking the emesis was related to the stomach ache. RN B said "I didn't relate it to the fall." 6. During an interview on [DATE] at 10:52 a.m. CNA C said she was the shower aide on [DATE]. CNA C said Resident #16 had Alzheimer's, sometimes she could tell you if she needed to go to the bathroom but often she would be incontinent. CNA C said Resident #16 was "never mean, she had a big appetite that is how you knew if she was not feeling good." CNA C said Resident #16 "threw up the black stuff three times that Saturday." ([DATE]) CNA C said Resident #16 "threw up in the dining room during breakfast." She said they took her back to bed. She said the resident threw up again and the staff "had to change everything." CNA C acknowledged the nurse (LVN A) came to the room to assess the resident. She said the nurse told the staff to "sit her up in bed" and she ordered her a liquid diet. CNA C said she heard Resident #16 threw up again before day shift left and somebody from night shift helped clean her up. CNA C said normally Resident #16 would be up in her wheelchair all day and participate in activities. CNA C said from "Friday to Saturday she made a 360 degree turn." CNA C said she was not aware Resident #16 had a fall Friday night ([DATE]). CNA C said about once a week Resident #16 would stay up all night then sleep during the day. 7. During an interview on [DATE] at 11:30 a.m. CNA M verified she worked [DATE] on the 7:00 a.m. to 7:00 p.m. shift. CNA M said Resident #16 was "confused, hallucinated, never had a clear thought, would fidget and couldn't sit still." CNA M said if Resident #16 fell she could "probably not" tell you if she hit her head. CNA M said "that day ([DATE]) she complained of stomach pains." CNA M said she took Resident #16 to the bathroom and Resident #16 said "hurts so bad, hurts so bad." CNA M said she could not remember who she reported it to. CNA M said before she left Resident #16 complained about her stomach hurting again and she reported it to LVN N (charge nurse). CNA M said Resident #16 ate lunch and supper but it was not uncommon for her not to eat breakfast. CNA M said a few days after this the DON, Administrator and ADON asked her what happened. CNA M said she told them Resident #16 had complained of a stomach ache and she had reported it to the nurse. 8. During an interview on [DATE] at 3:30 p.m. LVN N said she worked the 7 a.m. to 7 p.m. shift on [DATE] (the day of the fall, before the fall occurred). LVN N confirmed she worked with Resident #16. LVN N said she did not believe there was anything going on with Resident #16, "she seemed fine to me." LVN N described Resident #16 as "happily confused." LVN N said she did not recall the aides reporting that Resident #16's stomach hurt. LVN N said "if they did, I went and assessed her. I don't remember going." LVN N said Resident #16 was normally confused in the morning and hard to wake up. LVN N said Resident #16 was "not really" lethargic "but you had to really talk to her to make sure she was alert." LVN N said Resident #16 could be up 24 - 48 hours at times despite her medications and then "be out" for 8 - 10 hours and "then she'd be up again." She said Resident #16 would follow this cycle every couple of days. LVN N said Resident #16 was "difficult to arouse at times." LVN N said Resident #16 could answer immediate yes or no questions. LVN N said if more than 15 minutes then Resident #16 probably could not tell if she hit her head. LVN N said the facility did neuro-checks any time the facility could confirm the resident hit their head. LVN N said she would "automatically initiate neuro-checks herself" because Resident #16 was confused. LVN N said the facility would not normally start neuro-checks if there were no signs of injury. LVN N confirmed if a cognitively impaired resident fell and there were no signs of injury the staff would do three vital signs (initially before moving the resident, then one minute after getting resident up, then three minutes after getting the resident up) and an incident/ accident report. She said she did not recall Resident #16 having any changes in condition or nausea/ vomiting nor did she recall the aide telling her anything. 9. During an interview on [DATE] at 3:55 p.m. LVN O said she remembered Resident #16. LVN O said she remembered LVN A calling her into Resident #16's room to assess the vomit ([DATE]). LVN O said it was "mainly food particles and dark green in color." LVN O said she only knew of Resident #16 vomiting only one time. LVN O said "in her mind" it was between breakfast and lunch, "but it could have been later." LVN O said she did not remember the vomit having an odor. LVN O said she did not know that Resident #16 had no urine output. LVN O said LVN A could have mentioned it and she not remember. LVN O said she only knew of the vomiting. LVN O said Resident #16 "was kinda weak" and did not remember Resident #16 saying anything. LVN O said Resident #16 would stay up for 24 - 48 hours and then sleep for 24 hours. LVN O said if there was an unwitnessed fall the nurses would do an incident/ accident report, take vital signs while the resident was on the floor and assess for any injuries, and range of motion. LVN O said after that staff would put the resident back in the wheelchair or bed then take the vital signs again. LVN O said vital signs were done one minute and then three minutes after getting the resident up. LVN O said "in the past" neuro-checks were only done when the resident hit their head. 10. Review of CNA G's [DATE] unsigned, typed statement CNA G saw Resident #16 in the room and she was "up moving around in bed messing with her stuff in the drawer. So I raised her head up so she can see what she was doing. She was fine when I was in the room getting (Resident #9's) glasses out the room." During an interview on [DATE] at 4:30 p.m. CNA G confirmed she worked the 7 a.m. to 7 p.m. shift on [DATE]. CNA G said Resident #9 (Resident #16's roommate) said she forgot her glasses around 7:30 a.m. CNA G said Resident #16 "was fine." CNA G said Resident #16 was in bed messing with stuff in her drawer. CNA G said Resident #16 told her "hi" when CNA G asked what Resident #16 was doing. CNA G said she gave Resident #16 a sip of water with no problems. CNA G said she asked Resident #16 if she needed anything and Resident #16 said she was doing good so she left to go feed resident in the dining room. CNA G said at about 8:15 a.m. they came to the dining room to say Resident #16 passed. She said some days Resident #16 acted like she knew what was going on and some days she would not. CNA G described Resident #16 as she "slept a lot, liked to talk a lot, liked to drink a lot." CNA G said she wrote her statement the following Monday ([DATE]) because she wanted staff to know what she saw. CNA G said she wrote it for herself and no one asked her to. 11. During an interview on [DATE] at 9:15 a.m. CNA P said she worked Saturday [DATE] during the day shift (7 a.m. through 7 p.m.). CNA P said she was not informed of the fall but noticed Resident #16 was "a little tired" and she did not want to do anything. CNA P said they got Resident #16 up for breakfast that day but did not think she ate anything. CNA P said Resident #16 would usually "just pick" at her food. CNA P said "at 8:30ish" Resident #16 was ok, she was asleep. CNA P said she remembered Resident #16 "didn't wet" that entire day and that was unusual. CNA P said after she took Resident #16 to bed she did showers and when she was done she went to check on Resident #16. CNA P said Resident #16 would answer yes/no questions and only with yes/no. CNA P said usually Resident #16 would try to have a conversation with the aides. CNA P said they did not get Resident #16 up for lunch that day and that was unusual. She said Resident #16 would not eat her lunch and she slept through it. CNA P said she reported that to the nurse. CNA P said Resident #16 still had not wet when she checked on her after putting other residents down after lunch. CNA P said she took lunch between 1:30 and 2 p.m. She said the staff came and got her during her lunch to say Resident #16 had gotten sick. She said she went and got CNA R to help clean up Resident #16. CNA P described Resident #16's vomit as thick," "blackish-brownish" with no smell and that it was "all over" Resident #16. CNA P said the vomit went off the bed onto the floor mat. CNA P said she went and got the nurse who told her it was probably something Resident #16 ate. CNA P said they got Resident #16 cleaned up and Resident #16 wanted out of bed. CNA P said they got Resident #16 up and she was "normal" for about 15 - 20 minutes. CNA P said they noticed Resident #16 was "slouched" in her wheelchair sleeping so they put her back to bed. CNA P said Resident #16 still had not wet by supper time and was still sleeping. CNA P said the nurse told her to hold her tray since she threw up and ordered her a liquid diet but Resident #16 did not eat any of it. CNA P said Resident #16 "finally wet" on her last rounds but it was not a normal amount. CNA P said Resident #16 "was fine" when she left at 7 p.m. that night. CNA P said she reported it to the oncoming shift but did not remember who. CNA P said Resident #16 vomited one time her shift. She said Resident #16 did not complain of pain. CNA P said she worked on [DATE] (Sunday) but was not assigned to Resident #16's room. She said she looked in on Resident #16 to see who the night shift had gotten up and who they had not. She said Resident #16 was in her room like normal and she just thought the vomiting was a stomach bug. CNA P said she offered Resident #16 a couple of sips of water, straightened her up in bed and left the room to feed residents in the dining room. CNA P said Resident #16 did not talk to her that day. She said the agency aide came in to ask who had Resident #16's room and told them Resident #16 died . CNA P said she went back to hall and saw that there was "vomit everywhere." CNA P said Resident #16 had not stayed in bed all day before [DATE] and just thought it was for the day. She said Resident #16 would just pick at her food which was not normal and she did not drink as much as she usually did as well. She said Resident #16 did not talk on [DATE] and that was not her normal. CNA P said she was unaware Resident #16 fell on [DATE]. CNA P said there was not a lot of communication between the nurses and the aides. CNA P said if the aides knew about the [DATE] fall they would have known more about what was going on with the resident "but no one said anything in report." 12. Review of CNA F's [DATE] statement documented CNA F worked Sunday [DATE]. CNA F documented she got Resident #16 her breakfast tray "at 7:40 a.m. took it to her room and she was in bed her head was moving. So I decided to get her up because she was awake. I brought her tray back to the cart at the end of the hall, went back to there room and seen a pool of liquid all over the floor. I said what did you (do) now Mrs. (Resident #16) she did not respond so I pushed on her shoulder and she fell back there was no sign of life. I checked for a pulse and eyes then went out in hall and yelled for help." During an interview on [DATE] at 4:45 p.m. CNA F said she worked with Resident #16 on [DATE] (7 a.m. to 7 p.m.). CNA F said she took Resident #16 her breakfast tray. CNA F said Resident #16 was awake, leaning on the side of the bed and digging through her drawer. CNA F said she returned Resident #16's breakfast tray to the hall cart and returned to the room, which took "two - three minutes at the most." CNA F said there was a "big flood" of brown looking stuff on the floor. CNA F said she checked Resident #16's pulse and her eyes, pulled the call light, and went to holler down the hall. CNA F said the fluid was reddish-brown and there was a "big, huge puddle, like a river" on the floor. CNA F said it did not smell. She said the fluid was all down the bed, to the floor. She said Resident #16's head of bed was up. 13. During an interview on [DATE] at 1:30 p.m. Medical Director BB said he had conferred with Medical Director AA about the case. He confirmed the facility did not call Medical Director AA (Resident #16's physician) the Friday ([DATE]) night concerning the fall. He said the staff "probably faxed" the notification to the doctor and there was no one who would have looked at it until Monday ([DATE]). Medical Director BB said if Resident #16 was vomiting "someone should have been notified." 14. During an interview on [DATE] at 3:55 p.m. the Administrator, DON, and ADON was informed of the identification of an IJ situation. 15. During an interview on [DATE] at 8:55 a.m. Medical Director AA said she was called Sunday Morning ([DATE]) about Resident #16. Medical Director AA said she did see the emesis. Medical Director AA said the emesis was on the mats and on the floor. Medical Director AA described the emesis as "brown." Medical Director AA said she used a urine dip stick to test the emesis for blood and it showed positive. Medical Director AA said Resident #16 was at risk for a GI Bleed because she was on [MEDICATION NAME] and she had GERD. Medical Director AA said the family just wanted Resident #16 comfortable. Medical Director AA said she had a hard time with Resident #16's behaviors due to end stage [MEDICAL CONDITION]. Medical Director AA said she should have been notified of Resident #16 "not taking medication, not being arrousable, having no urine output." She said "all of these things equal a change in condition." 16. During an interview on [DATE] at 10:09 a.m. CNA Q said she worked for an agency but did remember taking care of Resident #16 the night of [DATE] during the 7:00 p.m. to 7:00 a.m. shift. CNA Q said Resident #16 "vomited black vomit two times" during her shift and she reported it to the nurse (RN B). CNA Q said Resident #16 would wake up when she provided incontinent care but then went right back to sleep. 17. Review of the Employee Counseling Report dated [DATE] and signed by the DON and LVN A documented in p

Based on interview and record review the facility failed to ensure two of two nurses immediately consulted with the physician when there was a change in the physical status and a need to alter treatment or to commence a new form of treatment for 1 of 3 discharged residents (Resident #16). A) Licensed Vocational Nurse (LVN) A failed to notify the physician when Resident #16 had dark brown emesis, was unable to arouse resident to take medications, had no urine output and had "jerky movements" on [DATE]. B) Registered Nurse (RN) B did not notify the physician when she assisted Resident #16 to bed and documented Resident #16 was too lethargic to take her medications on [DATE] and had brown emesis on [DATE]. Resident #16 died on [DATE]. These deficient practices resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE] at 3:55 p.m. While the IJ was removed on [DATE] at 4:21 p.m., the facility remained out of compliance at a level of Actual Harm at a Pattern that was not IJ because the facility had not had time to implement and monitor policies and procedures. This failure could place 40 residents residing on Hall One at risk for delay in treatment, serious complications and/or death. Findings included: The Health survey was re-opened on [DATE]. An Extended Health Survey was conducted with an exit of [DATE]. 1. Review of Resident #16's Admission Record documented she was admitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Resident #16 had a Do Not Resuscitate (DNR) order. Review of the facility's Physician Discharge Summary signed by the physician on [DATE] documented Resident #16's final [DIAGNOSES REDACTED]. Review of Resident #16's [DATE] quarterly MDS (Minimum Data Set) assessment documented in part: - Makes self understood: sometimes understood - ability is limited to making concrete requests. - Mental Status: 3 of 15 (,[DATE] is considered severe cognitive impairment.) - [MEDICAL CONDITION] (misconceptions or beliefs that are firmly held, contrary to reality) - Resident was occasionally incontinent of bladder. - Resident had two or more falls without any injury and two or more falls with injuries (skin tears, abrasions, superficial bruises, hematomas, and sprains). Resident #16 had no falls with a major injury. Review of Resident #16's care plan last updated [DATE] documented, in part: - Resident #16 was "at risk for falls, injury d/t (due to) unsteady gait and cognitive impairment, [MEDICATION NAME] PRN (as needed), [MEDICATION NAME] q (every) d (day), and hx (history) of fall at home." The facility identified the following approaches: "w/c (wheelchair) used primarily self-propel short distance and without direction must be redirected." "monitor for s/sx (signs and symptoms) of med and report significant to doctor." "Personal safety alarm in bed and wheelchair pressure alarm." - Cognitive loss or alternation in thought processes related to dx of [MEDICAL CONDITION], as evidenced by moderately impaired decision making and short term and/or long term memory loss. - Resident has episodes of combative behavior with staff. Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [DATE] ,[DATE] (with morning medications) - [DATE] ,[DATE] (with morning medications) - [DATE] ,[DATE] (with morning medications) - [DATE] No Blood Pressure was documented - [DATE] ,[DATE] (with morning medications) Nurses notes dated [DATE] at 2215 (10:15 p.m.) documented: Called by north station nurse: observed resident laying on floor on L (left) side in front of w/c in TV (television) room, assessed resident, no apparent injuries observed. VS (vital signs) ,[DATE]-[DATE].5, assisted resident to w/c after 1 min (minute) VS ,[DATE]-[DATE].9, after 3 min in w/c - VS: ,[DATE]-[DATE].8 - no apparent distress, no c/o (complaints) voiced. Assisted resident to bed. At 2230 (10:30 p.m.) Notified resident's daughter. Notified Doctor per protocol (faxed to doctor's office). Encouraged resident to ask for assist. Personal alarm was on and sounding when found resident, WCTM (will continue to monitor). Signed by RN B. Review of the [DATE] Incident/Accident report completed by RN B documented Resident #16 had a fall at 2215 (10:15 p.m.) in the television room. RN B documented Resident #16 was confused. RN B documented Resident #16 did not have any apparent injuries at the time of the fall. Review of Resident #16's Post Fall Investigation for the [DATE] 10:15 p.m. fall documented: 1. Was the fall observed? No. 2. Resident's Vital Signs: 96.5 (temperature), 78 pulse, 18 respirations, ,[DATE] blood pressure, second blood pressure ,[DATE] sitting. 3. What was resident's response to "why do you think you fell ?" RN B documented: "Resident unable to tell why she thinks she fell . Resident delusional and responses are inappropriate for situation. Resident appeared to think she was in bed and was stating the bed not comfortable." Review of the second page of the Post Fall Investigation documented Resident #16 was Confused and Disoriented prior to and following the fall. Nurses notes dated [DATE] at 0400 (4:00 a.m.) documented: Resident in bed with eyes closed, no apparent distress observed. Alarms in place and on. WCTM. Signed by RN B. Review of Resident #16's ,[DATE] MAR indicated [REDACTED] Nurses notes dated [DATE] at 1540 (3:40 p.m.) documented: Resident in bed all day, unable to rouse resident sufficiently to administer 0800 (8 a.m.) or 1200 (noon) medications. Approximately 1430 (2:30 p.m.) dark emesis noted staining resident's face, bedding and clothing. VS - 96XXX,[DATE]-,[DATE]-22, O2 (oxygen saturation) 93 on RA (room air), occasional jerky movements, no intelligible conversation, responds to requests to open eyes, "squeeze fingers (very weakly)", HR (heart rate) apical vs (verses) radial is = (equal), no urine produced at this time on this shift, given water only to this time, will inform oncoming shift. Signed by LVN A. (No documentation the physician was notified). Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - LVN A circled as not given the following 7 a.m. through 7 p.m. medications on [DATE] - [MEDICATION NAME] 100mg (milligrams) for a stool softener. (8 a.m.) - [MEDICATION NAME] 7XXX,[DATE]mg for pain (8 a.m.) - Vitamin D3 2000 IU (units) for vitamin supplement (8 a.m.) - [MEDICATION NAME] 50 mg for dementia with behaviors (8 a.m.) - [MEDICATION NAME] 25mg (noon) - Artificial Tears for dry eyes (8 a.m.) - [MEDICATION NAME] 300mg for hypertension (8 a.m.) - [MEDICATION NAME] 100mg for osteoarthros (8 a.m.) - [MEDICATION NAME] XL 100 mg for hypertension (8 a.m.) - [MEDICATION NAME] 10mg for asthma (8 a.m.) LVN A documented "all 0800 meds held - resident sleeping could not rouse." and "1200 [MEDICATION NAME] held - Resident asleep could not rouse." Nurses notes dated [DATE] at 2030 (8:30 p.m.) documented: VS: ,[DATE]-[DATE]XXX,[DATE]% on RA. Assisted resident to bed, very lethargic at this time. Holding meds due to not waking enough to swallow. No apparent injuries observed from fall on [DATE]. Alarms in place, WCTM. Signed by RN B. (No documentation the physician was notified). Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - RN B circled as not given the following evening medications on [DATE]: - Klonopin 0.5 mg for [MEDICAL CONDITION] - [MEDICATION NAME] 7XXX,[DATE] (8 p.m.) - [MEDICATION NAME] 20mg for [MEDICAL CONDITION] (8 p.m.) Nurses notes dated [DATE] at 0230 (2:30 a.m.) documented: Vomited moderate amount of brown emesis, bowel sounds hyperactive, continues to be lethargic. Daughter had stated yesterday that her mom had been c/o stomach ache. CNA (Certified Nurse Aide) flowbook shows resident had large BM (bowel movement) on [DATE]. Will continue to monitor for further emesis or any other problems. Signed by RN B. (No documentation the physician was notified). Review of the ,[DATE] MAR indicated [REDACTED] Nurses notes dated [DATE] at 0950 (9:50 a.m.) documented: At approximately 0845 (8:45 a.m.) (CNA F) entered resident's room because she observed resident in bed and fluid on floor. At some time earlier another (CNA P) reported to this nurse resident was awake and (CNA G) had raised HOB (head of bed) and placed call light in reach. Resident was unresponsive when this nurse entered the room - no respirations, no blood pressure. At 0850 (8:50 a.m.) House Supervisor and Doctor were called. At 0915 (9:15 a.m.) Doctor arrived and pronounced death. Signed by LVN A. 2. During an interview on [DATE] at 11:55 a.m. the Director of Nurses (DON) said the nurse should call the physician due to abnormal symptoms such as heart rate, blood pressure or any change in condition. The DON said if residents have no apparent injuries then they only have to do vital signs after the fall. During a follow-up interview on [DATE] at 2:05 p.m. with the Administrator and DON present. The DON said the physician should be notified when there was an "abnormal change," not something the resident did all the time. The DON said an abnormal change would be breath sounds, heart rate, blood pressure right off the top of her head. The DON said she could not put a time limit on when a nurse should notify the physician. The DON pointed out the witness statements said Resident #16 was okay. The DON said the physician should be notified if a resident missed a dose depending on the medication. The DON said Resident #16 had no signs or symptoms of injuries so she did not have anything to stimulate a neuro-check. She said there was no suspicion of Resident #16 having a head injury. The DON said Resident #16 could tell you sometimes what happened. The Administrator added Resident #16 could communicate "immediate" needs or happenings. The Administrator said Resident #16 would have been able to report if she hit her head during a fall. The Administrator asked what the change in condition was. Surveyor outlined the nurses notes of vomiting and lethargic at times. The Administrator said Resident #16 was up and about in her wheelchair and was doing normal stuff and there was no reason to do neuro checks. The DON acknowledged LVN A was written up for not notifying the doctor. The DON said after Resident #16's fall she had to take a licensed nurse's word there were no signs or symptoms of injury and she did not think of the situation as neglect. She acknowledged not all injuries from a fall were immediately apparent but said with a head injury there was usually a raised area, a red area, a blue area. She said a delayed injury usually showed up in an arm or a leg. She said with a head injury there was a bruise or a lump quick. The DON said Resident #16 fell at 10:15 p.m. on [DATE] and it was 1:30 p.m. the next day when the nurse charted Resident #16 was in bed all day. The DON said Resident #16's vital signs were within normal limits, her oxygen level was alright, she opened her eyes and squeezed fingers (surveyor had to point out the note read "squeezed fingers weakly") and her heart rate was good. The DON said when she wrote LVN A up all this "other stuff" (anything after [DATE] at 10:30 p.m.) had not happened yet (LVN A was not written up until [DATE]) . She said she had to take the other nurse's word. The DON said "I don't think there was any neglect, I think it was stupid" The DON said Resident #16's vital signs were still good and the charting that Resident #16 was "lethargic" happened at night when she was in bed. The DON acknowledged the doctor should have been called. A review of a calendar documented [DATE] was a Saturday. The DON said she read LVN A's notes on the Monday after it happened ([DATE]). The DON said she thought LVN A failed to call the doctor and she did not think LVN A neglected Resident #16. The DON said when she noticed LVN A did not call the doctor she wrote her up. The Administrator said the nurses "all knew to notify the family, the doctor, and the state if something went wrong." According to the Mayo Clinic website based off Mayo Clinic Family Health book 4th Edition documented on Traumatic Brain Injuries Signs and Symptoms included, in part: nausea or vomiting, fatigue or drowsiness, sleeping more than usual. Moderate to severe traumatic brain injuries had the following symptoms: inability to wake from sleep, repeated vomiting or nausea. 3. During an interview on [DATE] at 3:30 p.m. Resident #16's physician verified she was not notified that Resident #16 had the change in condition of dark emesis, no urine output, jerky movements, incoherent speech, not taking her medication and that the resident was lethargic. She said she should have been notified that day. She said the staff called her on the day the resident passed but no one called and notified her of the change in condition. 4. Review of LVN A's undated written statement documented on [DATE] at approximately 1800 (6 p.m.) LVN A saw Resident #16 "up in wheelchair in day room. Family visiting with young children. Resident acknowledges greetings. 1800 meds (medications) administered at this time." During an interview on [DATE] at 3:45 p.m. LVN A said "I had seen Resident #16 "stay up all night at times and thought that was the reason we could not arouse her. I should have checked on the fact that she had no urine output. There is no time line for my charting and that is a mistake and not calling the physician (with the change of condition) was a mistake. I took another nurse (LVN O) to Resident #16's room and she said the vomiting did not smell like blood." 5. During an interview on [DATE] at 1:35 p.m. RN B said she had worked the 7:00 p.m. to 7:00 a.m. shift for three months. RN B confirmed she worked the weekend of [DATE] through [DATE]. She described Resident #16 as "very out of it, confused, disoriented." RN B said Resident #16 would stay up for "hours and hours and days and days" and then would "be out of it, sleeping." RN B said the other night nurse called her into the television room when Resident #16 was on the floor. RN B said she assessed Resident #16 and did all the vital signs and there were no apparent injuries observed. RN B said the staff put Resident #16 to bed at that time and at 4 a.m. she was asleep, in no distress and the alarms were on. RN B acknowledged Resident #16 was unable to answer appropriately if she hit her head. RN B acknowledged Resident #16's blood pressure was high, but noted that the blood pressure was going down on the third check. RN B confirmed she did not start neuro-checks. RN B said on [DATE] (Saturday 7 p.m.) she saw Resident #16 up in her wheelchair at the beginning of her shift with her grandchildren. She said Resident #16 was "lethargic." RN B explained Resident #16 was "out of it, not talking, and not responding that much." RN B said she briefly talked with the family and told them the staff would put Resident #16 to bed. RN B said Resident #16 being lethargic "wasn't anything abnormal," since that was how Resident #16 was when she had been up for hours. RN B said she was told in report that Resident #16 had vomited. RN B said she remembered the daughter saying Resident #16's stomach hurt. RN B said she held Resident #16's 8:30 p.m. medications because of the lethargy. RN B said "I didn't want to put medications in her mouth, it was not the first time this was the case." RN B said she did not know the facility's policy and procedure about holding medications. She said she did not feel comfortable putting medications in Resident #16's mouth. She said the medication was Klonopin which she didn't need because it was something to make her more lethargic. RN B said Resident #16 did vomit some on her shift. RN B said the vomit was brown and not coffee ground colored. RN B said Resident #16 had not acted any different at that point. RN B said there was nothing to report to the physician. She said Resident #16 vomited "once, that was it, she was stable." RN B pointed out the facility had standing orders for nausea/ vomiting, "but it was just that one time." RN B said she did not want to give Resident #16 the [MEDICATION NAME] because "if it was not necessary it would knock her out even more." RN B said again there was nothing abnormal about Resident #16 being lethargic other than the one time vomiting. She said the vomit was not "dark or coffee grounds or smelled." RN B said the aides did not tell her Resident #16 was acting any different. RN B said the facility did not do neuro-checks if the resident said they did not hit their head. She said it seemed odd to her and it "made sense" to do them if it was an unwitnessed fall. She said in her orientation she was told to do neuro- checks only if there were signs or symptoms or if you saw the resident hit their head. RN B said "if there were no signs or symptoms if they hit their head you didn't do them." RN B said she was not in-serviced about the neuro-check policy and procedure. RN B said she knew to call the doctor with a change in condition. RN B said "other than" Resident #16 "vomiting, there was nothing out of her normal behavior or I definitely would have" called the doctor. RN B said vomiting after a fall was not a good thing. She said with Resident #16's daughter saying her stomach hurting prior to the fall she was thinking the emesis was related to the stomach ache. RN B said "I didn't relate it to the fall." 6. During an interview on [DATE] at 10:52 a.m. CNA C said she was the shower aide on [DATE]. CNA C said Resident #16 had Alzheimer's, sometimes she could tell you if she needed to go to the bathroom but often she would be incontinent. CNA C said Resident #16 was "never mean, she had a big appetite that is how you knew if she was not feeling good." CNA C said Resident #16 "threw up the black stuff three times that Saturday." ([DATE]) CNA C said Resident #16 "threw up in the dining room during breakfast." She said they took her back to bed. She said the resident threw up again and the staff "had to change everything." CNA C acknowledged the nurse (LVN A) came to the room to assess the resident. She said the nurse told the staff to "sit her up in bed" and she ordered her a liquid diet. CNA C said she heard Resident #16 threw up again before day shift left and somebody from night shift helped clean her up. CNA C said normally Resident #16 would be up in her wheelchair all day and participate in activities. CNA C said from "Friday to Saturday she made a 360 degree turn." CNA C said she was not aware Resident #16 had a fall Friday night ([DATE]). CNA C said about once a week Resident #16 would stay up all night then sleep during the day. 7. During an interview on [DATE] at 11:30 a.m. CNA M verified she worked [DATE] on the 7:00 a.m. to 7:00 p.m. shift. CNA M said Resident #16 was "confused, hallucinated, never had a clear thought, would fidget and couldn't sit still." CNA M said if Resident #16 fell she could "probably not" tell you if she hit her head. CNA M said "that day ([DATE]) she complained of stomach pains." CNA M said she took Resident #16 to the bathroom and Resident #16 said "hurts so bad, hurts so bad." CNA M said she could not remember who she reported it to. CNA M said before she left Resident #16 complained about her stomach hurting again and she reported it to LVN N (charge nurse). CNA M said Resident #16 ate lunch and supper but it was not uncommon for her not to eat breakfast. CNA M said a few days after this the DON, Administrator and ADON asked her what happened. CNA M said she told them Resident #16 had complained of a stomach ache and she had reported it to the nurse. 8. During an interview on [DATE] at 3:30 p.m. LVN N said she worked the 7 a.m. to 7 p.m. shift on [DATE] (the day of the fall, before the fall occurred). LVN N confirmed she worked with Resident #16. LVN N said she did not believe there was anything going on with Resident #16, "she seemed fine to me." LVN N described Resident #16 as "happily confused." LVN N said she did not recall the aides reporting that Resident #16's stomach hurt. LVN N said "if they did, I went and assessed her. I don't remember going." LVN N said Resident #16 was normally confused in the morning and hard to wake up. LVN N said Resident #16 was "not really" lethargic "but you had to really talk to her to make sure she was alert." LVN N said Resident #16 could be up 24 - 48 hours at times despite her medications and then "be out" for 8 - 10 hours and "then she'd be up again." She said Resident #16 would follow this cycle every couple of days. LVN N said Resident #16 was "difficult to arouse at times." LVN N said Resident #16 could answer immediate yes or no questions. LVN N said if more than 15 minutes then Resident #16 probably could not tell if she hit her head. LVN N said the facility did neuro-checks any time the facility could confirm the resident hit their head. LVN N said she would "automatically initiate neuro-checks herself" because Resident #16 was confused. LVN N said the facility would not normally start neuro-checks if there were no signs of injury. LVN N confirmed if a cognitively impaired resident fell and there were no signs of injury the staff would do three vital signs (initially before moving the resident, then one minute after getting resident up, then three minutes after getting the resident up) and an incident/ accident report. She said she did not recall Resident #16 having any changes in condition or nausea/ vomiting nor did she recall the aide telling her anything. 