Every finding on record at Pike Creek Nursing & Rehabilitation Center

Based on observation, interview, policy review, and review of the Food and Drug Administration (FDA) Food Code guidelines, the facility failed to ensure refrigerated and frozen food was properly labeled and dated, protected from contamination, and stored in a sanitary manner; failed to ensure kitchen equipment and residents' nutrition pantries were maintained in a sanitary condition; and failed to ensure dietary staff followed proper hand hygiene and glove-use practices during food preparation and tray-line service. This deficient practice had the potential to affect 163 of 165 residents who received meals and nourishment prepared in the facility kitchen. Findings include: Observation on 08/23/26 at 10:30 AM in the kitchen revealed the following: Inside the walk-in refrigerator, a tray containing a yellow-colored substance was stored without a label or date and was covered with plastic wrap. Also stored on a shelf was a tray of discolored, overripe, and waterlogged strawberries that was not labeled or dated. The plastic covering contained a large hole, leaving the product inadequately protected from contamination. [NAME] 1 confirmed at the time of the observation that the items were strawberries and pineapples and acknowledged they should have been labeled, dated, and properly secured. [NAME] 1 stated the items appeared to be beyond their use. Observation also revealed onion husks and other debris on the walk-in refrigerator floor. Observation of the walk-in freezer revealed excessive frost accumulation. The freezer lacked an internal thermometer for monitoring freezer temperatures. Observation of the reach-in freezer revealed an unlabeled, partially consumed bottle of Gatorade and a large unlabeled and undated clear bag containing frozen, yellow-colored food items. When questioned at the time of the observation, [NAME] 1 stated he believed the contents were eggs but could not identify why the product was stored or how long it had been present. Opened hot dogs, gravy, cooked ground chicken, chicken noodle soup, pork chops, and pasta were not labeled or dated. [NAME] 1 stated that the evening cook sometimes placed leftovers into storage and waited until the following day to label and date the food items. Observation of the kitchen ice machine revealed dark residue and pink-colored buildup on the interior surfaces and seams of the machine. During an interview on 08/24/26 at 11:39 AM, the Dietary Manager (DM) and Regional Dietary Manager (RDM) were informed of the food-labeling, storage, and sanitation concerns identified on 08/23/26. The DM stated all staff, particularly cooks, should properly store, label, and date foods before placing them into refrigeration. When shown the buildup within the ice machine, the DM stated maintenance staff were responsible for cleaning the ice machine. During the interview and observation of the ice machine, the DM removed an ice scoop that had been stored inside the ice machine and acknowledged it should not be stored in contact with the ice. The RDM stated the ice scoop should not have been stored in the ice bin. Review of the facility's policy titled Ice, dated May 2014, indicated: Ice will be prepared and distributed in a safe and sanitary manner . Ice bins will be cleaned monthly . Ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention. Review of the facility's policy titled Dietary Equipment, dated May 2014, indicated: All food service equipment will be clean, sanitary, and in proper working order. During tray-line observation beginning on 08/24/26 at 12:12 PM, while preparing cheese quesadillas and wearing gloves, the DM touched food items and multiple food-contact and non-food-contact surfaces, including tortillas, cheese, bread, utensils, refrigerator doors, oven handles, temperature controls, steam-table components, pans, and containers, without changing gloves or performing hand hygiene. At 12:24 PM, the DM removed his gloves and did not perform hand hygiene. At 12:45 PM, the DM donned gloves without performing hand hygiene and resumed food preparation. At 12:54 PM, the DM changed gloves without performing hand hygiene. Review of the facility's policy titled Food Preparation, dated May 2014, indicated staff were to practice proper handwashing techniques and glove use. Review of the facility's policy titled Standard Precautions, dated May 2014, required staff to remove gloves promptly after use and perform hand hygiene upon glove removal. Observation on 08/26/26 at 11:46 AM in the Rehoboth Unit residents' nutrition pantry revealed the ice breaker within the ice machine was covered with a pink-colored substance, and water was observed dripping from the component directly onto the ice. Observation also revealed unlabeled beverages and partially consumed food items stored in the pantry, including a fruit-flavored beverage, a half-filled bottle of juice, a bottle of soda, a bottle of water, an open bag of candy, an unopened microwave meal, and an individual package of peanut butter cups. The interior surfaces and glass plate of the microwave contained food splatter. Observation on 08/26/26 at 11:51 AM in the [NAME] Unit residents' nutrition pantry revealed the interior surfaces and glass plate of the microwave contained food splatter. The pantry freezer did not seal properly because of excessive frost accumulation and contained an unlabeled microwave meal and an unlabeled carton of ice cream. Food debris and frozen-liquid residue were observed throughout the freezer compartment. Review of the facility's Food Preparation policy stated, All foods are prepared in accordance with the FDA Food Code. Review of the U.S. FDA Food Code, available at https://www.fda.gov/food/retail-food-protection/fda-food-code, indicated food shall be protected from contamination during storage, preparation, and service; refrigerated ready-to-eat, time/temperature control for safety (TCS) foods shall be properly date marked; food-contact surfaces and equipment shall be maintained clean to sight and touch; food employees shall perform hand hygiene at appropriate times, including after glove removal; and gloves shall be changed as necessary to prevent contamination of food.

Based on record review, staff interview, and policy review, the facility failed to implement policies and procedures to ensure antibiotics were not used without the presence of a diagnosed infection and failed to complete an infection screening evaluation for one of three residents (Resident (R) 137) reviewed for antibiotic stewardship. The failure had the potential to increase the risk of adverse events, including the development of antibiotic-resistant organisms, resulting from unnecessary or inappropriate antibiotic use. Findings include: Review of R137's admission Record located under the Profile tab of the electronic medical record (EMR), indicated R137 was admitted to the facility on [DATE]. Review of R137's quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 03/13/26, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R137 was moderately cognitively impaired. Review of R137's quarterly MDS located under the MDS tab with an ARD of 06/10/26, revealed a BIMS score of 3 out of 15, which indicated R137 was severely cognitively impaired. Review of R137's Orders located under the Orders tab of the EMR revealed an order for a urinalysis and culture dated 06/09/26. Review of Progress notes dated 06/09/26 through 06/10/26, located under the Prog Notes tab of the EMR, documented no behavioral concerns and contained no documentation supporting a suspected infection or the reason for ordering a urinalysis and culture. Review of R137's laboratory results dated [DATE], provided by the facility, revealed a [NAME] Blood Cell (WBC) count of 7.5, which was within the normal range. Review of R137's Progress Notes dated 06/11/26 at 7:24 AM, located under the Prog Notes tab of the EMR documented, Patient monitored for behaviors no c/o [complaints of] noted, refused to give urine for ua-c+s [urinalysis, culture and sensitivity], NO S/S [signs or symptoms] of distress noted. Review of hospital records dated 06/14/26, provided by the facility, revealed R137 was evaluated in the emergency room following a fall and documentation indicated, . No reported infectious symptoms. There was no record a urine specimen was collected. Review of R137's Orders located under the Orders tab of the EMR, revealed an order dated 06/15/26 for Cephalexin (an antibiotic) 500 milligrams, one tablet by mouth every 12 hours for a urinary tract infection (UTI) for five days. Review of R137's Medical Note located under the Prog Notes tab of the EMR dated 06/15/26, revealed the provider did not document signs or symptoms of infection, a diagnosis of a UTI or a rationale for ordering an antibiotic. Review of the facility's Weekly Director of Nursing Report-Infections (antibiotic stewardship line listing) located in the infection control binder and dated 06/11/26 through 06/17/26, indicated, R137 suspected UTI, facility acquired, and cephalexin. The facility identified R137 as having a suspected UTI; however, the line listing did not contain documentation of symptoms, laboratory results, treatment dates, or evidence the antibiotic met facility antibiotic stewardship criteria. Review of R137's June 2026 Medication Administration Record (MAR) located under the Orders tab of the EMR revealed Cephalexin was administered from 06/16/26 through completion of the prescribed five-day course. During an interview on 08/26/26 at 11:17 AM, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated the antibiotic was ordered for R137 because of increased confusion, increased aggression, and a decline in the BIMS score from 11 to three. The ADON/IP stated, R137 should have had an Infection Screen Evaluation initiated in the EMR and it was not completed. I would have expected the provider to document a rationale for ordering antibiotics without laboratory results. We use McGeer criteria. Review of the antibiotic ordered on 06/15/26 did not meet criteria. Review of the facility's policy titled, Antibiotic Stewardship Program, dated 10/24/22, indicated, The Center is committed to providing quality care through implementation of an Antibiotic Stewardship Program designed to promote appropriate antibiotic use and reduce antibiotic resistance. Antimicrobial therapy should be based on McGeer/[NAME]/CDC criteria.

Based on record review, interview, and policy review, the facility failed to ensure the results of an investigation involving an allegation of physical abuse were reported to the State Agency (SA) within five working days for one (Resident (R) 29) of seven abuse investigations reviewed from a sample of 42 residents. This deficient practice had the potential to delay SA oversight and intervention, which could affect the timely identification and correction of conditions that may place residents at risk for abuse. Findings include: Review of R29's electronic medical record (EMR) revealed the resident was originally admitted on [DATE] with a diagnosis of dementia. The EMR contained an admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/25/26 and a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Review of the facility's abuse investigation documentation revealed that R29 alleged staff-to-resident physical abuse. Documentation indicated that the Director of Nursing (DON)/Administrator notified the SA of the allegation on 07/30/26. The facility's investigation concluded that the allegation could not be substantiated. However, the investigation file contained no evidence that the facility submitted the required final five-working-day report to the SA. During an interview on 08/26/26 at 12:28 PM, the Administrator confirmed the facility did not report its investigation findings to the SA within the required five-working-day timeframe. The Administrator stated staff had overlooked the reporting requirement. Review of the facility's policy titled Abuse, dated 02/05/23, indicated, The Administrator must thoroughly investigate and file a complete written report of the investigation of the submitted FRI to the State Agency within five (5) working days of the incident.