9. During an interview on [DATE] at 3:55 p.m. LVN O said she remembered Resident #16. LVN O said she remembered LVN A calling her into Resident #16's room to assess the vomit ([DATE]). LVN O said it was "mainly food particles and dark green in color." LVN O said she only knew of Resident #16 vomiting only one time. LVN O said "in her mind" it was between breakfast and lunch, "but it could have been later." LVN O said she did not remember the vomit having an odor. LVN O said she did not know that Resident #16 had no urine output. LVN O said LVN A could have mentioned it and she not remember. LVN O said she only knew of the vomiting. LVN O said Resident #16 "was kinda weak" and did not remember Resident #16 saying anything. LVN O said Resident #16 would stay up for 24 - 48 hours and then sleep for 24 hours. LVN O said if there was an unwitnessed fall the nurses would do an incident/ accident report, take vital signs while the resident was on the floor and assess for any injuries, and range of motion. LVN O said after that staff would put the resident back in the wheelchair or bed then take the vital signs again. LVN O said vital signs were done one minute and then three minutes after getting the resident up. LVN O said "in the past" neuro-checks were only done when the resident hit their head. 10. Review of CNA G's [DATE] unsigned, typed statement CNA G saw Resident #16 in the room and she was "up moving around in bed messing with her stuff in the drawer. So I raised her head up so she can see what she was doing. She was fine when I was in the room getting (Resident #9's) glasses out the room." During an interview on [DATE] at 4:30 p.m. CNA G confirmed she worked the 7 a.m. to 7 p.m. shift on [DATE]. CNA G said Resident #9 (Resident #16's roommate) said she forgot her glasses around 7:30 a.m. CNA G said Resident #16 "was fine." CNA G said Resident #16 was in bed messing with stuff in her drawer. CNA G said Resident #16 told her "hi" when CNA G asked what Resident #16 was doing. CNA G said she gave Resident #16 a sip of water with no problems. CNA G said she asked Resident #16 if she needed anything and Resident #16 said she was doing good so she left to go feed resident in the dining room. CNA G said at about 8:15 a.m. they came to the dining room to say Resident #16 passed. She said some days Resident #16 acted like she knew what was going on and some days she would not. CNA G described Resident #16 as she "slept a lot, liked to talk a lot, liked to drink a lot." CNA G said she wrote her statement the following Monday ([DATE]) because she wanted staff to know what she saw. CNA G said she wrote it for herself and no one asked her to. 11. During an interview on [DATE] at 9:15 a.m. CNA P said she worked Saturday [DATE] during the day shift (7 a.m. through 7 p.m.). CNA P said she was not informed of the fall but noticed Resident #16 was "a little tired" and she did not want to do anything. CNA P said they got Resident #16 up for breakfast that day but did not think she ate anything. CNA P said Resident #16 would usually "just pick" at her food. CNA P said "at 8:30ish" Resident #16 was ok, she was asleep. CNA P said she remembered Resident #16 "didn't wet" that entire day and that was unusual. CNA P said after she took Resident #16 to bed she did showers and when she was done she went to check on Resident #16. CNA P said Resident #16 would answer yes/no questions and only with yes/no. CNA P said usually Resident #16 would try to have a conversation with the aides. CNA P said they did not get Resident #16 up for lunch that day and that was unusual. She said Resident #16 would not eat her lunch and she slept through it. CNA P said she reported that to the nurse. CNA P said Resident #16 still had not wet when she checked on her after putting other residents down after lunch. CNA P said she took lunch between 1:30 and 2 p.m. She said the staff came and got her during her lunch to say Resident #16 had gotten sick. She said she went and got CNA R to help clean up Resident #16. CNA P described Resident #16's vomit as thick," "blackish-brownish" with no smell and that it was "all over" Resident #16. CNA P said the vomit went off the bed onto the floor mat. CNA P said she went and got the nurse who told her it was probably something Resident #16 ate. CNA P said they got Resident #16 cleaned up and Resident #16 wanted out of bed. CNA P said they got Resident #16 up and she was "normal" for about 15 - 20 minutes. CNA P said they noticed Resident #16 was "slouched" in her wheelchair sleeping so they put her back to bed. CNA P said Resident #16 still had not wet by supper time and was still sleeping. CNA P said the nurse told her to hold her tray since she threw up and ordered her a liquid diet but Resident #16 did not eat any of it. CNA P said Resident #16 "finally wet" on her last rounds but it was not a normal amount. CNA P said Resident #16 "was fine" when she left at 7 p.m. that night. CNA P said she reported it to the oncoming shift but did not remember who. CNA P said Resident #16 vomited one time her shift. She said Resident #16 did not complain of pain. CNA P said she worked on [DATE] (Sunday) but was not assigned to Resident #16's room. She said she looked in on Resident #16 to see who the night shift had gotten up and who they had not. She said Resident #16 was in her room like normal and she just thought the vomiting was a stomach bug. CNA P said she offered Resident #16 a couple of sips of water, straightened her up in bed and left the room to feed residents in the dining room. CNA P said Resident #16 did not talk to her that day. She said the agency aide came in to ask who had Resident #16's room and told them Resident #16 died . CNA P said she went back to hall and saw that there was "vomit everywhere." CNA P said Resident #16 had not stayed in bed all day before [DATE] and just thought it was for the day. She said Resident #16 would just pick at her food which was not normal and she did not drink as much as she usually did as well. She said Resident #16 did not talk on [DATE] and that was not her normal. CNA P said she was unaware Resident #16 fell on [DATE]. CNA P said there was not a lot of communication between the nurses and the aides. CNA P said if the aides knew about the [DATE] fall they would have known more about what was going on with the resident "but no one said anything in report." 12. Review of CNA F's [DATE] statement documented CNA F worked Sunday [DATE]. CNA F documented she got Resident #16 her breakfast tray "at 7:40 a.m. took it to her room and she was in bed her head was moving. So I decided to get her up because she was awake. I brought her tray back to the cart at the end of the hall, went back to there room and seen a pool of liquid all over the floor. I said what did you (do) now Mrs. (Resident #16) she did not respond so I pushed on her shoulder and she fell back there was no sign of life. I checked for a pulse and eyes then went out in hall and yelled for help." During an interview on [DATE] at 4:45 p.m. CNA F said she worked with Resident #16 on [DATE] (7 a.m. to 7 p.m.). CNA F said she took Resident #16 her breakfast tray. CNA F said Resident #16 was awake, leaning on the side of the bed and digging through her drawer. CNA F said she returned Resident #16's breakfast tray to the hall cart and returned to the room, which took "two - three minutes at the most." CNA F said there was a "big flood" of brown looking stuff on the floor. CNA F said she checked Resident #16's pulse and her eyes, pulled the call light, and went to holler down the hall. CNA F said the fluid was reddish-brown and there was a "big, huge puddle, like a river" on the floor. CNA F said it did not smell. She said the fluid was all down the bed, to the floor. She said Resident #16's head of bed was up. 13. During an interview on [DATE] at 1:30 p.m. Medical Director BB said he had conferred with Medical Director AA about the case. He confirmed the facility did not call Medical Director AA (Resident #16's physician) the Friday ([DATE]) night concerning the fall. He said the staff "probably faxed" the notification to the doctor and there was no one who would have looked at it until Monday ([DATE]). Medical Director BB said if Resident #16 was vomiting "someone should have been notified." 14. During an interview on [DATE] at 3:55 p.m. the Administrator, DON, and ADON was informed of the identification of an IJ situation. 15. During an interview on [DATE] at 8:55 a.m. Medical Director AA said she was called Sunday Morning ([DATE]) about Resident #16. Medical Director AA said she did see the emesis. Medical Director AA said the emesis was on the mats and on the floor. Medical Director AA described the emesis as "brown." Medical Director AA said she used a urine dip stick to test the emesis for blood and it showed positive. Medical Director AA said Resident #16 was at risk for a GI Bleed because she was on [MEDICATION NAME] and she had GERD. Medical Director AA said the family just wanted Resident #16 comfortable. Medical Director AA said she had a hard time with Resident #16's behaviors due to end stage [MEDICAL CONDITION]. Medical Director AA said she should have been notified of Resident #16 "not taking medication, not being arrousable, having no urine output." She said "all of these things equal a change in condition." 16. During an interview on [DATE] at 10:09 a.m. CNA Q said she worked for an agency but did remember taking care of Resident #16 the night of [DATE] during the 7:00 p.m. to 7:00 a.m. shift. CNA Q said Resident #16 "vomited black vomit two times" during her shift and she reported it to the nurse (RN B). CNA Q said Resident #16 would wake up when she provided incontinent care but then went right back to sleep. 17. Review of the Employee Counseling Report dated [DATE] and signed by the DON and LVN A documented in part that on [DATE] LVN A did not notify the physician on resident's change in condition "LVN will always notify physician on change of condition." 18. Review of the facility's [DATE] In-service on Assessment and Documentation of Residents Change of Condition and Notifying Physician documented, in part: Medicine/ drug chart: "if you cannot give the drug for some reason (e.g. patient is in another department or their physical condition contraindicates giving the drug), make sure that this fact is recorded on the medicine/ drug chart and the doctor is informed if necessary." 19. Review of the facility's [DATE] policy and procedure on Fall Prevention Program documented in part: Immediately after

Based on interview and record review the facility failed to ensure that two of two nurses implemented the policy and procedures that prohibit neglect for 1 of 11 residents (Resident #16) reviewed for neglect.: A) Registered Nurse (RN) B failed to initiate neuro-checks per the facility's policy after Resident #16 fell on [DATE] and was unable to say if she hit her head. B) Licensed Vocational Nurse (LVN) A failed to notify the physician when Resident #16 had dark brown emesis, was unable to arouse resident to take medications, had no urine output and had "jerky movements" on [DATE]. C) RN B did not notify the physician when Resident #16 was "too lethargic to take her medications" on [DATE] and Resident #16 had brown emesis on [DATE]. Approximately 35 hours after the fall, Resident #16 died on [DATE] at 9:15 a.m. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of Actual Harm at a Pattern because the facility had not had a chance to monitor the effectiveness of their implemented policies and procedures. These failures placed 40 residents who resided on Hall One at risk of not receiving care and services, delay in treatment, complications, hospitalization , or death. Findings Include: The Health survey was re-opened on [DATE]. An Extended Health Survey was conducted with an exit of [DATE]. 1. Review of Resident #16's Admission Record documented she was admitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Resident #16 had a Do Not Resuscitate (DNR) order. Review of the facility's Physician Discharge Summary signed by the physician on [DATE] documented Resident #16's final [DIAGNOSES REDACTED]. Review of Resident #16's [DATE] quarterly MDS (Minimum Data Set) assessment documented in part: - Makes self understood: sometimes understood - ability is limited to making concrete requests. - Mental Status: 3 of 15 (,[DATE] is considered severe cognitive impairment.) - [MEDICAL CONDITION] (misconceptions or beliefs that are firmly held, contrary to reality) - Resident was occasionally incontinent of bladder. - Resident had two or more falls without any injury and two or more falls with injuries (skin tears, abrasions, superficial bruises, hematomas, and sprains). Resident #16 had no falls with a major injury. Review of Resident #16's care plan last updated [DATE] documented, in part: - Resident #16 was "at risk for falls, injury d/t (due to) unsteady gait and cognitive impairment, [MEDICATION NAME] PRN (as needed), [MEDICATION NAME] q (every) d (day), and hx (history) of fall at home." The facility identified the following approaches: "w/c (wheelchair) used primarily self-propel short distance and without direction must be redirected." "monitor for s/sx (signs and symptoms) of med and report significant to doctor." "Personal safety alarm in bed and wheelchair pressure alarm." - Cognitive loss or alternation in thought processes related to dx of [MEDICAL CONDITION], as evidenced by moderately impaired decision making and short term and/or long term memory loss. - Resident has episodes of combative behavior with staff. Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [DATE] ,[DATE] (with morning medications) - [DATE] ,[DATE] (with morning medications) - [DATE] ,[DATE] (with morning medications) - [DATE] No Blood Pressure was documented - [DATE] ,[DATE] (with morning medications) Nurses notes dated [DATE] at 2215 (10:15 p.m.) documented: Called by north station nurse: observed resident laying on floor on L (left) side in front of w/c in TV (television) room, assessed resident, no apparent injuries observed. VS (vital signs) ,[DATE]-[DATE].5, assisted resident to w/c after 1 min (minute) VS ,[DATE]-[DATE].9, after 3 min in w/c - VS: ,[DATE]-[DATE].8 - no apparent distress, no c/o (complaints) voiced. Assisted resident to bed. At 2230 (10:30 p.m.) Notified resident's daughter. Notified Doctor per protocol (faxed to doctor's office). Encouraged resident to ask for assist. Personal alarm was on and sounding when found resident, WCTM (will continue to monitor). Signed by RN B. Review of the [DATE] Incident/Accident report completed by RN B documented Resident #16 had a fall at 2215 (10:15 p.m.) in the television room. RN B documented Resident #16 was confused. RN B documented Resident #16 did not have any apparent injuries at the time of the fall. Review of Resident #16's Post Fall Investigation for the [DATE] 10:15 p.m. fall documented: 1. Was the fall observed? No. 2. Resident's Vital Signs: 96.5 (temperature), 78 pulse, 18 respirations, ,[DATE] blood pressure, second blood pressure ,[DATE] sitting. 3. What was resident's response to "why do you think you fell ?" RN B documented: "Resident unable to tell why she thinks she fell . Resident delusional and responses are inappropriate for situation. Resident appeared to think she was in bed and was stating the bed not comfortable." Review of the second page of the Post Fall Investigation documented Resident #16 was Confused and Disoriented prior to and following the fall. Nurses notes dated [DATE] at 0400 (4:00 a.m.) documented: Resident in bed with eyes closed, no apparent distress observed. Alarms in place and on. WCTM. Signed by RN B. Review of Resident #16's ,[DATE] MAR indicated [REDACTED] Nurses notes dated [DATE] at 1540 (3:40 p.m.) documented: Resident in bed all day, unable to rouse resident sufficiently to administer 0800 (8 a.m.) or 1200 (noon) medications. Approximately 1430 (2:30 p.m.) dark emesis noted staining resident's face, bedding and clothing. VS - 96XXX,[DATE]-,[DATE]-22, O2 (oxygen saturation) 93% on RA (room air), occasional jerky movements, no intelligible conversation, responds to requests to open eyes, "squeeze fingers (very weakly)", HR (heart rate) apical vs (verses) radial is = (equal), no urine produced at this time on this shift, given water only to this time, will inform oncoming shift. Signed by LVN A. (No documentation the physician was notified). Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - LVN A circled as not given the following 7 a.m. through 7 p.m. medications on [DATE] - [MEDICATION NAME] 100mg (milligrams) for a stool softener. (8 a.m.) - [MEDICATION NAME] 7XXX,[DATE]mg for pain (8 a.m.) - Vitamin D3 2000 IU (units) for vitamin supplement (8 a.m.) - [MEDICATION NAME] 50 mg for dementia with behaviors (8 a.m.) - [MEDICATION NAME] 25mg (noon) - Artificial Tears for dry eyes (8 a.m.) - [MEDICATION NAME] 300mg for hypertension (8 a.m.) - [MEDICATION NAME] 100mg for osteoarthros (8 a.m.) - [MEDICATION NAME] XL 100 mg for hypertension (8 a.m.) - [MEDICATION NAME] 10mg for asthma (8 a.m.) LVN A documented "all 0800 meds held - resident sleeping could not rouse." and "1200 [MEDICATION NAME] held - Resident asleep could not rouse." Nurses notes dated [DATE] at 2030 (8:30 p.m.) documented: VS: ,[DATE]-[DATE]XXX,[DATE]% on RA. Assisted resident to bed, very lethargic at this time. Holding meds due to not waking enough to swallow. No apparent injuries observed from fall on [DATE]. Alarms in place, WCTM. Signed by RN B. (No documentation the physician was notified). Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - RN B circled as not given the following evening medications on [DATE]: - Klonopin 0.5 mg for [MEDICAL CONDITION] - [MEDICATION NAME] 7XXX,[DATE] (8 p.m.) - [MEDICATION NAME] 20mg for [MEDICAL CONDITION] (8 p.m.) Nurses notes dated [DATE] at 0230 (2:30 a.m.) documented: Vomited moderate amount of brown emesis, bowel sounds hyperactive, continues to be lethargic. Daughter had stated yesterday that her mom had been c/o stomach ache. CNA (Certified Nurse Aide) flowbook shows resident had large BM (bowel movement) on [DATE]. Will continue to monitor for further emesis or any other problems. Signed by RN B. (No documentation the physician was notified). Review of the ,[DATE] MAR indicated [REDACTED] Nurses notes dated [DATE] at 0950 (9:50 a.m.) documented: At approximately 0845 (8:45 a.m.) (CNA F) entered resident's room because she observed resident in bed and fluid on floor. At some time earlier another (CNA P) reported to this nurse resident was awake and (CNA G) had raised HOB (head of bed) and placed call light in reach. Resident was unresponsive when this nurse entered the room - no respirations, no blood pressure. At 0850 (8:50 a.m.) House Supervisor and Doctor were called. At 0915 (9:15 a.m.) Doctor arrived and pronounced death. Signed by LVN A. 2. During an interview on [DATE] at 11:55 a.m. the Director of Nurses (DON) said the nurse should call the physician due to abnormal symptoms such as heart rate, blood pressure or any change in condition. The DON said if residents have no apparent injuries then they only have to do vital signs after the fall. During a follow-up interview on [DATE] at 2:05 p.m. with the Administrator and DON present. The DON said the physician should be notified when there was an "abnormal change," not something the resident did all the time. The DON said an abnormal change would be breath sounds, heart rate, blood pressure right off the top of her head. The DON said she could not put a time limit on when a nurse should notify the physician. The DON pointed out the witness statements said Resident #16 was okay. The DON said the physician should be notified if a resident missed a dose depending on the medication. The DON said Resident #16 had no signs or symptoms of injuries so she did not have anything to stimulate a neuro-check. She said there was no suspicion of Resident #16 having a head injury. The DON said Resident #16 could tell you sometimes what happened. The Administrator added Resident #16 could communicate "immediate" needs or happenings. The Administrator said Resident #16 would have been able to report if she hit her head during a fall. The Administrator asked what the change in condition was. Surveyor outlined the nurses notes of vomiting and lethargic at times. The Administrator said Resident #16 was up and about in her wheelchair and was doing normal stuff and there was no reason to do neuro checks. The DON acknowledged LVN A was written up for not notifying the doctor. The DON said after Resident #16's fall she had to take a licensed nurse's word there were no signs or symptoms of injury and she did not think of the situation as neglect. She acknowledged not all injuries from a fall were immediately apparent but said with a head injury there was usually a raised area, a red area, a blue area. She said a delayed injury usually showed up in an arm or a leg. She said with a head injury there was a bruise or a lump quick. The DON said Resident #16 fell at 10:15 p.m. on [DATE] and it was 1:30 p.m. the next day when the nurse charted Resident #16 was in bed all day. The DON said Resident #16's vital signs were within normal limits, her oxygen level was alright, she opened her eyes and squeezed fingers (surveyor had to point out the note read "squeezed fingers weakly") and her heart rate was good. The DON said when she wrote LVN A up all this "other stuff" (anything after [DATE] at 10:30 p.m.) had not happened yet (LVN A was not written up until [DATE]) . She said she had to take the other nurse's word. The DON said "I don't think there was any neglect, I think it was stupid" The DON said Resident #16's vital signs were still good and the charting that Resident #16 was "lethargic" happened at night when she was in bed. The DON acknowledged the doctor should have been called. A review of a calendar documented [DATE] was a Saturday. The DON said she read LVN A's notes on the Monday after it happened ([DATE]). The DON said she thought LVN A failed to call the doctor and she did not think LVN A neglected Resident #16. The DON said when she noticed LVN A did not call the doctor she wrote her up. The Administrator said the nurses "all knew to notify the family, the doctor, and the state if something went wrong." According to the Mayo Clinic website based off Mayo Clinic Family Health book 4th Edition documented on Traumatic Brain Injuries Signs and Symptoms included, in part: nausea or vomiting, fatigue or drowsiness, sleeping more than usual. Moderate to severe traumatic brain injuries had the following symptoms: inability to wake from sleep, repeated vomiting or nausea. 3. During an interview on [DATE] at 3:30 p.m. Resident #16's physician verified she was not notified that Resident #16 had the change in condition of dark emesis, no urine output, jerky movements, incoherent speech, not taking her medication and that the resident was lethargic. She said she should have been notified that day. She said the staff called her on the day the resident passed but no one called and notified her of the change in condition. 4. Review of LVN A's undated written statement documented on [DATE] at approximately 1800 (6 p.m.) LVN A saw Resident #16 "up in wheelchair in day room. Family visiting with young children. Resident acknowledges greetings. 1800 meds (medications) administered at this time." During an interview on [DATE] at 3:45 p.m. LVN A said "I had seen Resident #16 "stay up all night at times and thought that was the reason we could not arouse her. I should have checked on the fact that she had no urine output. There is no time line for my charting and that is a mistake and not calling the physician (with the change of condition) was a mistake. I took another nurse (LVN O) to Resident #16's room and she said the vomiting did not smell like blood." 5. During an interview on [DATE] at 1:35 p.m. RN B said she had worked the 7:00 p.m. to 7:00 a.m. shift for three months. RN B confirmed she worked the weekend of [DATE] through [DATE]. She described Resident #16 as "very out of it, confused, disoriented." RN B said Resident #16 would stay up for "hours and hours and days and days" and then would "be out of it, sleeping." RN B said the other night nurse called her into the television room when Resident #16 was on the floor. RN B said she assessed Resident #16 and did all the vital signs and there were no apparent injuries observed. RN B said the staff put Resident #16 to bed at that time and at 4 a.m. she was asleep, in no distress and the alarms were on. RN B acknowledged Resident #16 was unable to answer appropriately if she hit her head. RN B acknowledged Resident #16's blood pressure was high, but noted that the blood pressure was going down on the third check. RN B confirmed she did not start neuro-checks. RN B said on [DATE] (Saturday 7 p.m.) she saw Resident #16 up in her wheelchair at the beginning of her shift with her grandchildren. She said Resident #16 was "lethargic." RN B explained Resident #16 was "out of it, not talking, and not responding that much." RN B said she briefly talked with the family and told them the staff would put Resident #16 to bed. RN B said Resident #16 being lethargic "wasn't anything abnormal," since that was how Resident #16 was when she had been up for hours. RN B said she was told in report that Resident #16 had vomited. RN B said she remembered the daughter saying Resident #16's stomach hurt. RN B said she held Resident #16's 8:30 p.m. medications because of the lethargy. RN B said "I didn't want to put medications in her mouth, it was not the first time this was the case." RN B said she did not know the facility's policy and procedure about holding medications. She said she did not feel comfortable putting medications in Resident #16's mouth. She said the medication was Klonopin which she didn't need because it was something to make her more lethargic. RN B said Resident #16 did vomit some on her shift. RN B said the vomit was brown and not coffee ground colored. RN B said Resident #16 had not acted any different at that point. RN B said there was nothing to report to the physician. She said Resident #16 vomited "once, that was it, she was stable." RN B pointed out the facility had standing orders for nausea/ vomiting, "but it was just that one time." RN B said she did not want to give Resident #16 the [MEDICATION NAME] because "if it was not necessary it would knock her out even more." RN B said again there was nothing abnormal about Resident #16 being lethargic other than the one time vomiting. She said the vomit was not "dark or coffee grounds or smelled." RN B said the aides did not tell her Resident #16 was acting any different. RN B said the facility did not do neuro-checks if the resident said they did not hit their head. She said it seemed odd to her and it "made sense" to do them if it was an unwitnessed fall. She said in her orientation she was told to do neuro- checks only if there were signs or symptoms or if you saw the resident hit their head. RN B said "if there were no signs or symptoms if they hit their head you didn't do them." RN B said she was not in-serviced about the neuro-check policy and procedure. RN B said she knew to call the doctor with a change in condition. RN B said "other than" Resident #16 "vomiting, there was nothing out of her normal behavior or I definitely would have" called the doctor. RN B said vomiting after a fall was not a good thing. She said with Resident #16's daughter saying her stomach hurting prior to the fall she was thinking the emesis was related to the stomach ache. RN B said "I didn't relate it to the fall." 6. During an interview on [DATE] at 10:52 a.m. CNA C said she was the shower aide on [DATE]. CNA C said Resident #16 had Alzheimer's, sometimes she could tell you if she needed to go to the bathroom but often she would be incontinent. CNA C said Resident #16 was "never mean, she had a big appetite that is how you knew if she was not feeling good." CNA C said Resident #16 "threw up the black stuff three times that Saturday." ([DATE]) CNA C said Resident #16 "threw up in the dining room during breakfast." She said they took her back to bed. She said the resident threw up again and the staff "had to change everything." CNA C acknowledged the nurse (LVN A) came to the room to assess the resident. She said the nurse told the staff to "sit her up in bed" and she ordered her a liquid diet. CNA C said she heard Resident #16 threw up again before day shift left and somebody from night shift helped clean her up. CNA C said normally Resident #16 would be up in her wheelchair all day and participate in activities. CNA C said from "Friday to Saturday she made a 360 degree turn." CNA C said she was not aware Resident #16 had a fall Friday night ([DATE]). CNA C said about once a week Resident #16 would stay up all night then sleep during the day. 7. During an interview on [DATE] at 11:30 a.m. CNA M verified she worked [DATE] on the 7:00 a.m. to 7:00 p.m. shift. CNA M said Resident #16 was "confused, hallucinated, never had a clear thought, would fidget and couldn't sit still." CNA M said if Resident #16 fell she could "probably not" tell you if she hit her head. CNA M said "that day ([DATE]) she complained of stomach pains." CNA M said she took Resident #16 to the bathroom and Resident #16 said "hurts so bad, hurts so bad." CNA M said she could not remember who she reported it to. CNA M said before she left Resident #16 complained about her stomach hurting again and she reported it to LVN N (charge nurse). CNA M said Resident #16 ate lunch and supper but it was not uncommon for her not to eat breakfast. CNA M said a few days after this the DON, Administrator and ADON asked her what happened. CNA M said she told them Resident #16 had complained of a stomach ache and she had reported it to the nurse. 8. During an interview on [DATE] at 3:30 p.m. LVN N said she worked the 7 a.m. to 7 p.m. shift on [DATE] (the day of the fall, before the fall occurred). LVN N confirmed she worked with Resident #16. LVN N said she did not believe there was anything going on with Resident #16, "she seemed fine to me." LVN N described Resident #16 as "happily confused." LVN N said she did not recall the aides reporting that Resident #16's stomach hurt. LVN N said "if they did, I went and assessed her. I don't remember going." LVN N said Resident #16 was normally confused in the morning and hard to wake up. LVN N said Resident #16 was "not really" lethargic "but you had to really talk to her to make sure she was alert." LVN N said Resident #16 could be up 24 - 48 hours at times despite her medications and then "be out" for 8 - 10 hours and "then she'd be up again." She said Resident #16 would follow this cycle every couple of days. LVN N said Resident #16 was "difficult to arouse at times." LVN N said Resident #16 could answer immediate yes or no questions. LVN N said if more than 15 minutes then Resident #16 probably could not tell if she hit her head. LVN N said the facility did neuro-checks any time the facility could confirm the resident hit their head. LVN N said she would "automatically initiate neuro-checks herself" because Resident #16 was confused. LVN N said the facility would not normally start neuro-checks if there were no signs of injury. LVN N confirmed if a cognitively impaired resident fell and there were no signs of injury the staff would do three vital signs (initially before moving the resident, then one minute after getting resident up, then three minutes after getting the resident up) and an incident/ accident report. She said she did not recall Resident #16 having any changes in condition or nausea/ vomiting nor did she recall the aide telling her anything. 9. During an interview on [DATE] at 3:55 p.m. LVN O said she remembered Resident #16. LVN O said she remembered LVN A calling her into Resident #16's room to assess the vomit ([DATE]). LVN O said it was "mainly food particles and dark green in color." LVN O said she only knew of Resident #16 vomiting only one time. LVN O said "in her mind" it was between breakfast and lunch, "but it could have been later." LVN O said she did not remember the vomit having an odor. LVN O said she did not know that Resident #16 had no urine output. LVN O said LVN A could have mentioned it and she not remember. LVN O said she only knew of the vomiting. LVN O said Resident #16 "was kinda weak" and did not remember Resident #16 saying anything. LVN O said Resident #16 would stay up for 24 - 48 hours and then sleep for 24 hours. LVN O said if there was an unwitnessed fall the nurses would do an incident/ accident report, take vital signs while the resident was on the floor and assess for any injuries, and range of motion. LVN O said after that staff would put the resident back in the wheelchair or bed then take the vital signs again. LVN O said vital signs were done one minute and then three minutes after getting the resident up. LVN O said "in the past" neuro-checks were only done when the resident hit their head. 10. Review of CNA G's [DATE] unsigned, typed statement CNA G saw Resident #16 in the room and she was "up moving around in bed messing with her stuff in the drawer. So I raised her head up so she can see what she was doing. She was fine when I was in the room getting (Resident #9's) glasses out the room." During an interview on [DATE] at 4:30 p.m. CNA G confirmed she worked the 7 a.m. to 7 p.m. shift on [DATE]. CNA G said Resident #9 (Resident #16's roommate) said she forgot her glasses around 7:30 a.m. CNA G said Resident #16 "was fine." CNA G said Resident #16 was in bed messing with stuff in her drawer. CNA G said Resident #16 told her "hi" when CNA G asked what Resident #16 was doing. CNA G said she gave Resident #16 a sip of water with no problems. CNA G said she asked Resident #16 if she needed anything and Resident #16 said she was doing good so she left to go feed resident in the dining room. CNA G said at about 8:15 a.m. they came to the dining room to say Resident #16 passed. She said some days Resident #16 acted like she knew what was going on and some days she would not. CNA G described Resident #16 as she "slept a lot, liked to talk a lot, liked to drink a lot." CNA G said she wrote her statement the following Monday ([DATE]) because she wanted staff to know what she saw. CNA G said she wrote it for herself and no one asked her to. 11. During an interview on [DATE] at 9:15 a.m. CNA P said she worked Saturday [DATE] during the day shift (7 a.m. through 7 p.m.). CNA P said she was not informed of the fall but noticed Resident #16 was "a little tired" and she did not want to do anything. CNA P said they got Resident #16 up for breakfast that day but did not think she ate anything. CNA P said Resident #16 would usually "just pick" at her food. CNA P said "at 8:30ish" Resident #16 was ok, she was asleep. CNA P said she remembered Resident #16 "didn't wet" that entire day and that was unusual. CNA P said after she took Resident #16 to bed she did showers and when she was done she went to check on Resident #16. CNA P said Resident #16 would answer yes/no questions and only with yes/no. CNA P said usually Resident #16 would try to have a conversation with the aides. CNA P said they did not get Resident #16 up for lunch that day and that was unusual. She said Resident #16 would not eat her lunch and she slept through it. CNA P said she reported that to the nurse. CNA P said Resident #16 still had not wet when she checked on her after putting other residents down after lunch. CNA P said she took lunch between 1:30 and 2 p.m. She said the staff came and got her during her lunch to say Resident #16 had gotten sick. She said she went and got CNA R to help clean up Resident #16. CNA P described Resident #16's vomit as thick," "blackish-brownish" with no smell and that it was "all over" Resident #16. CNA P said the vomit went off the bed onto the floor mat. CNA P said she went and got the nurse who told her it was probably something Resident #16 ate. CNA P said they got Resident #16 cleaned up and Resident #16 wanted out of bed. CNA P said they got Resident #16 up and she was "normal" for about 15 - 20 minutes. CNA P said they noticed Resident #16 was "slouched" in her wheelchair sleeping so they put her back to bed. CNA P said Resident #16 still had not wet by supper time and was still sleeping. CNA P said the nurse told her to hold her tray since she threw up and ordered her a liquid diet but Resident #16 did not eat any of it. CNA P said Resident #16 "finally wet" on her last rounds but it was not a normal amount. CNA P said Resident #16 "was fine" when she left at 7 p.m. that night. CNA P said she reported it to the oncoming shift but did not remember who. CNA P said Resident #16 vomited one time her shift. She said Resident #16 did not complain of pain. CNA P said she worked on [DATE] (Sunday) but was not assigned to Resident #16's room. She said she looked in on Resident #16 to see who the night shift had gotten up and who they had not. She said Resident #16 was in her room like normal and she just thought the vomiting was a stomach bug. CNA P said she offered Resident #16 a couple of sips of water, straightened her up in bed and left the room to feed residents in the dining room. CNA P said Resident #16 did not talk to her that day. She said the agency aide came in to ask who had Resident #16's room and told them Resident #16 died . CNA P said she went back to hall and saw that there was "vomit everywhere." CNA P said Resident #16 had not stayed in bed all day before [DATE] and just thought it was for the day. She said Resident #16 would just pick at her food which was not normal and she did not drink as much as she usually did as well. She said Resident #16 did not talk on [DATE] and that was not her normal. CNA P said she was unaware Resident #16 fell on [DATE]. CNA P said there was not a lot of communication between the nurses and the aides. CNA P said if the aides knew about the [DATE] fall they would have known more about what was going on with the resident "but no one said anything in report." 12. Review of CNA F's [DATE] statement documented CNA F worked Sunday [DATE]. CNA F documented she got Resident #16 her breakfast tray "at 7:40 a.m. took it to her room and she was in bed her head was moving. So I decided to get her up because she was awake. I brought her tray back to the cart at the end of the hall, went back to there room and seen a pool of liquid all over the floor. I said what did you (do) now Mrs. (Resident #16) she did not respond so I pushed on her shoulder and she fell back there was no sign of life. I checked for a pulse and eyes then went out in hall and yelled for help." During an interview on [DATE] at 4:45 p.m. CNA F said she worked with Resident #16 on [DATE] (7 a.m. to 7 p.m.). CNA F said she took Resident #16 her breakfast tray. CNA F said Resident #16 was awake, leaning on the side of the bed and digging through her drawer. CNA F said she returned Resident #16's breakfast tray to the hall cart and returned to the room, which took "two - three minutes at the most." CNA F said there was a "big flood" of brown looking stuff on the floor. CNA F said she checked Resident #16's pulse and her eyes, pulled the call light, and went to holler down the hall. CNA F said the fluid was reddish-brown and there was a "big, huge puddle, like a river" on the floor. CNA F said it did not smell. She said the fluid was all down the bed, to the floor. She said Resident #16's head of bed was up. 13. During an interview on [DATE] at 1:30 p.m. Medical Director BB said he had conferred with Medical Director AA about the case. He confirmed the facility did not call Medical Director AA (Resident #16's physician) the Friday ([DATE]) night concerning the fall. He said the staff "probably faxed" the notification to the doctor and there was no one who would have looked at it until Monday ([DATE]). Medical Director BB said if Resident #16 was vomiting "someone should have been notified." 14. During an interview on [DATE] at 3:55 p.m. the Administrator, DON, and ADON was informed of the identification of an IJ situation. 15. During an interview on [DATE] at 8:55 a.m. Medical Director AA said she was called Sunday Morning ([DATE]) about Resident #16. Medical Director AA said she did see the emesis. Medical Director AA said the emesis was on the mats and on the floor. Medical Director AA described the emesis as "brown." Medical Director AA said she used a urine dip stick to test the emesis for blood and it showed positive. Medical Director AA said Resident #16 was at risk for a GI Bleed because she was on [MEDICATION NAME] and she had GERD. Medical Director AA said the family just wanted Resident #16 comfortable. Medical Director AA said she had a hard time with Resident #16's behaviors due to end stage [MEDICAL CONDITION]. Medical Director AA said she should have been notified of Resident #16 "not taking medication, not being arrousable, having no urine output." She said "all of these things equal a change in condition." 16. During an interview on [DATE] at 10:09 a.m. CNA Q said she worked for an agency but did remember taking care of Resident #16 the night of [DATE] during the 7:00 p.m. to 7:00 a.m. shift. CNA Q said Resident #16 "vomited black vomit two times" during her shift and she reported it to the nurse (RN B). CNA Q said Resident #16 would wake up when she provided incontinent care but then went right back to sleep. 17. Review of the Employee Counseling Report dated [DATE] and signed by the DON and LVN A documented in part that on [DATE] LVN A did not notify the physician on resident's change in condition "LVN will always notify physician on change of condition." 18. Review of the facility's [DATE] In-service on Assessment and Documentation of Residents Change of Condition and Notifying Physician documented, in part: Medicine/ drug chart: "if you cannot give the drug for some reason (e.g. patient is in another department or their physical condition contraindicates giving the drug), make sure that this fact is recorded on the medicine/ drug chart and the doctor is informed if necessary." 19. Review of the facility's [DATE] policy and proce

Based on interview and record review, the facility failed to implement their written policy and procedures that prohibit abuse and neglect for two residents (Resident #7 and #16) of 11 residents reviewed for abuse or neglect: A) Registered Nurse (RN) B failed to initiate neuro-checks per the facility's policy after Resident #16 fell on [DATE] and was unable to say if she hit her head. B) Licensed Vocational Nurse (LVN) A failed to notify the physician when Resident #16 had dark brown emesis, was unable to arouse resident to take medications, had no urine output and had "jerky movements" on [DATE]. C) RN B did not notify the physician when Resident #16 was "too lethargic to take her medications" on [DATE] and Resident #16 had brown emesis on [DATE]. Approximately 35 hours after the fall, Resident #16 died on [DATE] at 9:15 a.m. These deficient practices resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of Actual Harm at a Pattern because the facility had not had a chance to monitor the effectiveness of their implemented policies and procedures. These failures placed 40 residents who resided on Hall One at risk of not receiving care and services, delay in treatment, complications, hospitalization , or death. D) At least three staff members failed to immediately report an allegation of aides being rough or mean to Resident #7 on [DATE] and [DATE] for four days (The social worker (SW), LVN I, and RN J). This failure placed nine residents with behavioral issues at increased risk of abuse. Findings Include: Review of the facility's undated Abuse Prevention Policy and Procedure documented, in part: "All allegations of abuse will be handled in the following manner: The staff member who receives the allegations of abuse will contact the Administrator and/or the DON immediately. The staff will take immediate action to protect the resident population from further allegations of abuse. - Review of the facility's [DATE] policy and procedure on Prevention of Neglect as it Relates to Staff Treatment and Direct Care documented, in part: "It is the intent of Permian Residential Care Center to prohibit mistreatment, neglect, and abuse of residents as well as misappropriation of resident property." 1. DON will in-service nursing staff on admission process to include completion of nursing assessments. - Review of the facility's undated policy and procedure on Recognizing Signs and Symptoms of Abuse/ Neglect documented, in part: "Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms or abuse/neglect to their supervisor or other designee immediately." Policy Interpretation and Implementation: b. Signs of or actual physical neglect: - improper use/ administration of medication; - inadequate provision of care; Review of the facility's revised [DATE] policy and procedure on Notifying the Physician (of Patient's Status) documented, in part: "It is the policy of the Permian Regional Medical Center to insure the safety and well being of our patients through a protocol for notifying physicians of significant changes in patient's status. I. It shall be the responsibility of the Charge Nurse to notify the attending physician of any untoward changes in the patient's condition. IV Information to Have on Hand Prior to Calling Physicians' 8. Nausea and/or vomiting: If so, how much emesis - its appearance and how long has patient been complaining of nausea? Medicated? With what? Any abdominal distention? 10. Level of Consciousness: Alert and wakeful? Lethargic or restless? Is patient oriented? Does patient respond to simple commands? Does patient respond to pain? Does patient have corneal and gag reflexes? Review of the facility's [DATE] policy and procedure on Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." "Procedure: The Licenses Nurse will: a. encircle time of scheduled administration if medication is omitted." Review of the facility's [DATE] policy and procedure on Fall Prevention Program documented in part: "It is the policy of Permian Residential Care Center to create a safe environment that encourages independence and anticipates problem areas. Purpose: 1. The enhance resident's mobility; 2. To encourage independence; 3. To minimize the occurrence of falls; 4. To assist in identifying the cause and implementing interventions to prevent falls; 5. To minimize the risk of injury to residents who fall in our facility. Immediately after a fall: 1. If a resident has just fallen, or is found in the floor without a witness to the event, nursing staff will record vital signs and evaluate the resident for possible injuries prior to the resident being moved from the floor. 2. IF there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. 3. Once the assessment rules out significant injury nursing staff will help the resident to a comfortable position. 4. Nursing staff will notify the resident's attending physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the physician immediately by phone. When a fall does not result in a significant injury or condition change, nursing staff will notify the physician routinely (e.g. by fax or phone the next office day.) 5. Neuro-checks will be implemented for unobserved falls when a resident with a cognitive impairment is unable to indicate whether they hit their head upon falling. Neuro-checks will be implemented on all falls involving the resident hitting their head. (Neuro-check guidelines are included in the Appendix for this policy.) 6. Nursing staff will observe for complications of a fall for approximately 72 hours and will document the findings in the clinical record. Review of the [DATE] Memo to All license nurses on Neuro Checks documented: Please collect neurological signs as follows and record on the Neurological Assessment form: a. Every 15 minutes x 4 times b. Every 30 minutes x 2 times c. Every 2 hours x 24 d. Every shift until stable or e. As ordered by Physician. Please notify physician if the resident's neuro signs are not improving or signs and symptoms of suspected head injury worsen. Review of the facility's revised [DATE] policy and procedure on Notifying the Physician (of Patient's Status) documented, in part: "It is the policy of (the facility) to insure the safety and well being of our patients through a protocol for notifying physicians of significant changes in patient's status. I. It shall be the responsibility of the Charge Nurse to notify the attending physician of any untoward changes in the patient's condition. IV Information to Have on Hand Prior to Calling Physicians' 8. Nausea and/or vomiting: If so, how much emesis - its appearance and how long has patient been complaining of nausea? Medicated? With what? Any abdominal distention? 10. Level of Consciousness: Alert and wakeful? Lethargic or restless? Is patient oriented? Does patient respond to simple commands? Does patient respond to pain? Does patient have corneal and gag reflexes? The Health survey was re-opened on [DATE]. An Extended Health Survey was conducted with an exit of [DATE]. 1. Review of Resident #16's Admission Record documented she was admitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Resident #16 had a Do Not Resuscitate (DNR) order. Review of the facility's Physician Discharge Summary signed by the physician on [DATE] documented Resident #16's final [DIAGNOSES REDACTED]. Review of Resident #16's [DATE] quarterly MDS (Minimum Data Set) assessment documented in part: - Makes self understood: sometimes understood - ability is limited to making concrete requests. - Mental Status: 3 of 15 (,[DATE] is considered severe cognitive impairment.) - [MEDICAL CONDITION] (misconceptions or beliefs that are firmly held, contrary to reality) - Resident was occasionally incontinent of bladder. - Resident had two or more falls without any injury and two or more falls with injuries (skin tears, abrasions, superficial bruises, hematomas, and sprains). Resident #16 had no falls with a major injury. Review of Resident #16's care plan last updated [DATE] documented, in part: - Resident #16 was "at risk for falls, injury d/t (due to) unsteady gait and cognitive impairment, [MEDICATION NAME] PRN (as needed), [MEDICATION NAME] q (every) d (day), and hx (history) of fall at home." The facility identified the following approaches: "w/c (wheelchair) used primarily self-propel short distance and without direction must be redirected." "monitor for s/sx (signs and symptoms) of med and report significant to doctor." "Personal safety alarm in bed and wheelchair pressure alarm." - Cognitive loss or alternation in thought processes related to dx of [MEDICAL CONDITION], as evidenced by moderately impaired decision making and short term and/or long term memory loss. - Resident has episodes of combative behavior with staff. Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [DATE] ,[DATE] (with morning medications) - [DATE] ,[DATE] (with morning medications) - [DATE] ,[DATE] (with morning medications) - [DATE] No Blood Pressure was documented - [DATE] ,[DATE] (with morning medications) Nurses notes dated [DATE] at 2215 (10:15 p.m.) documented: Called by north station nurse: observed resident laying on floor on L (left) side in front of w/c in TV (television) room, assessed resident, no apparent injuries observed. VS (vital signs) ,[DATE]-[DATE].5, assisted resident to w/c after 1 min (minute) VS ,[DATE]-[DATE].9, after 3 min in w/c - VS: ,[DATE]-[DATE].8 - no apparent distress, no c/o (complaints) voiced. Assisted resident to bed. At 2230 (10:30 p.m.) Notified resident's daughter. Notified Doctor per protocol (faxed to doctor's office). Encouraged resident to ask for assist. Personal alarm was on and sounding when found resident, WCTM (will continue to monitor). Signed by RN B. Review of the [DATE] Incident/Accident report completed by RN B documented Resident #16 had a fall at 2215 (10:15 p.m.) in the television room. RN B documented Resident #16 was confused. RN B documented Resident #16 did not have any apparent injuries at the time of the fall. Review of Resident #16's Post Fall Investigation for the [DATE] 10:15 p.m. fall documented: 1. Was the fall observed? No. 2. Resident's Vital Signs: 96.5 (temperature), 78 pulse, 18 respirations, ,[DATE] blood pressure, second blood pressure ,[DATE] sitting. 