Based on interviews, record review, and policy review, the facility failed to protect one of seven residents (Resident (R) 36) reviewed for physical abuse by another resident (R21) among 42 sampled residents. This failure had the potential to result in physical and/or psychosocial harm. Findings include: The deficient practice was determined to be past noncompliance related to the facility identifying the resident-to-resident abuse and implementing interventions to prevent reoccurrence of the situation, completed on 06/17/26. The facility's actions included the following: The aggressive resident (R21) involved in the 06/09/26 resident-to-resident abuse incident was removed from the situation and placed on one-to-one (1:1) supervision. R21 was transferred to the emergency room for evaluation. R21 was cleared to return to the facility, and 1:1 supervision resumed The aggressive resident (R21) was moved to the second floor away from (R36), who was on the first floor The police department was notified, and the situation was investigated. Family of both residents notified of incident and Medical Doctor notified Psychiatric Evaluation completed 06/17/26 for both R21 and R36 Staff were in-serviced on abuse prevention Care plan was revised with interventions No other abuse incidents involving R21 and other residents since the 06/09/26 incident Findings include: Review of R36's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R36 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, major depressive disorder, and cognitive communication deficit. Review of R36's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 06/05/26 revealed a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment. Review of R36's Care Plan, revised on 06/16/26, revealed R36 had signs and symptoms of depression and was at risk of adverse reactions related to a recent negative interaction with a male resident. Review of R21's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R21 was admitted to the facility on [DATE] with diagnoses including alcohol dependence with alcohol-induced persisting dementia, cognitive communication deficit, dementia, anxiety disorder, and alcohol abuse with other alcohol-induced disorder. Review of R21's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 08/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating R21 was unable to complete the interview. A Staff Assessment for Mental Status (SAMS) indicated R21 had long- and short-term memory problems. Review of R21's Care Plan Report, revised on 06/10/26, revealed R21 exhibited behaviors including use of profanity, refusing showers and treatments, being verbally aggressive toward staff and residents, pacing the hallway, wandering into other residents' rooms, and being physically aggressive toward other residents and staff. The Care Plan indicated an intervention initiated on 01/19/26 directing staff to ensure familiar staff members worked with R21. An intervention initiated on 02/23/25 directed staff to provide R21 with diversional activities and take him to a quiet area if he became overstimulated. Review of Incident Tracking, dated 06/09/26, revealed R21 entered R36's room and hit R36 on the forehead. R36 then lifted her arm to shield her face, and R21 grabbed her arm, causing a scratch. Staff immediately redirected R21 out of the room and placed him on 1:1 staff supervision. Review of Licensed Practical Nurse (LPN) 11's written statement, dated 06/09/26, revealed she was in the hallway and heard yelling coming from R36's room. LPN11 documented that R36 reported R21 had attacked her. R36 showed LPN11 a scratch on her left forearm caused by R21. Review of Certified Nurse Aide (CNA) 9's undated written statement revealed she heard yelling coming from R36's room. R36 and R174, R36's roommate, were yelling, hey, stop get out (sic)!! CNA9 entered the room and saw R21 standing in front of R36. R21 then turned and walked out of the room. R36 stated R21 was swinging at her and hit her. Review of LPN10's written statement, dated 06/09/26, revealed LPN11 informed him that R21 had punched another resident. LPN10 spoke with R36, who reported that R21 had punched her in the face and scratched her forearm. LPN10 observed a scratch on R36's arm. During a telephone interview on 08/25/26 at 6:15 PM, LPN11 stated she heard yelling coming from R36's room. As LPN11 entered the room, CNA9 was escorting R21 out of the room. R36 told LPN11 that R21 had hit her on the head and scratched her arm. LPN11 stated she immediately notified LPN10. During a telephone interview on 08/25/26 at 6:36 PM, LPN10 stated LPN11 notified him of the incident. He stated he spoke with R36, who reported that R21 had entered her room, hit her on the head, and scratched her arm. During an interview on 08/26/26 at 12:12 PM, the Assistant Director of Nursing (ADON) stated R21 hit R36. She stated R21 had not previously displayed aggression toward other residents; however, following the incident, he was placed on 1:1 staff supervision. During an interview on 08/26/26 at 1:26 PM, the Administrator stated R21 hit R36. He stated R21 had not previously had incidents involving other residents. The Administrator further stated that following the incident, R21 was placed on 1:1 staff supervision. The facility's records identified R21 as exhibiting verbal aggression toward residents, wandering into other residents' rooms, and being physically aggressive toward other residents and staff. Despite these identified behaviors, R21 entered R36's room and physically struck her, resulting in a scratch to her forearm. Review of the facility's policy titled Abuse/Neglect/Misappropriation/Crime, dated 10/17/23, specified, There is zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center . And all suspected or witnessed incidents of patient/patient abuse . or any reasonable suspicion of a crime against a patient . brought to the attention of the Center's Administration will result in internal investigation, appropriate and timely reporting to the State Survey agency . Patients are provided with a description of their legal rights, which include: The right to be free from . physical abuse .

Based on observation, interview, record review and review of other facility documentation, it was determined that for two (R29 and R30) out of three residents sampled for quality of care, the facility failed to ensure that R29 and R30 were assessed by a Registered Nurse after it was identified that they had fallen to the floor. The facility also failed to ensure that the post fall documentation was completed, and the physician and responsible parties were notified in a timely manner. Due to the facility's corrective measures completed on 5/11/26, the facility was notified that R29's and R30's incidents were past non-compliance. Findings include:1. R29's clinical record revealed:3/26/26 - R29 was admitted to the facility with diagnoses including, but not limited to, right shoulder fracture and lung cancer.4/4/26 - R29's MDS assessment documented a BIMS score of 15, indicating a fully intact cognitive status. The assessment also documented that R29 required the assistance of one staff member for transfers.5/7/26 3:23 PM - A facility incident report submitted to the Division included, . The resident [R29] told the therapy staff that she sat on the floor this morning and scooted to the call bell and rang and someone helped her up. She stated a nice gentleman, and a lady picked her up.5/19/26 9:30 AM - During a telephone interview, E7 (CNA) stated, I saw her [R29] sitting on the floor near her bed. I held her hand and helped her back to her bed. The Surveyor asked E7 if nurse was informed that the resident was found sitting on the floor. E7 stated, No, I forgot to tell the nurse.5/19/26 10:00 AM - A review of R29's clinical record lacked evidence of a post-fall assessment by a Registered Nurse for possible injuries after she was found sitting on the floor and before being moved by the CNA.2. R30's clinical record revealed:4/29/26 - R30 was admitted to the facility with diagnoses including, but not limited to, Parkinson's disease and acute pain due to trauma.5/6/26 - R30's MDS assessment documented a BIMS score of 13, indicating a mild cognitive impairment, and was dependent on staff for all transfers.5/7/26 12:00 PM - A facility incident report submitted to the Division included, . An anonymous note was received by the HR (Human Resources) Office alleging that [R30] had fallen on 5/5/26 and the fall went unreported. The facility's investigation revealed that the incident had occurred on 5/6/26 at approximately 6:30 AM.5/19/26 12:30 PM - During a telephone interview, E8 (CNA) stated, I was passing by the room, and I saw the resident [R30] on the floor in a kneeling position on the side of his bed. His hands were on the bed like he was trying to get himself back up. I saw his aide [E9 CNA] in the hallway and told her that the resident was on the floor. I then saw the nurse [E10 LPN] and the aide [E9] in the hallway and told them that he was on the floor. They went into his room. The Surveyor asked E8 how she became aware that the fall was not reported. E8 stated, Because no one asked me for a statement about the fall.5/19/26 12:45 PM - During a telephone interview, E9 stated, The nurse [E10] and I went into the room and saw the resident kneeling on the side of the bed. We helped him back into his bed. The Surveyor asked E9 whether a nursing assessment had been completed before R30 was helped back to his bed. E9 stated, No, we just put him back to bed.5/19/26 1:00 PM - The Surveyor left a telephone message for E10 requesting a return call. E10 did not call back while the survey was in progress.5/19/26 1:30 PM - During an interview, E1 (NHA) and E3 (DON) stated that they were aware that R29 and R30's falls were not reported, the post-fall assessments, physician and family notification, and documentation were not being completed, and they immediately began a plan of correction.5/19/26 2:00 PM - The facility provided the Surveyor the following information:a. The staff members who did not report the falls received disciplinary action and education on reporting falls.b. Falls for the past 2 weeks were reviewed to ensure that they have the risk management report and required documentation completed.c. A Quality Assurance meeting was held to address physician and responsible party notification, and education started for all staff related to reporting falls, documentation required to include a risk management report at the time of the fall. RN fall documentation, post-fall investigation, and fall risk scoring tool.d. The DON/designee will audit all falls to ensure the required assessments and documentation are completed, and if necessary, reported to the proper State Agency. These audits will be completed daily x 5 days, then weekly x 3 weeks, and then monthly x 2 weeks. The results will be brought to QAPI for review and follow-up as needed.5/19/26 2:15 PM - The Surveyor conducted record review, and staff interviews, and the plan of correction was verified.5/19/26 3:15 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the Exit Conference.

Based on observation, interview, record review and review of other facility documentation, it was determined that for one (R2) out of three residents sampled for accidents, it was determined that the facility failed to ensure that R2 received adequate supervision and assistive devices to prevent accidents to the extent possible. Findings include:1/29/24 - A facility document entitled, Falls Management Program, included, A fall is defined as an unintentional change in elevation coming to rest on the ground or onto the next lower surface (e.g. onto a bed, chair or bedside mat.) An episode where a patient would have fallen, if not for staff intervention, is considered a fall.R2's clinical record revealed:11/25/25 - R2 was admitted to the facility with diagnoses including, but not limited to, congestive heart failure and chronic arterial ulcer of the right foot.2/24/26 - R2's quarterly MDS assessment documented a BIMS score of 11, indicating a moderately impaired cognitive status (decisions poor; cues/supervision required). The MDS also documented that R2 was dependent on staff for wheelchair mobility.11/26/26 - R2's fall care plan included, .At risk for falls related to poor balance.4/19/26 11:15 AM - R2's nursing progress note included, . Per CNA assigned to the resident, the resident fell while being helped out of the bathroom back to her room. The resident was sitting in her w/c [wheelchair], and the CNA was behind her. Resident was requested to put her legs up while sitting on her w/c, and all of a sudden, before she could even do it, she fell.5/19/26 9:15 AM - During an interview, R2 stated, I had just finished in the bathroom, and the girl [CNA] was wheeling me back to my room, and I fell forward out of the chair. I am glad I was not hurt. The Surveyor asked R2 whether the foot pedals were on the wheelchair when she was in the wheelchair. R2 stated, No.5/19/26 10:00 AM - During an interview, the Surveyor asked E6 (OT) whether R2 could keep her lower extremities elevated during transportation with the wheelchair. E6 stated, No. [R2] is dependent on wheelchair mobility.5/19/26 11:00 AM - The facility's investigation included, The CNA stated she was going to take the resident back to bed. She requested the resident lift her legs and feet, and the resident fell forward out of the wheelchair.The facility failed to ensure that R2 was free from accidents when she fell while she was transported in a wheelchair without footrests. 5/19/26 3:15 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the Exit Conference.

Based on observations and interview, the facility failed to timely dispose of dry food storage, ensure proper food handling practices, and maintain sanitary conditions. Findings include:1. Initial and subsequent kitchen tours revealed: 8/4/25 9:20 AM - Two containers of cake icing were observed in dry storage room shelf labeled 4/29. 8/6/25 9:31 AM - Two containers of cake icing were observed in dry storage room shelf labeled 4/29. 8/13/25 8:41 AM - Two containers of cake icing were observed in dry storage room labeled 4/29. 8/13/25 8:41 AM - During an interview, E5 stated We get rid of opened containers after two months. 4/29 means these containers were opened on April 29th of this year. The opened cake icing containers were stored in the kitchen dry food pantry for over 3 months. 2. Initial and subsequent observations of food preparation revealed: 8/4/25 9:20 AM - E6 (DA) was observed not wearing a beard cover while spooning food into serving cups. 8/6/25 9:31 AM - E6 was observed not wearing a beard cover while spooning food into serving cups. E7 (DA) was observed not wearing a hairnet or beard cover while slicing meat. 8/6/25 9:31 AM - During an interview, E5 (DOD) confirmed E6 and E7 were not wearing a hair net or beard covers. 8/13/25 8:41 AM - E6 was observed not wearing a beard cover while spooning food into serving cups. 3. Observations revealed the following: 8/6/25 9:31 AM – During a kitchen tour with E5 (DOD), the surveyor observed the floor was sticky and some small debris and trash were scattered around. 8/13/25 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (RDCS), E3 (DON), E4 (ADON) and representatives with the management company, MC1 and MC2.

Based on observation, the facility failed to ensure the kitchen dry food storage room was free of pests. Findings include:8/4/25 9:20 AM - During the initial kitchen tour, ants were observed crawling on containers in the dry food storage room. Findings confirmed by E5 (DOD).8/12/25 12:15 PM - Documentation from contracted pest control servicer stated, .I checked all traps in the kitchen and treated all around for ants .8/13/25 3:00 PM - Findings were observed during the exit conference with E1 (NHA), E2 (RDCS), E3 (DON), E4 (ADON), and representatives with the management company, MC1 and MC2.

Based on observation and interview, it was determined that the facility failed to promote resident dignity as evidenced by observations during dining and entering resident rooms without permission. Findings include:1. Review of R7's clinical record revealed: 7/15/25 - R7 was readmitted to the facility with diagnoses including chronic respiratory failure and polyneuropathy. 7/15/25 - A quarterly MDS documented R7 as cognitively intact with a BIMS score of 15. 8/6/25 12:54 PM - R7's meal was served with a plastic aluminum sealed container of juice and a carton of milk. No cup or glass was observed on R7's meal tray. 8/7/25 8:59 AM - A breakfast meal tray was delivered to R7 with a plastic aluminum sealed container of juice and a carton of milk. No cup or glass was observed on R7's meal tray. 8/12/25 10:45 AM - During an interview, E5 (DOD) confirmed that residents are not given cups or glasses with meals. 8/13/25 12:34 PM - During an interview R7 stated, I don't like drinking from the plastic containers that everyone touches. I would like to have a cup to use. 2. 8/6/25 11:48 AM - Observation of the [NAME] Unit revealed that residents' meal trays lacked glasses or drinkware. Surveyor observed only plastic self-sealed juice cups where residents would have to pull back the aluminum cover to drink from it and paper milk cartons on the residents' meal trays. 3. Observations by the surveyor revealed the following: -8/5/25 10:09 AM - during an interview between a surveyor and an anonymous resident with the door closed, E12 (LPN) knocked, opened the door and entered the room without asking permission to enter the resident's room. -8/6/25 9:45 AM - observed a resident's call light triggered and E13 (LPN) knocked, entered room without asking permission to enter. -8/6/25 11:33 AM - observed E14 (HA) knock, state housekeeping and entered a room without asking permission to enter as a resident was currently in the room. -8/6/25 11:43 AM - observed E14 (HA) knock, state housekeeping and entered another room without asking permission to enter as a resident was currently in the room. -8/6/25 12:08 PM - observed E15 (CNA) respond to a triggered call light by walking into the room without knocking and asking permission to enter. -8/6/25 12:13 PM - observed E16 (HA) knock and walk into two residents' rooms in succession without asking permission to enter. -8/7/25 9:49 AM - observed E17 (contracted NP) walk into a resident's room without knocking and asking permission to enter. -8/7/25 10:20 AM - observed E18 (HA) knock, announce housekeeping and walk into a resident's room. 8/13/25 9:15 AM - During an interview, finding was reviewed with E3 (DON). Surveyor asked what is the expectation of staff before entering resident rooms, E3 stated that they should knock and ask permission before entering. 8/13/25 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (RDCS), E3, E4 (ADON) and representatives with the management company, MC1 and MC2.

Based on record review and interview, it was determined that for five (R46, R98, R111, R167, R179) out of five residents sampled for hospitalization and three residents sampled for discharge review, the facility failed to notify in writing R46, R98 and R5's representatives of the notice of transfer to the hospital. In addition, the facility failed to notify the State Ombudsman of R46's transfer to the hospital. Findings include:The following residents were transferred to the hospital for emergent medical needs: 1. Review of R46's record revealed: 1a. R46 was transferred emergently to the hospital and was admitted on [DATE] and 4/12/25. 8/12/25 1:00 PM - A review of R46's records lacked evidence that R46's representative was notified in writing of R46's transfer to the hospital on both dates. 8/12/25 2:20 PM – In an interview, E3 (DON) confirmed that the facility lacked evidence that written notices of hospital transfer were sent to R46's representative when she was transferred to the hospital on 2/1/25 and 4/12/25. 1b. 8/12/25 1:15 PM – Review of the facility's April 2025 Transfer Log lacked evidence that the Ombudsman was notified of R46's transfer to the hospital on 4/12/25. 8/12/25 2:21 PM - In a follow up interview, E3 confirmed that the Ombudsman was not notified of R46's hospital transfer on 4/12/25. 2. Review of R98's clinical record revealed: 4/28/25 – R98 was transferred emergently to the hospital and was admitted . 8/12/25 1:56 PM - A review of R98's records lacked evidence that R98's representative was notified in writing of R98's transfer to the hospital. 8/12/25 2:22 PM – In an interview, E3 (DON) confirmed that the facility lacked evidence that a written notice of hospital transfer was sent to R98's representative when she was transferred to the hospital on 4/28/25. 8/12/25 2:33 PM – Findings were discussed with E2 (RDCS) and E3 (DON). 3. Review of R111's clinical record revealed: 7/22/25 - R111 was transferred to the hospital from the facility. 8/12/25 - A review of R111's records lacked evidence that R111, or their representative, was notified in writing of the transfer to the hospital. 8/12/25 2:20 PM – In an interview, E3 (DON) confirmed that the facility lacked evidence that written notice of hospital transfer was sent to R111, or their representative, when he was transferred to the hospital on 7/22/25. 4. Review of R167's clinical record revealed: 5/26/25 – R167 was transferred to the hospital from the facility. 8/12/25 – A review of R111's records lacked evidence that R167, or their representative, was notified in writing of the transfer to the hospital. 8/12/25 2:21 PM - In an interview, E3 (DON) confirmed that the facility lacked evidence that written notice of hospital transfer was sent to R167, or their representative, when he was transferred to the hospital on 5/26/25. 5. Review of R179's clinical record revealed: R179 was sent to hospital on 3/25/25. The facility lacked evidence of a notice of transfer to R179's representative. 8/13/25 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (RDCS), E3 (DON), E4 (ADON) and representatives with the management company, MC1 and MC2.

Based on record review and interviews, it was determined that for one (R25) out of five residents sampled for medication review, the facility failed to ensure that R25 was adequately monitored for side effects of antipsychotic medications. Findings include: Review of R25's clinical record revealed:12/24/23 - R25 was admitted to the facility.12/24/23 - A care plan was developed for R25's antipsychotic use and its risk for adverse reactions secondary to diagnosis of bipolar. R25's interventions included, AIMS assessment as indicated. 6/19/25 - A Consultant Pharmacist Recommendations to Nursing revealed, Category: Antipsychotic therapy recommendation. Resident is currently receiving antipsychotic therapy with Seroquel and requires an AIMS assessment at baseline every 6 months while on antipsychotic therapy. The last AIMS assessment in his chart is from 8/8/24. Please update.7/4/25 - The Nursing Staff, E3 (DON), signed and documented Done 7/6/25 per the pharmacy recommendation.8/11/25 9:38 AM - Review of R25's May 2025 through August 2025 eMAR (Electronic Medication Administration Record) revealed that R25 continued to receive the antipsychotic Seroquel. 8/11/25 12:05 PM - E3 (DON) presented to this surveyor a copy of R25's completed AIMS assessment dated [DATE]. E2 (DON) further confirmed that R25's AIMS assessment was only completed after the pharmacist's July 2025 recommendation and that moving forward, the assessments will be done quarterly. 8/13/25 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (RDCS) and E3 (DON).