3. What was resident's response to "why do you think you fell ?" RN B documented: "Resident unable to tell why she thinks she fell . Resident delusional and responses are inappropriate for situation. Resident appeared to think she was in bed and was stating the bed not comfortable." Review of the second page of the Post Fall Investigation documented Resident #16 was Confused and Disoriented prior to and following the fall. Nurses notes dated [DATE] at 0400 (4:00 a.m.) documented: Resident in bed with eyes closed, no apparent distress observed. Alarms in place and on. WCTM. Signed by RN B. Review of Resident #16's ,[DATE] MAR indicated [REDACTED] Nurses notes dated [DATE] at 1540 (3:40 p.m.) documented: Resident in bed all day, unable to rouse resident sufficiently to administer 0800 (8 a.m.) or 1200 (noon) medications. Approximately 1430 (2:30 p.m.) dark emesis noted staining resident's face, bedding and clothing. VS - 96XXX,[DATE]-,[DATE]-22, O2 (oxygen saturation) 93 on RA (room air), occasional jerky movements, no intelligible conversation, responds to requests to open eyes, "squeeze fingers (very weakly)", HR (heart rate) apical vs (verses) radial is = (equal), no urine produced at this time on this shift, given water only to this time, will inform oncoming shift. Signed by LVN A. (No documentation the physician was notified). Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - LVN A circled as not given the following 7 a.m. through 7 p.m. medications on [DATE] - [MEDICATION NAME] 100mg (milligrams) for a stool softener. (8 a.m.) - [MEDICATION NAME] 7XXX,[DATE]mg for pain (8 a.m.) - Vitamin D3 2000 IU (units) for vitamin supplement (8 a.m.) - [MEDICATION NAME] 50 mg for dementia with behaviors (8 a.m.) - [MEDICATION NAME] 25mg (noon) - Artificial Tears for dry eyes (8 a.m.) - [MEDICATION NAME] 300mg for hypertension (8 a.m.) - [MEDICATION NAME] 100mg for osteoarthros (8 a.m.) - [MEDICATION NAME] XL 100 mg for hypertension (8 a.m.) - [MEDICATION NAME] 10mg for asthma (8 a.m.) LVN A documented "all 0800 meds held - resident sleeping could not rouse." and "1200 [MEDICATION NAME] held - Resident asleep could not rouse." Nurses notes dated [DATE] at 2030 (8:30 p.m.) documented: VS: ,[DATE]-[DATE]XXX,[DATE]% on RA. Assisted resident to bed, very lethargic at this time. Holding meds due to not waking enough to swallow. No apparent injuries observed from fall on [DATE]. Alarms in place, WCTM. Signed by RN B. (No documentation the physician was notified). Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - RN B circled as not given the following evening medications on [DATE]: - Klonopin 0.5 mg for [MEDICAL CONDITION] - [MEDICATION NAME] 7XXX,[DATE] (8 p.m.) - [MEDICATION NAME] 20mg for [MEDICAL CONDITION] (8 p.m.) Nurses notes dated [DATE] at 0230 (2:30 a.m.) documented: Vomited moderate amount of brown emesis, bowel sounds hyperactive, continues to be lethargic. Daughter had stated yesterday that her mom had been c/o stomach ache. CNA (Certified Nurse Aide) flowbook shows resident had large BM (bowel movement) on [DATE]. Will continue to monitor for further emesis or any other problems. Signed by RN B. (No documentation the physician was notified). Review of the ,[DATE] MAR indicated [REDACTED] Nurses notes dated [DATE] at 0950 (9:50 a.m.) documented: At approximately 0845 (8:45 a.m.) (CNA F) entered resident's room because she observed resident in bed and fluid on floor. At some time earlier another (CNA P) reported to this nurse resident was awake and (CNA G) had raised HOB (head of bed) and placed call light in reach. Resident was unresponsive when this nurse entered the room - no respirations, no blood pressure. At 0850 (8:50 a.m.) House Supervisor and Doctor were called. At 0915 (9:15 a.m.) Doctor arrived and pronounced death. Signed by LVN A. 2. During an interview on [DATE] at 11:55 a.m. the Director of Nurses (DON) said the nurse should call the physician due to abnormal symptoms such as heart rate, blood pressure or any change in condition. The DON said if residents have no apparent injuries then they only have to do vital signs after the fall. During a follow-up interview on [DATE] at 2:05 p.m. with the Administrator and DON present. The DON said the physician should be notified when there was an "abnormal change," not something the resident did all the time. The DON said an abnormal change would be breath sounds, heart rate, blood pressure right off the top of her head. The DON said she could not put a time limit on when a nurse should notify the physician. The DON pointed out the witness statements said Resident #16 was okay. The DON said the physician should be notified if a resident missed a dose depending on the medication. The DON said Resident #16 had no signs or symptoms of injuries so she did not have anything to stimulate a neuro-check. She said there was no suspicion of Resident #16 having a head injury. The DON said Resident #16 could tell you sometimes what happened. The Administrator added Resident #16 could communicate "immediate" needs or happenings. The Administrator said Resident #16 would have been able to report if she hit her head during a fall. The Administrator asked what the change in condition was. Surveyor outlined the nurses notes of vomiting and lethargic at times. The Administrator said Resident #16 was up and about in her wheelchair and was doing normal stuff and there was no reason to do neuro checks. The DON acknowledged LVN A was written up for not notifying the doctor. The DON said after Resident #16's fall she had to take a licensed nurse's word there were no signs or symptoms of injury and she did not think of the situation as neglect. She acknowledged not all injuries from a fall were immediately apparent but said with a head injury there was usually a raised area, a red area, a blue area. She said a delayed injury usually showed up in an arm or a leg. She said with a head injury there was a bruise or a lump quick. The DON said Resident #16 fell at 10:15 p.m. on [DATE] and it was 1:30 p.m. the next day when the nurse charted Resident #16 was in bed all day. The DON said Resident #16's vital signs were within normal limits, her oxygen level was alright, she opened her eyes and squeezed fingers (surveyor had to point out the note read "squeezed fingers weakly") and her heart rate was good. The DON said when she wrote LVN A up all this "other stuff" (anything after [DATE] at 10:30 p.m.) had not happened yet (LVN A was not written up until [DATE]) . She said she had to take the other nurse's word. The DON said "I don't think there was any neglect, I think it was stupid" The DON said Resident #16's vital signs were still good and the charting that Resident #16 was "lethargic" happened at night when she was in bed. The DON acknowledged the doctor should have been called. A review of a calendar documented [DATE] was a Saturday. The DON said she read LVN A's notes on the Monday after it happened ([DATE]). The DON said she thought LVN A failed to call the doctor and she did not think LVN A neglected Resident #16. The DON said when she noticed LVN A did not call the doctor she wrote her up. The Administrator said the nurses "all knew to notify the family, the doctor, and the state if something went wrong." According to the Mayo Clinic website based off Mayo Clinic Family Health book 4th Edition documented on Traumatic Brain Injuries Signs and Symptoms included, in part: nausea or vomiting, fatigue or drowsiness, sleeping more than usual. Moderate to severe traumatic brain injuries had the following symptoms: inability to wake from sleep, repeated vomiting or nausea. 3. During an interview on [DATE] at 3:30 p.m. Resident #16's physician verified she was not notified that Resident #16 had the change in condition of dark emesis, no urine output, jerky movements, incoherent speech, not taking her medication and that the resident was lethargic. She said she should have been notified that day. She said the staff called her on the day the resident passed but no one called and notified her of the change in condition. 4. Review of LVN A's undated written statement documented on [DATE] at approximately 1800 (6 p.m.) LVN A saw Resident #16 "up in wheelchair in day room. Family visiting with young children. Resident acknowledges greetings. 1800 meds (medications) administered at this time." During an interview on [DATE] at 3:45 p.m. LVN A said "I had seen Resident #16 "stay up all night at times and thought that was the reason we could not arouse her. I should have checked on the fact that she had no urine output. There is no time line for my charting and that is a mistake and not calling the physician (with the change of condition) was a mistake. I took another nurse (LVN O) to Resident #16's room and she said the vomiting did not smell like blood." 5. During an interview on [DATE] at 1:35 p.m. RN B said she had worked the 7:00 p.m. to 7:00 a.m. shift for three months. RN B confirmed she worked the weekend of [DATE] through [DATE]. She described Resident #16 as "very out of it, confused, disoriented." RN B said Resident #16 would stay up for "hours and hours and days and days" and then would "be out of it, sleeping." RN B said the other night nurse called her into the television room when Resident #16 was on the floor. RN B said she assessed Resident #16 and did all the vital signs and there were no apparent injuries observed. RN B said the staff put Resident #16 to bed at that time and at 4 a.m. she was asleep, in no distress and the alarms were on. RN B acknowledged Resident #16 was unable to answer appropriately if she hit her head. RN B acknowledged Resident #16's blood pressure was high, but noted that the blood pressure was going down on the third check. RN B confirmed she did not start neuro-checks. RN B said on [DATE] (Saturday 7 p.m.) she saw Resident #16 up in her wheelchair at the beginning of her shift with her grandchildren. She said Resident #16 was "lethargic." RN B explained Resident #16 was "out of it, not talking, and not responding that much." RN B said she briefly talked with the family and told them the staff would put Resident #16 to bed. RN B said Resident #16 being lethargic "wasn't anything abnormal," since that was how Resident #16 was when she had been up for hours. RN B said she was told in report that Resident #16 had vomited. RN B said she remembered the daughter saying Resident #16's stomach hurt. RN B said she held Resident #16's 8:30 p.m. medications because of the lethargy. RN B said "I didn't want to put medications in her mouth, it was not the first time this was the case." RN B said she did not know the facility's policy and procedure about holding medications. She said she did not feel comfortable putting medications in Resident #16's mouth. She said the medication was Klonopin which she didn't need because it was something to make her more lethargic. RN B said Resident #16 did vomit some on her shift. RN B said the vomit was brown and not coffee ground colored. RN B said Resident #16 had not acted any different at that point. RN B said there was nothing to report to the physician. She said Resident #16 vomited "once, that was it, she was stable." RN B pointed out the facility had standing orders for nausea/ vomiting, "but it was just that one time." RN B said she did not want to give Resident #16 the [MEDICATION NAME] because "if it was not necessary it would knock her out even more." RN B said again there was nothing abnormal about Resident #16 being lethargic other than the one time vomiting. She said the vomit was not "dark or coffee grounds or smelled." RN B said the aides did not tell her Resident #16 was acting any different. RN B said the facility did not do neuro-checks if the resident said they did not hit their head. She said it seemed odd to her and it "made sense" to do them if it was an unwitnessed fall. She said in her orientation she was told to do neuro- checks only if there were signs or symptoms or if you saw the resident hit their head. RN B said "if there were no signs or symptoms if they hit their head you didn't do them." RN B said she was not in-serviced about the neuro-check policy and procedure. RN B said she knew to call the doctor with a change in condition. RN B said "other than" Resident #16 "vomiting, there was nothing out of her normal behavior or I definitely would have" called the doctor. RN B said vomiting after a fall was not a good thing. She said with Resident #16's daughter saying her stomach hurting prior to the fall she was thinking the emesis was related to the stomach ache. RN B said "I didn't relate it to the fall." 6. During an interview on [DATE] at 10:52 a.m. CNA C said she was the shower aide on [DATE]. CNA C said Resident #16 had Alzheimer's, sometimes she could tell you if she needed to go to the bathroom but often she would be incontinent. CNA C said Resident #16 was "never mean, she had a big appetite that is how you knew if she was not feeling good." CNA C said Resident #16 "threw up the black stuff three times that Saturday." ([DATE]) CNA C said Resident #16 "threw up in the dining room during breakfast." She said they took her back to bed. She said the resident threw up again and the staff "had to change everything." CNA C acknowledged the nurse (LVN A) came to the room to assess the resident. She said the nurse told the staff to "sit her up in bed" and she ordered her a liquid diet. CNA C said she heard Resident #16 threw up again before day shift left and somebody from night shift helped clean her up. CNA C said normally Resident #16 would be up in her wheelchair all day and participate in activities. CNA C said from "Friday to Saturday she made a 360 degree turn." CNA C said she was not aware Resident #16 had a fall Friday night ([DATE]). CNA C said about once a week Resident #16 would stay up all night then sleep during the day. 7. During an interview on [DATE] at 11:30 a.m. CNA M verified she worked [DATE] on the 7:00 a.m. to 7:00 p.m. shift. CNA M said Resident #16 was "confused, hallucinated, never had a clear thought, would fidget and couldn't sit still." CNA M said if Resident #16 fell she could "probably not" tell you if she hit her head. CNA M said "that day ([DATE]) she complained of stomach pains." CNA M said she took Resident #16 to the bathroom and Resident #16 said "hurts so bad, hurts so bad." CNA M said she could not remember who she reported it to. CNA M said before she left Resident #16 complained about her stomach hurting again and she reported it to LVN N (charge nurse). CNA M said Resident #16 ate lunch and supper but it was not uncommon for her not to eat breakfast. CNA M said a few days after this the DON, Administrator and ADON asked her what happened. CNA M said she told them Resident #16 had complained of a stomach ache and she had reported it to the nurse. 8. During an interview on [DATE] at 3:30 p.m. LVN N said she worked the 7 a.m. to 7 p.m. shift on [DATE] (the day of the fall, before the fall occurred). LVN N confirmed she worked with Resident #16. LVN N said she did not believe there was anything going on with Resident #16, "she seemed fine to me." LVN N described Resident #16 as "happily confused." LVN N said she did not recall the aides reporting that Resident #16's stomach hurt. LVN N said "if they did, I went and assessed her. I don't remember going." LVN N said Resident #16 was normally confused in the morning and hard to wake up. LVN N said Resident #16 was "not really" lethargic "but you had to really talk to her to make sure she was alert." LVN N said Resident #16 could be up 24 - 48 hours at times despite her medications and then "be out" for 8 - 10 hours and "then she'd be up again." She said Resident #16 would follow this cycle every couple of days. LVN N said Resident #16 was "difficult to arouse at times." LVN N said Resident #16 could answer immediate yes or no questions. LVN N said if more than 15 minutes then Resident #16 probably could not tell if she hit her head. LVN N said the facility did neuro-checks any time the facility could confirm the resident hit their head. LVN N said she would "automatically initiate neuro-checks herself" because Resident #16 was confused. LVN N said the facility would not normally start neuro-checks if there were no signs of injury. LVN N confirmed if a cognitively impaired resident fell and there were no signs of injury the staff would do three vital signs (initially before moving the resident, then one minute after getting resident up, then three minutes after getting the resident up) and an incident/ accident report. She said she did not recall Resident #16 having any changes in condition or nausea/ vomiting nor did she recall the aide telling her anything. 