Based on record review, interviews and review of other facility documentation as indicated, it was determined that the facility failed to ensure that grievances and concerns received by the facility included prompt efforts to resolve problems for one (R107) out of 37 sampled residents. In addition, the facility failed to ensure that a written decision was issued to the complainant. Findings include:Review of the facility's policy titled, Service Concerns/Grievance effective 3/1/25 indicated:Policy: The Administrator is responsible for ensuring that the management staff are trained in appropriately resolving in - house patient/ family service concerns and grievances at the point of service as promptly as possible. The Management staff . is charged with listening and responding to questions, needs, problems, or concerns brought to their attention by patients and/or families .Procedure: 1. any team member receiving questions or issues of concern regarding care and/ services are to immediately respond at the point of service .2.Grievance form is to be promptly submitted by the staff member . 3.Manager receiving the concern actively and promptly initiates appropriate action (no later than 48 hours of receiving the concern) . 4. The Administrator will follow up as needed with patient/family . 5.the patient may be provided written response from the Administrator.Review of R107's records revealed the following:3/12/24 - R107 was admitted to the facility.4/15/25 1:37 PM - An activity report by E9 (BOM) documented, . [FM1] demanded that I met with her. She called me a liar and said I was frauding (sic) her and that I am good at my job and that I abused her. 4/23/25 1:21 PM - An activity report by E9 (BOM) documented, . [FM1] collected itemized bill.5/5/25 1:01 PM - An activity report by E9 (BOM) documented, . spoke to [FM1].needs another copy of itemized bill.6/18/25 2:59 PM - An activity report by E9 (BOM) documented, . [FM1] requested copy of itemized bill.7/7/25 12:11 PM - An activity report by E9 (BOM) documented, . provided itemized billing again.7/10/25 10:33 AM - An activity report by E9 (BOM) documented, . [FM1] wants to plan meeting to discuss payment on account. Gave my availability.7/28/25 10:06 AM - A social worker progress note documented, .spoke with [FM1] to reschedule business office meeting. [FM1] states that she will need to speak with the ombudsman first to reschedule (sic) financial meeting team notified.8/1/25 5:01 PM - A social worker progress note documented, . called [FM1] to check status of new appointment date. There was no answer, voicemail left.8/4/25 11:00 AM - During a phone interview, FM1 told the surveyor that she has been having billing issues with the facility. FM1 stated that the facility's itemized billing was not specific. FM1 also stated that she received a statement of claims from Medicare covering the period 2/27/25 through 6/27/25 for services that her mother [R107] did not receive. FM1 stated that her mother did not use catheter supplies and knee brace that were charged in the Medicare account. FM1 stated that she already reported this to the facility a few weeks ago and have spoken to E10 (SW1). FM1 added, She [E10, SW1] has a copy of the Medicare Statements. I also wrote a note for the BOM [E9] so she can sign and acknowledge that these were the fraudulent billing issues I wanted to get clarified as these were bothering me and causing me sleepless nights and anxiety. I have been wanting to meet with the facility's business department but I want the State Ombudsman [S1] to be there as well.8/6/25 1:30 PM - In an interview, E9 stated, It's an ongoing process and we were trying to set up a financial meeting to discuss the billing issues together with [FM1] and the Ombudsman on 8/19/25. It is taking that long to schedule because of the availability of the other attendees of the meeting. When asked if the facility identified the situation as a grievance concern, E9 stated, No. 8/7/25 9:59 AM - In an interview, S1 (SO) stated that she was aware of FM1's billing concerns with the facility and that the financial meeting dates were changing because of availability of the attendees.8/7/25 10:30 AM - During an interview, when asked if a grievance report was initiated to investigate and address FM1's concerns, E1 (NHA) stated, I am not aware. I will have to check. 8/7/25 12:40 PM - In an in person interview, FM1 presented to the surveyor a copy of the Medicare Summary Notice with indicated charges from a medical supply company for catheter and knee brace. FM1 told the surveyor that E10 (SW1) saw the statement and made a copy of it. Surveyor directed FM1 to speak with E1 and to present the Medicare Summary Notice statement of account to E1. 8/8/25 8:40 AM - In an interview, E1 told surveyor that he met with FM1 and FM2 (R107's granddaughter) to discuss the billing issues and initiated a Grievance/Concern report. 8/8/29 9:15 AM - During an interview, E10 (SW1) stated that she met with FM1 a few weeks ago and was made aware by FM1 of R107's Medicare Summary Notice statement of account. E10 stated, No we did not identify this as grievance but we were trying to set up a meeting with FM1 and the business office to clarify the billing issues but the dates were changing because of the attendees and their availability.8/12/25 9:00 AM - E1 presented to this surveyor a copy of the completed grievance report and resolution dated 8/11/25. Summary of investigation indicated that the facility had no knowledge or relationship with the company named on the statement. E1 notified FM2 of the findings at the request of both FM1 and FM2.8/13/25 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (RDCS) and E3 (DON).

Based on record review and interview, it was determined that for one (R153) out of two residents reviewed for pain, the facility failed to ensure the resident's oxycodone and ativan, both controlled medications, were dispensed and recorded accurately. Findings include:The facility's pharmacy policy and procedure entitled Controlled Substance Disposal, revised 08/2020, stated, Medications classified as controlled substances by the Drug Enforcement Administration (DEA) are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations . 2. When a dose of a controlled substance is removed from the container for administration . not given for any reason . It is destroyed in the presence of two licensed nursing personnel . and the disposal is documented on the accountability record on the line representing that dose . 3. All controlled substances remaining in the facility after a resident has been discharged or an order discontinued are disposed of: a. In the facility by the Director of Nursing and consultant pharmacist (or other licensed personnel as permitted by state regulations) . 4. Disposition is documented on the facility's Drug Destruction log or similar form . R153's clinical record revealed: 1a. 6/20/25 - A physician's order prescribed R153 ativan medication every 12 hours as needed for anxiety. Review of R153's June and July 2025 eMARs (electronic Medication Administration Records) and the ativan controlled substance accountability record revealed the following discrepancies:-6/21/25 9:00 AM, E21 (LPN) did not record administration on the eMAR;-6/22/25 9:00 AM, E21 (LPN) documented Wasted on the accountability record with no evidence of two licensed nurses witnessing the disposal.-6/22/25 7:47 PM, E22 (agency LPN) did not record administration on the eMAR.-6/25/25 7:43 PM, E23 (RN) did not record administration on the accountability record.-7/3/25, E24 (LPN) recorded two different administration times, 8:00 AM on the accountability record and 12:57 PM on the eMAR.-7/4/25, E25 (agency RN) recorded two different administration times, 12:45 AM on the eMAR and 5:18 AM on the accountability record.-7/10/25 6:00 PM, E26 (LPN) did not record administration on the eMAR. 7/17/25 - The Ativan physician's order was discontinued. 7/29/25 8:00 PM - Despite the discontinuation of R153's ativan physician order, E22 (agency LPN) administered and recorded it on the accountability record. 1b. 6/19/25 - A physician's order prescribed R153 oxycodone medication every 6 hours as needed for pain and was reordered on 7/21/25 after the resident was hospitalized from [DATE]-[DATE]. Review of R153's June, July and August 2025 eMARs and the oxycodone controlled substance accountability record revealed the following discrepancies:-6/20/25 4:00 PM, E22 (agency LPN) did not record the administration on the eMAR.-6/21/25 1:00 AM, E22 (agency LPN) did not record the administration on the eMAR.-6/21/25 9:00 AM, E21 (LPN) did not record the administration on the eMAR.-6/22/25 1:00 PM, E21 (LPN) did not record the administration on the eMAR.-6/22/25 9:00 PM, E22 (agency LPN) did not record the administration on the eMAR.-6/24/25 3:52 PM, E26 (LPN) did not record the administration on the eMAR.-7/4/25, E25 (agency RN) recorded two different administration times, 11:00 PM on the accountability record and 5:21 AM on 7/5/25 on the eMAR.-7/10/25 6:00 PM, E26 (LPN) did not record the administration on the eMAR.-7/22/25 6:35 AM, E27 (RN) did not record the administration on the eMAR.-7/25/25 8:08 AM, E28 (LPN) did not record the administration on the eMAR.-7/28/25 8:40 AM, E29 (agency LPN) did not record the administration on the eMAR.-7/28/25 4:00 PM, E22 (agency LPN) did not record the administration on the eMAR.-7/28/25 10:00 PM, E22 (agency LPN) did not record the administration on the eMAR.-7/29/25 7:00 PM, E22 (agency LPN) did not record the administration on the eMAR.-7/30/25 2:00 PM, E12 (LPN) did not record the administration on the eMAR.-8/1/25 8:00 PM, E22 (agency LPN) did not record the administration on the eMAR.-8/2/25, E22 (agency LPN) recorded two different administration times, 2:00 AM on the accountability record and 6:03 AM on the eMAR. 8/8/25 1:40 PM - During an interview, E12 (LPN) showed the surveyor two blister packs, oxycodone and ativan, that were in the medication cart's locked box. R153's ativan medication blister pack was still in the medication cart locked box despite it being discontinued on 7/17/25. When asked what is the process of discarding controlled substance medications, E12 stated that she would give them to the supervisor and they would discard it together. E12 also stated that it is the practice to record administration of ativan and oxycodone in both the eMAR and the accountability record at the same time. 8/8/25 at 1:44 PM - During an interview, surveyor reviewed findings with E4 (ADON). Also confirmed the date of 7/29/25 documented by E22 (agency LPN) when Ativan was administered after the physician's order was discontinued. 8/13/25 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (RDCS), E3 (DON), E4 (ADON) and representatives from the management company, MC1 and MC2.

Based on record review and interview, it was determined that for one (R153) out of two residents reviewed for pain, the facility failed to ensure non-pharmacological interventions were attempted prior to using pain medication. Findings include:R153's clinical record revealed: 6/19/25 - R153 was admitted to the facility with diagnoses that included, but were not limited to, lupus and chronic pain. 6/19/25 - A physician's order documented, Administer non-pharmacological pain intervention as applicable. Use the key below to document the non-pharm used, 1. Propped and reposition resident for comfort. 2. Music/Television of interest as appropriate. 3. Basic/Simple message. 4. Distraction/Diversional activities. 5. Reduce stimulation: Dim light/reduce noise. 6 Bed rest if sitting up for extended period. 7. Reminiscence/guided imagery. e. Effective. n. Not effective every shift for Pain. Enter the Number of non-pharm intervention used and whether it was effective or not (e.g. 2n - This means Music was used as an intervention but not effective). Review of R153's eMARs from June, July and August 2025 revealed: -from 6/19/25 to 6/30/25, R153 received 22 doses of oxycodone PRN pain medication. Out of 33 opportunities, nursing staff failed to follow the physician's order as written by not documenting the specific intervention that was used and whether or not the non-pharmacological intervention was effective. -from 7/1/25 to 7/11/25, R153 received 22 doses of oxycodone PRN pain medication. Out of 31 opportunities, nursing staff failed to follow the physician's order as written by not documenting the specific intervention that was used and whether or not the non-pharmacological intervention was effective. -from 7/21/25 to 7/31/25, R153 received 21 doses of oxycodone PRN pain medication. Out of 31 opportunities, nursing staff failed to follow the physician's order as written by not documenting the specific intervention that was used and whether or not the non-pharmacological intervention was effective. -from 8/1/25 to 8/8/25, R153 received 21 doses of oxycodone PRN pain medication. Out of 22 opportunities, nursing staff failed to follow the physician's order as written by not documenting the specific intervention that was used and whether or not the non-pharmacological intervention was effective. 8/13/25 9:15 AM - During an interview, the facility's failure to use non-pharmacological interventions before administering pain medication was reviewed and acknowledged with E3 (DON). 8/13/25 3:00 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (RDCS), E3 (DON), E4 (ADON) and representatives of the management company, MC1 and MC2.

Based on interview and review of the clinical record review and other documentation as indicated, it was determined that for one (R179) out of five residents reviewed for hospitalization, the facility failed to follow the plan of care requiring two staff with a Hoyer lift for transfers. Findings include:Cross refer to F777 R179's clinical record revealed: 10/2/23 - R179 was admitted to the facility with diagnoses that include, but were not limited to, traumatic brain injury and multiple contractures. 10/2/23 - R179 was care planned for at risk for falls with an intervention of using a Hoyer lift for transfers with 2 staff. 3/17/25 - R179's annual MDS assessment documented that R179 was non-verbal, rarely understood and understands, and dependent on staff for activities of daily living (showers, hygiene, dressing, rolling left and right in bed). 3/25/25 8:19 AM - The facility reported to the State Agency that R179 was sent to the hospital for evaluation after having increased drainage from the resident's left hip wound and an x-ray was ordered to rule out osteomyelitis. The 3/24/25 x-ray results showed a lateral dislocation of R179's left hip. The facility's investigation revealed E19's (CNA) written response that stated, .I transferred [R179] with the hoyer lift by myself on 3/17 and 3/24 . 8/12/25 10:48 AM - During an interview, E19 (CNA) confirmed that she transferred R179 by herself using the Hoyer lift twice. E19 stated that she was educated. 8/12/25 11:19 AM - During a combined interview with E3 (DON) and E4 (ADON), surveyor requested evidence of the facility's education of E19. 8/12/25 - The facility lacked documented evidence of E19's education. However, the surveyor was provided with a signed statement that was obtained by E19 on this date (8/12/25) documenting that she received education from E20 (former UM/LPN) on 3/26/25. E3 (DON) stated that E19's signed statement obtained today would be placed in her personnel file. 8/13/25 3:00 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (RDCS), E3, E4 and representatives with the management company, MC1 and MC2.

Based on observation, record review, and interview, it was determined that for two (R111 and R110) out of 37 residents sampled for investigation, the facility failed to ensure that residents received care and services in accordance with professional standards of practice, the comprehensive person centered care plan, and physician orders. For R111 the facility failed to implement discharge orders for vascular surgery follow up appointment for a surgical wound. For R110 the facility failed to collaborate with Hospice for the development, implementation, and revision of the coordinated plan of care for a resident receiving hospice services.1. R111's clinical record revealed: 7/7/25 – R111 was admitted to the facility with diagnoses including, but not limited to, an infection of the amputation stump on the left lower extremity. 7/7/25 – A review of R111’s discharge orders showed instructions to follow-up with Vascular Surgery Service within 2–7 days. 7/15/25 – A wound care progress note documented: “Left BKA site with increased depth and softening of eschar. No odor or warmth appreciated on exam. Recommending follow-up with vascular surgeon.” 7/22/25 – A wound care progress note documented: “Left BKA site with increased depth and softening of eschar. No odor or warmth appreciated on exam. Recommending follow-up with vascular surgeon. Unit manager attempted to facilitate an appointment last week.” 7/22/25 – Another wound care progress note stated: “Left BKA/stump site with increased depth and softening of eschar with new warmth and increased erythema (redness). Site includes medial (toward middle) and proximal (closer to body) wounds. Requesting patient be sent to ER for evaluation… Patient to be sent out (to the hospital).” 7/22/25 – A facility-reported incident documented: “Resident transferred to hospital this date related to increased redness of left below the knee amputation surgical site… on the 7/15/25 wound care provider visit when redness was initially assessed, a recommendation was made to schedule a visit with the vascular surgeon. E8 (unit clerk) was tasked with scheduling the appointment. As of 7/22/25, the appointment had not been scheduled and the surgical wound demonstrated further increased redness.” 8/12/25 – No documentation was found that E8 had attempted to schedule the vascular surgery follow-up appointment as ordered. 8/12/25 – Interview with E1 (NHA) confirmed the facility’s failure to schedule the vascular surgery follow-up appointment as per discharge orders. 2. R110's clinical record revealed: 7/11/25 – R110 admitted to the facility with diagnoses including, but not limited to, chronic obstructive pulmonary disease and chronic congestive heart failure. 8/1/25 – R110 was admitted into hospice services. 8/6/25 – A review of R110’s hospice care plan revealed a stated focus, “The resident is receiving hospice services and is not expected to improve in condition for diagnosis of CHF (Chronic Heart Failure).” The goal was documented as, “The resident’s care needs will be met, and they will be as comfortable as possible through review period.” The intervention listed was, “See Hospice plan of care.” 8/6/25 11:00 AM – An interview with E32 (LPN) confirmed that nursing staff can access the hospice care plan in the resident’s hospice binder. 8/6/25 11:24 AM – The surveyor requested R110’s hospice binder, which staff stated housed the hospice plan of care. The binder was not available at the nurse’s station. When the binder was located, it was empty and contained no hospice plan of care. 8/6/25 12:25 PM – During an interview, E10 (LSW) stated, “That is usually found in the hospice binder.” E10 and the surveyor reviewed the hospice binder together, but no care plan documents were found. E10 then stated, “We use our own facility care plan, which should include the hospice care plan.” A review of R110’s facility-generated comprehensive care plan revealed no evidence that the hospice plan of care had been incorporated into the resident’s care plan or that the facility collaborated with hospice staff to ensure the resident’s end-of-life needs and interventions were addressed. 8/6/25 12:40 PM – An interview with E3 (DON) confirmed the hospice plan of care was expected to be kept current and available in the hospice binder for staff reference. E3 stated, “The hospice nurses usually update the binder, and then we make changes as needed, but I see the binder is missing information, so that should have been addressed.” The facility’s failure to ensure the hospice plan of care was available and integrated into the comprehensive care plan resulted in staff not having access to up-to-date goals and interventions for R110’s hospice needs. 8/13/25 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (RDCS), and E3 (DON).

Based on interview and record review, it was determined that for one (R179) out of three residents reviewed for hospitalizations, the facility failed to promptly notify the on-call provider of R179's abnormal x-ray results on 3/24/25. Findings include:R179's clinical record revealed: 3/24/25 - A physician's order documented, Xray of left hip to r/o [rule out] osteomyelitis . 3/24/25 4:15 PM - A nurse's note documented, Xray completed at around 1530 [3:30 PM] hrs [hours]. Results still pending at this time. Oncoming nurse aware for a follow up. 3/24/25 7:55 PM - R179's Xray results report revealed that he had a . dislocation of left hip . 3/25/25 8:41 AM - A nurse's note documented, Writer was informed by charge nurse that [E30, contracted NP] has given an order to transfer resident to the ER for further evaluation related to 3/24/25 Left hip x-ray showing a lateral dislocation of the left hip . 8/12/25 10:10 AM - During an interview, E31 (RN) stated that it is the charge nurse's responsibility to follow-up on obtaining and notifying the on-call provider of x-ray results. 8/12/25 at 10:20 AM - During an interview, E30 stated that she was working until 8:00 PM on 3/24/25 and she did not receive any call about R179's abnormal x-ray results. E30 stated that she requested the message center call log today to see if a call was made after 8:00 PM on 3/24/25. No further information was provided to the surveyor prior to the exit conference. 8/13/25 3:00 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (RDCS), E3 (DON), E4 (ADON) and representatives of the management company, MC1 and MC2.