9. During an interview on [DATE] at 3:55 p.m. LVN O said she remembered Resident #16. LVN O said she remembered LVN A calling her into Resident #16's room to assess the vomit ([DATE]). LVN O said it was "mainly food particles and dark green in color." LVN O said she only knew of Resident #16 vomiting only one time. LVN O said "in her mind" it was between breakfast and lunch, "but it could have been later." LVN O said she did not remember the vomit having an odor. LVN O said she did not know that Resident #16 had no urine output. LVN O said LVN A could have mentioned it and she not remember. LVN O said she only knew of the vomiting. LVN O said Resident #16 "was kinda weak" and did not remember Resident #16 saying anything. LVN O said Resident #16 would stay up for 24 - 48 hours and then sleep for 24 hours. LVN O said if there was an unwitnessed fall the nurses would do an incident/ accident report, take vital signs while the resident was on the floor and assess for any injuries, and range of motion. LVN O said after that staff would put the resident back in the wheelchair or bed then take the vital signs again. LVN O said vital signs were done one minute and then three minutes after getting the resident up. LVN O said "in the past" neuro-checks were only done when the resident hit their head. 10. Review of CNA G's [DATE] unsigned, typed statement CNA G saw Resident #16 in the room and she was "up moving around in bed messing with her stuff in the drawer. So I raised her head up so she can see what she was doing. She was fine when I was in the room getting (Resident #9's) glasses out the room." During an interview on [DATE] at 4:30 p.m. CNA G confirmed she worked the 7 a.m. to 7 p.m. shift on [DATE]. CNA G said Resident #9 (Resident #16's roommate) said she forgot her glasses around 7:30 a.m. CNA G said Resident #16 "was fine." CNA G said Resident #16 was in bed messing with stuff in her drawer. CNA G said Resident #16 told her "hi" when CNA G asked what Resident #16 was doing. CNA G said she gave Resident #16 a sip of water with no problems. CNA G said she asked Resident #16 if she needed anything and Resident #16 said she was doing good so she left to go feed resident in the dining room. CNA G said at about 8:15 a.m. they came to the dining room to say Resident #16 passed. She said some days Resident #16 acted like she knew what was going on and some days she would not. CNA G described Resident #16 as she "slept a lot, liked to talk a lot, liked to drink a lot." CNA G said she wrote her statement the following Monday ([DATE]) because she wanted staff to know what she saw. CNA G said she wrote it for herself and no one asked her to. 11. During an interview on [DATE] at 9:15 a.m. CNA P said she worked Saturday [DATE] during the day shift (7 a.m. through 7 p.m.). CNA P said she was not informed of the fall but noticed Resident #16 was "a little tired" and she did not want to do anything. CNA P said they got Resident #16 up for breakfast that day but did not think she ate anything. CNA P said Resident #16 would usually "just pick" at her food. CNA P said "at 8:30ish" Resident #16 was ok, she was asleep. CNA P said she remembered Resident #16 "didn't wet" that entire day and that was unusual. CNA P said after she took Resident #16 to bed she did showers and when she was done she went to check on Resident #16. CNA P said Resident #16 would answer yes/no questions and only with yes/no. CNA P said usually Resident #16 would try to have a conversation with the aides. CNA P said they did not get Resident #16 up for lunch that day and that was unusual. She said Resident #16 would not eat her lunch and she slept through it. CNA P said she reported that to the nurse. CNA P said Resident #16 still had not wet when she checked on her after putting other residents down after lunch. CNA P said she took lunch between 1:30 and 2 p.m. She said the staff came and got her during her lunch to say Resident #16 had gotten sick. She said she went and got CNA R to help clean up Resident #16. CNA P described Resident #16's vomit as thick," "blackish-brownish" with no smell and that it was "all over" Resident #16. CNA P said the vomit went off the bed onto the floor mat. CNA P said she went and got the nurse who told her it was probably something Resident #16 ate. CNA P said they got Resident #16 cleaned up and Resident #16 wanted out of bed. CNA P said they got Resident #16 up and she was "normal" fo

Based on observation, interview and record review, the facility failed to ensure two of two nurses provided the necessary care and services to attain or maintain the highest practicable physical, well-being in accordance with the comprehensive assessment and plan of care for one of three discharged residents (Resident #16). A) Licensed Vocational Nurse (LVN) A failed to thoroughly assess and notify the physician when Resident #16 had dark brown emesis, was unable to arouse resident to take medications, had no urine output and had "jerky movements" on [DATE]. Resident #16 died on [DATE]. B) Registered Nurse (RN) B failed to initiate neuro-checks per the facility's policy after Resident #16 fell and was unable to say if she hit her head. C) RN B did not thoroghly assess and notify the physician when she assisted Resident #16 to bed and documented Resident #16 was too lethargic to take her medications on [DATE] at 8:30 p.m. and had brown emesis at [DATE] at 2:30 a.m. These deficient practices resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE] at 3:55 p.m. While the IJ was removed on [DATE] at 4:21 p.m., the facility remained out of compliance at a level of Actual Harm at a Pattern that was not IJ because the facility had not had time to implement and monitor policies and procedures. These failures resulted in the physician not being involved in the diagnosing and/or management of critical medical conditions/crises for Residents #16. This failure could place 40 residents residing on Hall One at risk for delay in treatment, serious complications and/or death. Findings included: The Health survey was re-opened on [DATE]. An Extended Health Survey was conducted with an exit of [DATE]. 1. Review of Resident #16's Admission Record documented she was admitted on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years old. Resident #16 had a Do Not Resuscitate (DNR) order. Review of the facility's Physician Discharge Summary signed by the physician on [DATE] documented Resident #16's final [DIAGNOSES REDACTED]. Review of Resident #16's [DATE] quarterly MDS (Minimum Data Set) assessment documented in part: - Makes self understood: sometimes understood - ability is limited to making concrete requests. - Mental Status: 3 of 15 (,[DATE] is considered severe cognitive impairment.) - [MEDICAL CONDITION] (misconceptions or beliefs that are firmly held, contrary to reality) - Resident was occasionally incontinent of bladder. - Resident had two or more falls without any injury and two or more falls with injuries (skin tears, abrasions, superficial bruises, hematomas, and sprains). Resident #16 had no falls with a major injury. Review of Resident #16's care plan last updated [DATE] documented, in part: - Resident #16 was "at risk for falls, injury d/t (due to) unsteady gait and cognitive impairment, [MEDICATION NAME] PRN (as needed), [MEDICATION NAME] q (every) d (day), and hx (history) of fall at home." The facility identified the following approaches: "w/c (wheelchair) used primarily self-propel short distance and without direction must be redirected." "monitor for s/sx (signs and symptoms) of med and report significant to doctor." "Personal safety alarm in bed and wheelchair pressure alarm." - Cognitive loss or alternation in thought processes related to dx of [MEDICAL CONDITION], as evidenced by moderately impaired decision making and short term and/or long term memory loss. - Resident has episodes of combative behavior with staff. Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - [DATE] ,[DATE] (with morning medications) - [DATE] ,[DATE] (with morning medications) - [DATE] ,[DATE] (with morning medications) - [DATE] No Blood Pressure was documented - [DATE] ,[DATE] (with morning medications) Nurses notes dated [DATE] at 2215 (10:15 p.m.) documented: Called by north station nurse: observed resident laying on floor on L (left) side in front of w/c in TV (television) room, assessed resident, no apparent injuries observed. VS (vital signs) ,[DATE]-[DATE].5, assisted resident to w/c after 1 min (minute) VS ,[DATE]-[DATE].9, after 3 min in w/c - VS: ,[DATE]-[DATE].8 - no apparent distress, no c/o (complaints) voiced. Assisted resident to bed. At 2230 (10:30 p.m.) Notified resident's daughter. Notified Doctor per protocol (faxed to doctor's office). Encouraged resident to ask for assist. Personal alarm was on and sounding when found resident, WCTM (will continue to monitor). Signed by RN B. Review of the [DATE] Incident/Accident report completed by RN B documented Resident #16 had a fall at 2215 (10:15 p.m.) in the television room. RN B documented Resident #16 was confused. RN B documented Resident #16 did not have any apparent injuries at the time of the fall. Review of Resident #16's Post Fall Investigation for the [DATE] 10:15 p.m. fall documented: 1. Was the fall observed? No. 2. Resident's Vital Signs: 96.5 (temperature), 78 pulse, 18 respirations, ,[DATE] blood pressure, second blood pressure ,[DATE] sitting. 3. What was resident's response to "why do you think you fell ?" RN B documented: "Resident unable to tell why she thinks she fell . Resident delusional and responses are inappropriate for situation. Resident appeared to think she was in bed and was stating the bed not comfortable." Review of the second page of the Post Fall Investigation documented Resident #16 was Confused and Disoriented prior to and following the fall. Nurses notes dated [DATE] at 0400 (4:00 a.m.) documented: Resident in bed with eyes closed, no apparent distress observed. Alarms in place and on. WCTM. Signed by RN B. Review of Resident #16's ,[DATE] MAR indicated [REDACTED] Nurses notes dated [DATE] at 1540 (3:40 p.m.) documented: Resident in bed all day, unable to rouse resident sufficiently to administer 0800 (8 a.m.) or 1200 (noon) medications. Approximately 1430 (2:30 p.m.) dark emesis noted staining resident's face, bedding and clothing. VS - 96XXX,[DATE]-,[DATE]-22, O2 (oxygen saturation) 93 on RA (room air), occasional jerky movements, no intelligible conversation, responds to requests to open eyes, "squeeze fingers (very weakly)", HR (heart rate) apical vs (verses) radial is = (equal), no urine produced at this time on this shift, given water only to this time, will inform oncoming shift. Signed by LVN A. (No documentation the physician was notified). Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - LVN A circled as not given the following 7 a.m. through 7 p.m. medications on [DATE] - [MEDICATION NAME] 100mg (milligrams) for a stool softener. (8 a.m.) - [MEDICATION NAME] 7XXX,[DATE]mg for pain (8 a.m.) - Vitamin D3 2000 IU (units) for vitamin supplement (8 a.m.) - [MEDICATION NAME] 50 mg for dementia with behaviors (8 a.m.) - [MEDICATION NAME] 25mg (noon) - Artificial Tears for dry eyes (8 a.m.) - [MEDICATION NAME] 300mg for hypertension (8 a.m.) - [MEDICATION NAME] 100mg for osteoarthros (8 a.m.) - [MEDICATION NAME] XL 100 mg for hypertension (8 a.m.) - [MEDICATION NAME] 10mg for asthma (8 a.m.) LVN A documented "all 0800 meds held - resident sleeping could not rouse." and "1200 [MEDICATION NAME] held - Resident asleep could not rouse." Nurses notes dated [DATE] at 2030 (8:30 p.m.) documented: VS: ,[DATE]-[DATE]XXX,[DATE]% on RA. Assisted resident to bed, very lethargic at this time. Holding meds due to not waking enough to swallow. No apparent injuries observed from fall on [DATE]. Alarms in place, WCTM. Signed by RN B. (No documentation the physician was notified). Review of Resident #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - RN B circled as not given the following evening medications on [DATE]: - Klonopin 0.5 mg for [MEDICAL CONDITION] - [MEDICATION NAME] 7XXX,[DATE] (8 p.m.) - [MEDICATION NAME] 20mg for [MEDICAL CONDITION] (8 p.m.) Nurses notes dated [DATE] at 0230 (2:30 a.m.) documented: Vomited moderate amount of brown emesis, bowel sounds hyperactive, continues to be lethargic. Daughter had stated yesterday that her mom had been c/o stomach ache. CNA (Certified Nurse Aide) flowbook shows resident had large BM (bowel movement) on [DATE]. Will continue to monitor for further emesis or any other problems. Signed by RN B. (No documentation the physician was notified). Review of the ,[DATE] MAR indicated [REDACTED] Nurses notes dated [DATE] at 0950 (9:50 a.m.) documented: At approximately 0845 (8:45 a.m.) (CNA F) entered resident's room because she observed resident in bed and fluid on floor. At some time earlier another (CNA P) reported to this nurse resident was awake and (CNA G) had raised HOB (head of bed) and placed call light in reach. Resident was unresponsive when this nurse entered the room - no respirations, no blood pressure. At 0850 (8:50 a.m.) House Supervisor and Doctor were called. At 0915 (9:15 a.m.) Doctor arrived and pronounced death. Signed by LVN A. 2. During an interview on [DATE] at 11:55 a.m. the Director of Nurses (DON) said the nurse should call the physician due to abnormal symptoms such as heart rate, blood pressure or any change in condition. The DON said if residents have no apparent injuries then they only have to do vital signs after the fall. During a follow-up interview on [DATE] at 2:05 p.m. with the Administrator and DON present. The DON said the physician should be notified when there was an "abnormal change," not something the resident did all the time. The DON said an abnormal change would be breath sounds, heart rate, blood pressure right off the top of her head. The DON said she could not put a time limit on when a nurse should notify the physician. The DON pointed out the witness statements said Resident #16 was okay. The DON said the physician should be notified if a resident missed a dose depending on the medication. The DON said Resident #16 had no signs or symptoms of injuries so she did not have anything to stimulate a neuro-check. She said there was no suspicion of Resident #16 having a head injury. The DON said Resident #16 could tell you sometimes what happened. The Administrator added Resident #16 could communicate "immediate" needs or happenings. The Administrator said Resident #16 would have been able to report if she hit her head during a fall. The Administrator asked what the change in condition was. Surveyor outlined the nurses notes of vomiting and lethargic at times. The Administrator said Resident #16 was up and about in her wheelchair and was doing normal stuff and there was no reason to do neuro checks. The DON acknowledged LVN A was written up for not notifying the doctor. The DON said after Resident #16's fall she had to take a licensed nurse's word there were no signs or symptoms of injury and she did not think of the situation as neglect. She acknowledged not all injuries from a fall were immediately apparent but said with a head injury there was usually a raised area, a red area, a blue area. She said a delayed injury usually showed up in an arm or a leg. She said with a head injury there was a bruise or a lump quick. The DON said Resident #16 fell at 10:15 p.m. on [DATE] and it was 1:30 p.m. the next day when the nurse charted Resident #16 was in bed all day. The DON said Resident #16's vital signs were within normal limits, her oxygen level was alright, she opened her eyes and squeezed fingers (surveyor had to point out the note read "squeezed fingers weakly") and her heart rate was good. The DON said when she wrote LVN A up all this "other stuff" (anything after [DATE] at 10:30 p.m.) had not happened yet (LVN A was not written up until [DATE]) . She said she had to take the other nurse's word. The DON said "I don't think there was any neglect, I think it was stupid" The DON said Resident #16's vital signs were still good and the charting that Resident #16 was "lethargic" happened at night when she was in bed. The DON acknowledged the doctor should have been called. A review of a calendar documented [DATE] was a Saturday. The DON said she read LVN A's notes on the Monday after it happened ([DATE]). The DON said she thought LVN A failed to call the doctor and she did not think LVN A neglected Resident #16. The DON said when she noticed LVN A did not call the doctor she wrote her up. The Administrator said the nurses "all knew to notify the family, the doctor, and the state if something went wrong." According to the Mayo Clinic website based off Mayo Clinic Family Health book 4th Edition documented on Traumatic Brain Injuries Signs and Symptoms included, in part: nausea or vomiting, fatigue or drowsiness, sleeping more than usual. Moderate to severe traumatic brain injuries had the following symptoms: inability to wake from sleep, repeated vomiting or nausea. 3. During an interview on [DATE] at 3:30 p.m. Resident #16's physician verified she was not notified that Resident #16 had the change in condition of dark emesis, no urine output, jerky movements, incoherent speech, not taking her medication and that the resident was lethargic. She said she should have been notified that day. She said the staff called her on the day the resident passed but no one called and notified her of the change in condition. 4. Review of LVN A's undated written statement documented on [DATE] at approximately 1800 (6 p.m.) LVN A saw Resident #16 "up in wheelchair in day room. Family visiting with young children. Resident acknowledges greetings. 1800 meds (medications) administered at this time." During an interview on [DATE] at 3:45 p.m. LVN A said "I had seen Resident #16 "stay up all night at times and thought that was the reason we could not arouse her. I should have checked on the fact that she had no urine output. There is no time line for my charting and that is a mistake and not calling the physician (with the change of condition) was a mistake. I took another nurse (LVN O) to Resident #16's room and she said the vomiting did not smell like blood." 