Based on observation, interview, and record review it was determined that for one (R25) out of thirty-seven sampled residents, the facility failed to review and revise the care plan to reflect an identified need. Findings include:Review of R25's clinical record revealed:12/24/23 - R25 was admitted to the facility with diagnoses including bipolar disorder, anxiety disorder and major depressive disorder. 12/24/23 - A care plan was developed for R25's history of behaviors related to bipolar disorder . and suicidal threats with interventions including but not limited to needed referrals for psyche services (12/24/23) . and behavior contract (12/13/24).10/30/24 2:14 PM - A psyche note documented . Facility requested to see patient r/t (related to) her feeling that she did not want to live anymore therefore she took her oxygen off. After being engaged with her mother, she did agree to wear her oxygen back on.7/22/25 12:47 PM - A psyche note documented . This writer was asked to see resident who had been refusing medication, expressing feelings of hopelessness, and reporting a desire to die. Resident presented in crisis and was very emotional and distraught.7/31/25 5:57 PM - An ER (Emergency Room) visit note documented that resident was seen in the ER for suicidal ideation.8/4/25 2:00 PM - A psyche note documented . This writer was asked to see resident who was sent to the ER last week due to suicidal threats.8/8/25 3:00 PM - A review of R25's behavior care plan lacked evidence that R25's interventions were revised to address her recurring suicidal ideation. 8/11/25 12:05 PM - In an interview, E3 (DON) confirmed that R25's care plan interventions for suicidal threats were not revised. 8/13/25 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (RDCS) and E3 (DON).

Based on record review and interview, it was determined that for two (R22, R153) out of 37 residents reviewed for care plans, the facility failed to develop a comprehensive person-centered care plan for each resident that addressed each resident's medical needs. Findings include:1. R22’s clinical record revealed: 7/8/25 - R22 was admitted to the facility with diagnoses that included, but were not limited to, a stroke, dysphagia and gastrostomy. 7/12/25 - R22 was care planned for at risk for complications related to the need for an enteral tube feeding. Review of the care plan lacked evidence of approaches for tube blockage and dislodgment. 8/13/25 8:00 AM - During an interview, E4 (ADON) was asked if R22's care plan approaches addressed potential complications of gastrostomy tube blockage and dislodgment. E4 reviewed R22's care plan and acknowledged that the care plan did not include these approaches. 2. R153’s clinical record revealed: 6/19/25 – R153 was admitted to the facility with diagnoses that included, but were not limited to, lupus and chronic pain. R153 had two care plans that addressed her pain, including:6/20/25 – Risk for pain related to recent hospitalization and recent fall at home; and 7/8/25 – OPIOIDS…at risk for complications. R153’s pain care plans lacked evidence of non-pharmacological interventions for pain management. 8/13/25 9:15 AM – During an interview, finding was reviewed with E3 (DON). No further information was provided to the surveyor prior to exit conference. 8/13/25 3:00 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (RDCS) and E3 (DON).

Based on interview and review of clinical record and other documentation as indicated, it was determined that for one (R179) out of five residents reviewed for hospitalization, the facility failed to report to the State Agency in the five day follow-up investigation that R179 was not transferred according to the resident's care plan by E19 (CNA) and what corrective action was taken. Findings include:Cross refer to F689Review of R179's clinical record revealed:10/2/23 - R179 was care planned for at risk for falls with an intervention of using a Hoyer lift for transfers with two staff.3/26/25 - The facility's investigation revealed E19's (CNA) written response that stated, . I transferred [R179] with the hoyer lift by myself on 3/17 and 3/24 .3/31/25 - The facility's five-day follow-up report submitted to the State Agency documented, .Resident was transferred to the shower gurney via the Hoyer lift on scheduled days . without any incidents .Despite having a statement from E19 that R179's plan of care was not followed twice, this was not identified and included in the facility's investigation, what corrective action taken, and reported to the State Agency in the five-day follow-up report.8/13/25 3:00 PM - Finding was reviewed during the exit conference with E1 (NHA), E2 (RDCS), E3 (DON), E4 (ADON) and representatives from the management company, MC1 and MC2.

Based on interview, review of clinical records including two incidents involving significant medication errors and other documentation as indicated, it was determined that for 29 out of 29 licensed nurses reviewed, the facility failed to have a system/process in place to ensure each licensed nurse had competencies and skills sets necessary to care for current residents' needs. - On 7/6/24, E43 (RN) administered another resident's medications to R322, which resulted in a serious adverse outcome. R322 required emergent admission to the ICU for treatment and monitoring. The facility failed to ensure E43 had a medication administration competency and skill set validated during his orientation. In addition, the facility allowed R322 to continue to administer medications for 14.5 days after the 7/6/24 incident without evidence of a competency and skill set validation for medication administration. An Immediate Jeopardy (IJ) was called on 8/26/24 at 7:07 PM. The IJ was abated on 8/30/24 at 5:00 PM. - On 8/18/24, E55 (LPN) administered another resident's medications to R95. The facility lacked evidence of E55's competency and skill set validation for medication administration during her orientation. - For 24 out of 24 nurses scheduled to work from 3 PM on 8/26/24 through 3 PM on 8/27/24 plus three additional nurses (E56, E57 and E58), the facility lacked evidence of each nurses' competency and skill set validations necessary to care for current residents' needs. Findings include: The facility assessment, dated 7/2024, documented, . 1.1 The facility is licensed to care for 177 residents . 3.5 Staff training/ education and competencies. All staff members have a competency checklist upon hire that is completed during orientation to provide adequate care for our residents . Topics . Date Presented: Orientation & Annually, and as needed . The facility's form entitled Skills Validation Record for a Charge Nurse, last revised 5/2024, included the following sections: -General: job description, employee guide, required education, customer service, survey process, policies & procedures, QAPI, Residents' Rights, Safe smoking practices, Abuse; -Environment: facility tour, emergency eye wash stations, security practices, water shut off process, oxygen storage, call light system, phone/paging system, work orders, missing person process, emergency preparedness/red book review; -Infection Control: hand hygiene/glove usage; cleaning and disinfecting equipment; linen handling/appropriate bagging; transmission based precautions; PPE (donning/doffing); Vaccines; PPD/Screening; -OSHA: Bloodborne standard; Hepatitis B vaccine protocol; Regulated Medical Waste; Respiratory Protection Program (N95 fit test); Exposure Control (post exposure process); -Equipment: Glucometer; Coagucheck; Vital sign machine; CPAP/Bipap; Trach oxygen compressor; Oxygen concentrator/tanks; Nebulizer machine; Device(s) filter care; Suction machine; Mechanical lifts/scales; IV pump; Tube feeding pump; Wound vac; Air mattresses; Fall prevention devices; -Supervising CNAs: Observe hygiene; Shower schedule; Turning/repositioning; Documentation verification; Hydration; Snacks; Feeding assistance; Rounds; -Clinical Processes: Nursing chain of command; Central Supply; Medication room; Medication Pass Observation; Treatment Pass Observation; Refusal process; Behavior management; Restorative nursing; Restraints; Code status (DNR validation, advanced directives, etc.); Code blue; Dietary Processes and communications; Dialysis protocols (communication form, medication scheduled, documentation, etc.); Scheduling (appointments, procedures, transportation, etc.); Nursing documentation best practices (dos & donts sic); ADL documentation review; -Pharmacy Services: Admission orders (cut off times, admission alert); Back up pharmacy; Omnicell review (narcotic code, adding new user); Narcotic processes (shift count, discontinued, ordering); OTC medication procedure (Medline); -PCC (PointClickCare) Clinical Documentation: Admissions/Readmissions; Risk Management; Allergies; Batch Orders; Dashboards; Discharges; Elopement; Emergency EMAR backup; Falls; Immunizations; Infection Control Dashboard; Labs and Radiology; Entering IV solution orders; Entering SSI orders; Order entry; Overview Clinical; POC documentation; Progress Notes; Receiving meds from Pharmacy and refills; Reports; Skin Assessments; Tasks; Weights and Vitals; -Clinical Skills Competencies: Intravenous catheters; Venipuncture; Enteral Feeding Tubes; Urinary Catheters (foley/suprapubic/straight/external); Ostomy; Respiratory Care; Tracheostomy; Wound Vac; JP Drain; and Center Specific Skills. 1. Cross refer F760, example 1 6/4/24 - E43 (RN) was hired by the facility. 7/6/24 at 3:40 PM - A nurse's note documented, Patient was given medications that were prescribed for another resident . 7/6/24 at 4:21 PM - The hospital record documented, . presents to the ED (emergency department) with hypoglycemia (low blood sugar) and hypotension (low blood pressure) after receiving the wrong medications at his rehab facility . will need an ICU admission for management . 7/11/24 - The facility submitted to the State Agency a five day follow up investigation and response to the 7/6/24 incident involving R322. In the follow up it stated that All licensed nurses were re-educated on the rights of medication administration and medication competencies were performed. Review of the facility's follow-up documentation provided to the Surveyor for the 7/6/24 incident revealed that re-education/competencies of all licensed facility nurses were incomplete. In addition, the facility lacked evidence that E43's skills/competency was validated after this incident. E43 continued to work in the facility for 14.5 days after the 7/6/24 medication error incident. 8/26/24 at 12:50 PM - During an interview, E48 reviewed the facility's form entitled Skills Validation Record for a Charge Nurse that was being used to validate each nurse's competency and skills set. E48 (Staff Educator) confirmed that she had no evidence of E43's competency and skill set. 8/26/24 at 7:07 PM (revised 9/5/24) - During a meeting with facility management, the Survey Team notified E1 (NHA), E2 (DON 1) and E59 (DON 2) of an Immediate Jeopardy for the failure to have evidence of E43's competency and skill set validation during his new hire orientation, as outlined in the facility assessment. 8/26/24 at 9:07 PM - E1 (NHA) submitted a signed, dated and timed written abatement plan to the State Agency. The facility's abatement included: - Licensed Nurses will be trained on the following competencies: enteral feeding tubes; respiratory care and oxygen equipment (to include CPAP and BiPAP); wounds/skin impairments; bladder scans; hemodialysis; urinary catheters; ostomy care; blood glucose monitoring. - The first staff members to be trained will be the Unit Managers, Shift Supervisors, and Staff Development Coordinator. Training will then be completed by Licensed Nurse Managers (DON, ADON, Unit Managers, Staff Development Coordinator) as well as Licensed Nurse Corporate Level Clinical Directors and will include return demonstration. Training will (sic) conducted on a daily basis until staff threshold met. - Licensed Nurses and Facility Manager will be educated on circumstances relating to Immediate Jeopardy tag. - Pending admissions will be evaluated based on needs to ensure staff working have required competencies completed to provide care. - Because the Center employs a high number of nurses and utilizes agency nurses when needed, education will be ongoing to ensure nurses are educated on the above competencies and the circumstances leading to this education. - 100% of Licensed Nurses will receive education with return demonstration by date of abatement . 8/30/24 at 5:00 PM - The IJ was abated based on interviews with licensed nursing staff and review of facility documentation of individual licensed nurses' competency and skill set education/validations of current residents' needs. 2. Cross refer F760, example 2 6/24/24 - E55 (LPN) was hired by the facility. The facility provided the Surveyor the following information on E55's schedule upon hire: -6/24/24 through 6/28/24, E55 was in classroom training; -7/3/24 through 7/15/24, E55 was trained on the floor; and -Starting 7/16/24, E55 was working on the floor by herself. 8/18/24 at 8:00 PM - The facility's incident report documented that R95 was administered R48's prescribed medications by E55 (LPN). 8/26/24 at 12:50 PM - During an interview, E48 (Staff Educator) stated that she took over the position of Staff Educator at the end of April 2024. E48 stated that nursing orientation includes the first week with classroom review/training, then orientation with another nurse on the floor for 5 to 8 days, based on the nurse's experience. When discussing the facility's Skills Validation Records for nursing staff, E48 stated that the forms were not being returned to her timely. In fact, E48 stated that E55's Skills Validation Record appeared on her desk recently. While reviewing E55's Skills Validation Record with the Surveyor, E48 confirmed that it was not completed correctly. E55's Skills Validation Record was signed off by E52, an agency RN, but never signed by E55 herself. E52 printed and signed her name, and utilized a down arrow for each section, but did not record the date that each skill was reviewed and validated. E52 signed and dated page 6 in the Supervisor's Signature section and dated 7/14/24. In response, the Surveyor requested to see E52's Skills Validation Record since she signed attesting that she validated E55's skills. E48 confirmed that the facility lacked evidence of E52's Skills Validation Record. Review of the facility's Employee Report revealed that E52's hire date was 10/31/23. The facility lacked evidence of E48 and E52's competency and skill set validation. 3. Review of 100 out of 165 current residents in the facility revealed the following nursing care needs, but were not limited to: -accucheck using a glucometer; -dialysis access sites: chest wall or AV fistula, care and assessment of bruit/thrill; -respiratory care (oxygen, nebulizer, CPAP, BiPAP, Aerobika, incentive spirometer, Acapella valve); -bladder scan; -urinary catheters: foley, straight catheter; -wound care; -enteral feeding: pH testing, checking placement, administering meds - G tube; -colostomy; -pacemaker; -urostomy, nephrostomy; and -Life Vest heart monitor. 8/26/24 at 3:50 PM - The Surveyor provided a list of the following scheduled nurses to facility management and requested each nurses' Skills Validation Record (Checklist): E9 (LPN), E16 (LPN), E18 (LPN), E36 (LPN), E38 (RN), E42 (LPN), E50 (LPN), E60 (RN), E61 (LPN), E62 (LPN), E63 (LPN), E64 (LPN), E65 (LPN), E66 (RN), E67 (RN), E68 (LPN), E69 (LPN), E70 (RN), E71 (LPN), E72 (LPN), E73 (LPN), E74 (LPN), E75 (LPN) and E76 (LPN). In response to the request, the facility was not able to provide the Surveyor with each nurse's most recent Skills Validation Record. The facility did provide some documentation on Relias web training completed by some nurses. 40264 4. Review of E56's (LPN) training and competencies records indicated that the employee was hired 7/8/24. No completed nursing skills validation checklist could be located for E56. Review of E57's (Agency RN) training and competencies records indicated that the agency staff's first day in the facility 3/25/24. No completed nursing skills validation checklist could be located for E57. Review of E58's (Agency LPN) training and competencies records indicated that the agency staffs first day in the facility 6/24/24. No completed nursing skills validation checklist could be located for E58. 8/26/24 1:25 PM - During an interview, E48 (Staff Educator) stated that the staff were not retuning the skills checklist after their orientation period on the floor with their preceptors. E48 further confirmed that E56, E57 and E58 did not have the nursing skills validation checklist on their training files. The facility failed to ensure that the required nursing skills validation checklist was completed for 29 out of 29 nursing staff reviewed 8/26/24 2:33 PM - Findings were discussed with E1 (NHA). 8/27/24 2:52 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E10 (VPO).