5. During an interview on [DATE] at 1:35 p.m. RN B said she had worked the 7:00 p.m. to 7:00 a.m. shift for three months. RN B confirmed she worked the weekend of [DATE] through [DATE]. She described Resident #16 as "very out of it, confused, disoriented." RN B said Resident #16 would stay up for "hours and hours and days and days" and then would "be out of it, sleeping." RN B said the other night nurse called her into the television room when Resident #16 was on the floor. RN B said she assessed Resident #16 and did all the vital signs and there were no apparent injuries observed. RN B said the staff put Resident #16 to bed at that time and at 4 a.m. she was asleep, in no distress and the alarms were on. RN B acknowledged Resident #16 was unable to answer appropriately if she hit her head. RN B acknowledged Resident #16's blood pressure was high, but noted that the blood pressure was going down on the third check. RN B confirmed she did not start neuro-checks. RN B said on [DATE] (Saturday 7 p.m.) she saw Resident #16 up in her wheelchair at the beginning of her shift with her grandchildren. She said Resident #16 was "lethargic." RN B explained Resident #16 was "out of it, not talking, and not responding that much." RN B said she briefly talked with the family and told them the staff would put Resident #16 to bed. RN B said Resident #16 being lethargic "wasn't anything abnormal," since that was how Resident #16 was when she had been up for hours. RN B said she was told in report that Resident #16 had vomited. RN B said she remembered the daughter saying Resident #16's stomach hurt. RN B said she held Resident #16's 8:30 p.m. medications because of the lethargy. RN B said "I didn't want to put medications in her mouth, it was not the first time this was the case." RN B said she did not know the facility's policy and procedure about holding medications. She said she did not feel comfortable putting medications in Resident #16's mouth. She said the medication was Klonopin which she didn't need because it was something to make her more lethargic. RN B said Resident #16 did vomit some on her shift. RN B said the vomit was brown and not coffee ground colored. RN B said Resident #16 had not acted any different at that point. RN B said there was nothing to report to the physician. She said Resident #16 vomited "once, that was it, she was stable." RN B pointed out the facility had standing orders for nausea/ vomiting, "but it was just that one time." RN B said she did not want to give Resident #16 the [MEDICATION NAME] because "if it was not necessary it would knock her out even more." RN B said again there was nothing abnormal about Resident #16 being lethargic other than the one time vomiting. She said the vomit was not "dark or coffee grounds or smelled." RN B said the aides did not tell her Resident #16 was acting any different. RN B said the facility did not do neuro-checks if the resident said they did not hit their head. She said it seemed odd to her and it "made sense" to do them if it was an unwitnessed fall. She said in her orientation she was told to do neuro- checks only if there were signs or symptoms or if you saw the resident hit their head. RN B said "if there were no signs or symptoms if they hit their head you didn't do them." RN B said she was not in-serviced about the neuro-check policy and procedure. RN B said she knew to call the doctor with a change in condition. RN B said "other than" Resident #16 "vomiting, there was nothing out of her normal behavior or I definitely would have" called the doctor. RN B said vomiting after a fall was not a good thing. She said with Resident #16's daughter saying her stomach hurting prior to the fall she was thinking the emesis was related to the stomach ache. RN B said "I didn't relate it to the fall." 6. During an interview on [DATE] at 10:52 a.m. CNA C said she was the shower aide on [DATE]. CNA C said Resident #16 had Alzheimer's, sometimes she could tell you if she needed to go to the bathroom but often she would be incontinent. CNA C said Resident #16 was "never mean, she had a big appetite that is how you knew if she was not feeling good." CNA C said Resident #16 "threw up the black stuff three times that Saturday." ([DATE]) CNA C said Resident #16 "threw up in the dining room during breakfast." She said they took her back to bed. She said the resident threw up again and the staff "had to change everything." CNA C acknowledged the nurse (LVN A) came to the room to assess the resident. She said the nurse told the staff to "sit her up in bed" and she ordered her a liquid diet. CNA C said she heard Resident #16 threw up again before day shift left and somebody from night shift helped clean her up. CNA C said normally Resident #16 would be up in her wheelchair all day and participate in activities. CNA C said from "Friday to Saturday she made a 360 degree turn." CNA C said she was not aware Resident #16 had a fall Friday night ([DATE]). CNA C said about once a week Resident #16 would stay up all night then sleep during the day. 7. During an interview on [DATE] at 11:30 a.m. CNA M verified she worked [DATE] on the 7:00 a.m. to 7:00 p.m. shift. CNA M said Resident #16 was "confused, hallucinated, never had a clear thought, would fidget and couldn't sit still." CNA M said if Resident #16 fell she could "probably not" tell you if she hit her head. CNA M said "that day ([DATE]) she complained of stomach pains." CNA M said she took Resident #16 to the bathroom and Resident #16 said "hurts so bad, hurts so bad." CNA M said she could not remember who she reported it to. CNA M said before she left Resident #16 complained about her stomach hurting again and she reported it to LVN N (charge nurse). CNA M said Resident #16 ate lunch and supper but it was not uncommon for her not to eat breakfast. CNA M said a few days after this the DON, Administrator and ADON asked her what happened. CNA M said she told them Resident #16 had complained of a stomach ache and she had reported it to the nurse. 8. During an interview on [DATE] at 3:30 p.m. LVN N said she worked the 7 a.m. to 7 p.m. shift on [DATE] (the day of the fall, before the fall occurred). LVN N confirmed she worked with Resident #16. LVN N said she did not believe there was anything going on with Resident #16, "she seemed fine to me." LVN N described Resident #16 as "happily confused." LVN N said she did not recall the aides reporting that Resident #16's stomach hurt. LVN N said "if they did, I went and assessed her. I don't remember going." LVN N said Resident #16 was normally confused in the morning and hard to wake up. LVN N said Resident #16 was "not really" lethargic "but you had to really talk to her to make sure she was alert." LVN N said Resident #16 could be up 24 - 48 hours at times despite her medications and then "be out" for 8 - 10 hours and "then she'd be up again." She said Resident #16 would follow this cycle every couple of days. LVN N said Resident #16 was "difficult to arouse at times." LVN N said Resident #16 could answer immediate yes or no questions. LVN N said if more than 15 minutes then Resident #16 probably could not tell if she hit her head. LVN N said the facility did neuro-checks any time the facility could confirm the resident hit their head. LVN N said she would "automatically initiate neuro-checks herself" because Resident #16 was confused. LVN N said the facility would not normally start neuro-checks if there were no signs of injury. LVN N confirmed if a cognitively impaired resident fell and there were no signs of injury the staff would do three vital signs (initially before moving the resident, then one minute after getting resident up, then three minutes after getting the resident up) and an incident/ accident report. She said she did not recall Resident #16 having any changes in condition or nausea/ vomiting nor did she recall the aide telling her anything. 9. During an interview on [DATE] at 3:55 p.m. LVN O said she remembered Resident #16. LVN O said she remembered LVN A calling her into Resident #16's room to assess the vomit ([DATE]). LVN O said it was "mainly food particles and dark green in color." LVN O said she only knew of Resident #16 vomiting only one time. LVN O said "in her mind" it was between breakfast and lunch, "but it could have been later." LVN O said she did not remember the vomit having an odor. LVN O said she did not know that Resident #16 had no urine output. LVN O said LVN A could have mentioned it and she not remember. LVN O said she only knew of the vomiting. LVN O said Resident #16 "was kinda weak" and did not remember Resident #16 saying anything. LVN O said Resident #16 would stay up for 24 - 48 hours and then sleep for 24 hours. LVN O said if there was an unwitnessed fall the nurses would do an incident/ accident report, take vital signs while the resident was on the floor and assess for any injuries, and range of motion. LVN O said after that staff would put the resident back in the wheelchair or bed then take the vital signs again. LVN O said vital signs were done one minute and then three minutes after getting the resident up. LVN O said "in the past" neuro-checks were only done when the resident hit their head. 10. Review of CNA G's [DATE] unsigned, typed statement CNA G saw Resident #16 in the room and she was "up moving around in bed messing with her stuff in the drawer. So I raised her head up so she can see what she was doing. She was fine when I was in the room getting (Resident #9's) glasses out the room." During an interview on [DATE] at 4:30 p.m. CNA G confirmed she worked the 7 a.m. to 7 p.m. shift on [DATE]. CNA G said Resident #9 (Resident #16's roommate) said she forgot her glasses around 7:30 a.m. CNA G said Resident #16 "was fine." CNA G said Resident #16 was in bed messing with stuff in her drawer. CNA G said Resident #16 told her "hi" when CNA G asked what Resident #16 was doing. CNA G said she gave Resident #16 a sip of water with no problems. CNA G said she asked Resident #16 if she needed anything and Resident #16 said she was doing good so she left to go feed resident in the dining room. CNA G said at about 8:15 a.m. they came to the dining room to say Resident #16 passed. She said some days Resident #16 acted like she knew what was going on and some days she would not. CNA G described Resident #16 as she "slept a lot, liked to talk a lot, liked to drink a lot." CNA G said she wrote her statement the following Monday ([DATE]) because she wanted staff to know what she saw. CNA G said she wrote it for herself and no one asked her to. 11. During an interview on [DATE] at 9:15 a.m. CNA P said she worked Saturday [DATE] during the day shift (7 a.m. through 7 p.m.). CNA P said she was not informed of the fall but noticed Resident #16 was "a little tired" and she did not want to do anything. CNA P said they got Resident #16 up for breakfast that day but did not think she ate anything. CNA P said Resident #16 would usually "just pick" at her food. CNA P said "at 8:30ish" Resident #16 was ok, she was asleep. CNA P said she remembered Resident #16 "didn't wet" that entire day and that was unusual. CNA P said after she took Resident #16 to bed she did showers and when she was done she went to check on Resident #16. CNA P said Resident #16 would answer yes/no questions and only with yes/no. CNA P said usually Resident #16 would try to have a conversation with the aides. CNA P said they did not get Resident #16 up for lunch that day and that was unusual. She said Resident #16 would not eat her lunch and she slept through it. CNA P said she reported that to the nurse. CNA P said Resident #16 still had not wet when she checked on her after putting other residents down after lunch. CNA P said she took lunch between 1:30 and 2 p.m. She said the staff came and got her during her lunch to say Resident #16 had gotten sick. She said she went and got CNA R to help clean up Resident #16. CNA P described Resident #16's vomit as thick," "blackish-brownish" with no smell and that it was "all over" Resident #16. CNA P said the vomit went off the bed onto the floor mat. CNA P said she went and got the nurse who told her it was probably something Resident #16 ate. CNA P said they got Resident #16 cleaned up and Resident #16 wanted out of bed. CNA P said they got Resident #16 up and she was "normal" for about 15 - 20 minutes. CNA P said they noticed Resident #16 was "slouched" in her wheelchair sleeping so they put her back to bed. CNA P said Resident #16 still had not wet by supper time and was still sleeping. CNA P said the nurse told her to hold her tray since she threw up and ordered her a liquid diet but Resident #16 did not eat any of it. CNA P said Resident #16 "finally wet" on her last rounds but it was not a normal amount. CNA P said Resident #16 "was fine" when she left at 7 p.m. that night. CNA P said she reported it to the oncoming shift but did not remember who. CNA P said Resident #16 vomited one time her shift. She said Resident #16 did not complain of pain. CNA P said she worked on [DATE] (Sunday) but was not assigned to Resident #16's room. She said she looked in on Resident #16 to see who the night shift had gotten up and who they had not. She said Resident #16 was in her room like normal and she just thought the vomiting was a stomach bug. CNA P said she offered Resident #16 a couple of sips of water, straightened her up in bed and left the room to feed residents in the dining room. CNA P said Resident #16 did not talk to her that day. She said the agency aide came in to ask who had Resident #16's room and told them Resident #16 died . CNA P said she went back to hall and saw that there was "vomit everywhere." CNA P said Resident #16 had not stayed in bed all day before [DATE] and just thought it was for the day. She said Resident #16 would just pick at her food which was not normal and she did not drink as much as she usually did as well. She said Resident #16 did not talk on [DATE] and that was not her normal. CNA P said she was unaware Resident #16 fell on [DATE]. CNA P said there was not a lot of communication between the nurses and the aides. CNA P said if the aides knew about the [DATE] fall they would have known more about what was going on with the resident "but no one said anything in report." 12. Review of CNA F's [DATE] statement documented CNA F worked Sunday [DATE]. CNA F documented she got Resident #16 her breakfast tray "at 7:40 a.m. took it to her room and she was in bed her head was moving. So I decided to get her up because she was awake. I brought her tray back to the cart at the end of the hall, went back to there room and seen a pool of liquid all over the floor. I said what did you (do) now Mrs. (Resident #16) she did not respond so I pushed on her shoulder and she fell back there was no sign of life. I checked for a pulse and eyes then went out in hall and yelled for help." During an interview on [DATE] at 4:45 p.m. CNA F said she worked with Resident #16 on [DATE] (7 a.m. to 7 p.m.). CNA F said she took Resident #16 her breakfast tray. CNA F said Resident #16 was awake, leaning on the side of the bed and digging through her drawer. CNA F said she returned Resident #16's breakfast tray to the hall cart and returned to the room, which took "two - three minutes at the most." CNA F said there was a "big flood" of brown looking stuff on the floor. CNA F said she checked Resident #16's pulse and her eyes, pulled the call light, and went to holler down the hall. CNA F said the fluid was reddish-brown and there was a "big, huge puddle, like a river" on the floor. CNA F said it did not smell. She said the fluid was all down the bed, to the floor. She said Resident #16's head of bed was up. 13. During an interview on [DATE] at 1:30 p.m. Medical Director BB said he had conferred with Medical Director AA about the case. He confirmed the facility did not call Medical Director AA (Resident #16's physician) the Friday ([DATE]) night concerning the fall. He said the staff "probably faxed" the notification to the doctor and there was no one who would have looked at it until Monday ([DATE]). Medical Director BB said if Resident #16 was vomiting "someone should have been notified." 14. During an interview on [DATE] at 3:55 p.m. the Administrator, DON, and ADON was informed of the identification of an IJ situation. 15. During an interview on [DATE] at 8:55 a.m. Medical Director AA said she was called Sunday Morning ([DATE]) about Resident #16. Medical Director AA said she did see the emesis. Medical Director AA said the emesis was on the mats and on the floor. Medical Director AA described the emesis as "brown." Medical Director AA said she used a urine dip stick to test the emesis for blood and it showed positive. Medical Director AA said Resident #16 was at risk for a GI Bleed because she was on [MEDICATION NAME] and she had GERD. Medical Director AA said the family just wanted Resident #16 comfortable. Medical Director AA said she had a hard time with Resident #16's behaviors due to end stage [MEDICAL CONDITION]. Medical Director AA said she should have been notified of Resident #16 "not taking medication, not being arrousable, having no urine output." She said "all of these things equal a change in condition." 16. During an interview on [DATE] at 10:09 a.m. CNA Q said she worked for an agency but did remember taking care of Resident #16 the night of [DATE] during the 7:00 p.m. to 7:00 a.m. shift. CNA Q said Resident #16 "vomited black vomit two times" during her shift and she reported it to the nurse (RN B). CNA Q said Resident #16 would wake up when she provided incontinent care but then went right back to sleep. 17. Review of the Employee Counseling Report dated [DATE] and signed by the DON and LVN A documented in part that on [DATE] LVN A did not notify the physician on resident's change in condition "LVN will always notify physician on change of condition." 18. Review of the facility's [DATE] In-service on Assessment and Documentation of Residents Change of Condition and Notifying Physician documented, in part: Medicin