Based on observation, interview, review of clinical records and other documentation as indicated, it was determined that for one (R322) out of three residents reviewed for hospitalization s and three (R22, R33 and R95) out of nine residents reviewed for medication administration, the facility failed to ensure that residents were free of significant medication errors. On [DATE], R322 was administered R144's prescribed medications. As a result, R322 was emergently sent to the hospital requiring treatment and monitoring in the Intensive Care Unit (ICU). The facility's multiple failures involved in this incident had the potential to cause a serious adverse outcome or death to R322 with respect to receiving another resident's multiple blood pressure medications and diabetic medications. Due to the failures, an Immediate Jeopardy (IJ) was called on [DATE] at 2:08 PM. The IJ was abated on [DATE] at 11:59 PM. On [DATE], R95 was administered R48's prescribed medications. R95 remained in the facility and was monitored for adverse effects. For R22 and R33, the facility failed to ensure that each resident received their meals within 15 minutes of the administration of short acting insulin. Findings include: The facility's pharmacy policy and procedure entitled, #8.2 General Guidelines for Medication Administration, last revised ,d+[DATE], stated the following: . Medications are administered as prescribed in accordance with good nursing principles and practices . Procedures: . I. Preparation . 4. At a minimum, the 5 Rights - right resident, right drug, right dose, right route, and right time - should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared and the medication is put away . II. Administration . 4. When medications are administered by mobile cart taken to the resident's location ., medications are administered at the time they are prepared . 6. Medications are administered without unnecessary interruptions . 8. Residents are identified before medication is administered using one method of identification. Methods of identification may include but not limited to: a. Checking the photograph attached to the medical record. b. Calling the resident by name (except in residents with cognitive impairment). c. Having the resident verify his/her last name. d. If necessary, verifying resident identification with other facility personnel . 12. Medications are administered within 60 minutes of the scheduled administration time, except before, with, or after meal orders, which are administered based on mealtimes. Unless otherwise specified by a prescriber, routine medications are administered according to the established medication administration schedule for the facility . IV. Documentation (including electronic) 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given . 1. Cross refer F726, example 2 Review of R144 and R322's clinical records revealed: For R144: [DATE] - R144 was admitted to the facility in room XXXX. [DATE], [DATE] and [DATE] - Review of the [DATE] eMAR, E43 (RN) administered R144's medications scheduled at 8:00 AM. R144 was scheduled to receive the following 13 medications on [DATE] at 8:00 AM: - Losartan Potassium 100 mg, 1 tablet, for hypertension (high blood pressure); - Coreg 12.5 mg, 1 tablet, for hypertension; - Hydralazine 50 mg, 1 tablet, for hypertension; - Spironolactone 25 mg, 1 tablet, for hypertension; - Metformin 1000 mg, 1 tablet, for diabetes mellitis (high blood sugar); - Glipizide 5 mg, 1 tablet, for diabetes mellitis; - Aspirin 81 mg, 1 tablet, for CVA (stroke) and heart health; - Sucralfate 1 gm, 1 tablet before meals scheduled at 7:30 AM, for stomach ulcer; - Omeprazole 40 mg, 1 capsule, for gerd (stomach acid flows back into the esophagus); - Tylenol 325 mg, 3 tablets, for pain; - Miralax powder, 1 scoop mix in water or juice, for constipation; - Senna 8.6 mg, 2 tablets, for constipation; - Symproic 0.2 mg, 1 tablet, for constipation; - FiberCon 625 mg, 2 tablets, for constipation. For R322: [DATE] - R322 was admitted to the facility for short-term rehabilitation with diagnoses, including but not limited to, pneumonia, chronic respiratory failure, pulmonary fibrosis (lung disease when lung tissue becomes damaged and scarred), chronic obstructive pulmonary disease (chronic inflammatory lung disease) and dependent on supplemental oxygen. R322's room was YYYY, which was located on a different hallway from R144. [DATE] - Review of the [DATE] eMAR, E43 (RN) administered R322's medications scheduled at 8:00 AM. [DATE] at 3:40 PM - A nurse's note by E44 (House Supervisor) documented, Patient was given medications that were prescribed for another resident. Patient was assessed; found to have an irregular pulse and low blood pressure. NP (Nurse Practitioner) and responsible party notify. Received order to send patient to ER (emergency room ) for evaluation. [DATE] at 4:00 PM - A transfer to hospital summary note by E43 (RN) documented, Patient received medications scheduled for patient [R144] . Patient unremarkable in appearance, denies pain, symptoms, vitals ,d+[DATE] BP (blood pressure), HR (heart rate) 94, pulse ox 98% on baseline 4L (liters), skin warm, pink, no signs of distress, patient states 'I feel fine' 'I don't want to go to [name of hospital]'. Supervisor contacted, On-call MD (Medical Doctor) and RN contacted, ADON contacted, patient, [name of F3, family member] . contacted, EMS (Emergency Medical Services) summoned to take patient to [name] ER. [DATE] at 4:21 PM - The hospital record documented the following: . presents to the ED (emergency department) with hypoglycemia (low blood sugar) and hypotension (low blood pressure) after receiving the wrong medications at his rehab facility . EMS was activated. Upon EMS arrival, patient was found to be hypoglycemic in the 50s and oral glucose was given. Upon arrival here in the ED, patient was found to be hypotensive and hypoglycemic . likely secondary to the diabetic medications and antihypertensives he was given. Patient does not have a history of diabetes and is no longer on antihypertensives due to being hypotensive at baseline. Given that the patient was given glipizide (diabetic medication), he will most likely have persistent drops in his glucose. He will likely require repeated boluses (large doses) of D50 (dextrose sugar in water solution) and may still need to be started on a dextrose (sugar) drip. Ultimately, patient will require frequent glucose (sugar) checks and will need an ICU admission for management . [DATE] at 4:45 PM - Two days later, the facility reported the [DATE] incident to the State Agency as Resident [name of R322] . received another resident's medications . Resident became hypotensive and was transferred to hospital for evaluation. Investigation in progress. All licensed nurses to be educated on medication administration. The facility's investigation included the following statements: -E43's (RN) written statement included: . date of incident: [DATE]; time of incident: 14:00 (2:00 PM); I passed medications, realized error, alerted MD and Supervisor . Name(s) of staff member(s) involved: [name of E43 (RN)], E44 (House Supervisor) . Please identify any statements made by resident: 'I feel fine.' Identify all people you spoke with regarding the incident and describe what was said (ie staff, family of resident, etc.): on call Dr (doctor) . [name of E44], EMS, pt (patient), [title of F3, family member], [title of F4, family member]. Identify any documentation you completed related to the incident: Incident . Please provide any additional information: n/a (not applicable). Date the statement completed: (incorrect date). Time statement completed: 1101 (11:01 AM). -E45's (COTA) written statement (undated/untimed) included: . Around 12:30 PM this writer went to attempt to perform OT (occupational therapy) services with resident. [Title of F3] present. Resident stated 'no' and 'I don't want to' multiple times so this writer came back around 2:00 PM to attempt again. Upon returning to room, this writer was informed by resident's [title of F3] that at around 12:00 PM this day, patient was given another resident's dose of medication. The resident stated 'I feel fine.' At this time, nurse was on phone with family member [title of F4] and the charge nurse had come into room. Vitals were taken on resident by nurse and charge nurse made the decision to send the resident to the hospital. Resident continued to say 'I feel fine, I don't want to go to hospital.' This writer and resident's [title of F3] explained the situation in full to resident and he agreed to go. This writer assisted resident in putting on pants, socks, and shoes prior to ambulance getting to facility. This writer assisted resident in sitting up at the edge of the bed and when paramedics arrived, assisted in transfer to stretcher . Resident didn't say anymore, however [title of F3] was upset about incident . [DATE] (date initiated) - The facility's Performance Improvement Plan documented that E43 (RN) had a review of his job performance which indicated a need to improve on Medication Administration. This document was signed and dated . by both E43 (RN) and E3 (ADON). [DATE] - The facility's Employee Corrective Action documented, On [DATE] [name of E43, RN] administered Patient . medications to Patient . resulting in Patient . requiring hospitalization . [name of E43] is being suspended pending investigation. This document was signed and dated [DATE] by E43 (RN), E3 (ADON) and E1 (NHA). [DATE] at 4:38 PM - R322's hospital discharge summary documented, . Patient had blood pressure as low as ,d+[DATE] . Patient had point-of-care glucose of 50 requiring ampules (sealed glass vessel holding solution to be injected) of D50. In the emergency department patient was started on norepinephrine infusion (intravenous infusion to raise blood pressure in patients with severe, acute hypotension). The patient was admitted to the ICU for shock (critical medical condition) related to iatrogenic (illness caused by treatment) antihypertensive medication, hypoglycemia (low blood sugar) related to glipizide (diabetic medication) ingestion. He was treated supportively with vasopressors (medications that increase blood pressure in emergency situations), fluids, and stress dose steroids (medication that aids in preventing complications) for his hypotension and shock. For his hypoglycemia, he was given dextrose infusions and ampules as needed. He was also started on octreotride drip (infusion medication to inhibit insulin release from the pancreas) for his sulfonylurea overdose (prolonged low blood sugar). With these interventions, his sugars normalized, and he was weaned off vasopressors by the morning of ,d+[DATE]. Stress dose steroids have also been discontinued . Patient is now maintaining his blood pressure and blood sugar without supportive medications . [DATE] - The facility submitted the following five day follow-up investigation to the State Agency: -root cause analysis: . Failure to dual identify the resident prior to medication administration resulted in the error. The resident's picture was not available in PointClickCare (PCC/electronic medical record) at the time of the error. -result of investigation: Staff member acknowledges medication error, stating 'I don't remember, in my head I thought I knew who the patient was. We don't bring the laptop in the room. I knew . who was in the room and who he was, but I had them confused, it turned out. On the MAR they were side by side, and I think I just read the first two letters . and got them confused . You stated his family was there, did you check with them on his name? No I didn't. To me, there was no question. I'd done that group of patients before. I just went too fast. I didn't check enough of my fail-safes. What fail-safes should you have checked? I could have verbally asked. To me, it was just a simple mistake on my part. At what point did you realize you had given the medications to the wrong resident? And how? I think it was about an hour from then, when I went to pass the medications to the second gentlemen (sic) and realized I had confused them before because the medications were different. All licensed nurses were reeducated on the rights of medication administration and medication competencies were performed. 100% audit was completed to confirm all residents have a picture in PCC or a bracelet ID (identification). Resident condition is unknown at this time as he did not return to the facility. -system changes: Resident's are to be issued name bracelets until photos are uploaded into PCC. Review of the facility's education after this incident by the Surveyor revealed that all licensed nurses were not educated nor competencies performed on medication administration. [DATE] at 11:58 AM - During an interview, E44 (House Supervisor) stated that she was completing a new admission on the second floor when E43 (RN) came up to ask her how to complete a medication occurrence. E44 stated that she explained the process and the nurse seemed very nonchalant (appearing relaxed and calm). E44 stated that she stopped working on the new admission because she thought she needed to follow-up on exactly what happened. E44 stated that when she arrived on the first floor, E43 was on the phone talking to the NP on-call and family. E44 stated that he [E43] told me at almost 2 PM. E44 stated that she reviewed the medications that were given which included 3 medications for blood pressure. E44 stated that she assessed the resident - blood pressure was low, heart rate irregular, resident has to go out. E44 stated that she called the doctor and received an order to send the resident out to the ER. [DATE] at 12:15 PM - On this date/time, the Surveyor placed a call and left a voicemail for E43 (RN) to return the call. As of [DATE] at 3:30 PM, no return call was received by the Surveyor. [DATE] at 9:44 AM - During an interview, E45 (COTA) stated that she entered the resident's room earlier on [DATE] and R322 declined therapy. E45 stated that when she went back to R322's room, she was present when the nurse, E43, came in and told the resident, with [F3, family member] present, that he gave him someone else's medications. The [title of F3] was upset and immediately called [title of F4] and [title of F4] was asking the nurse what medications were given. E45 stated that she was there when the charge nurse came in and said he was going to the ER. E45 stated that she assisted the resident with putting on his pants. While the facility documented the root cause analysis as R322's picture was not uploaded to PCC as an identifier, the facility failed to identify and address the following additional issues in their investigation: - identify the exact time E43 (RN) administered the wrong medications to R322. It was unclear in the facility's investigation exactly what time R322 was administered the wrong medications that were scheduled for 8:00 AM. Per E45's (COTA) written statement, [title of F3] told her that around 12 PM the resident was given another resident's dose of medications, four hours after the scheduled time. -failed to immediately suspend and/or remove E43 (RN) from administering medications to residents pending the facility's investigation. E43 continued to administer medications on [DATE] entire day shift, and on [DATE] morning day shift then was interviewed and suspended. E43 administered morning medications on [DATE] to R144. -failed to immediately report the significant medication error requiring emergent care to the State Agency within 8 hours, per State requirement. -failed to provide the Surveyor, as requested, with evidence of E43's (RN) education and medication competency before returning to work on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. -failed to perform an audit of the other resident's on E43's assignment on [DATE] for any medication errors, which included timeliness of administration, and document in the facility's investigation. [DATE] at approximately 11:30 AM - During a combined interview with E1 (NHA), E2 (DON), E3 (ADON) and E10 (VPO) to discuss R322's incident, the Surveyor asked about the education and competency of E43 (RN) as it was not included in the documentation provided. E3 (ADON) stated that it was included and immediately reviewed the red folder with the documentation that provided to the Surveyor. E3 (ADON) confirmed it was not there. No further documentation was provided to the Surveyor. The Surveyor also asked about E43's current status in the facility. E1 (NHA) stated that E43 resigned about two weeks ago. No reason provided. [DATE] at 9:40 AM - During a follow-up interview, E44 (House Supervisor) confirmed that she notified E36 (UM/on call nurse) and E3 (ADON) on [DATE] between 2 PM - 4 PM of the medication error and transfer to hospital. [DATE] at 12:12 PM - During an interview, F4 (R322's family member) stated that F3 (R322's family member) called me and told me that R322 received the wrong medications. F4 stated that [F3] left the facility to go get ice cream and came back and all hell broke loose. F4 stated that the nurse (E43, RN) reviewed all of the medications and what they were for over the phone and he said Oh we are going to monitor his vitals. He seemed calm and said - all well this happens. He was really rude. F4 said, He could have died . And he was a DNR (do not resuscitate) and if he died we would never have known. [DATE] at 2:18 PM - During an interview, F3 (R322's family member) stated that she kept notes and reviewed them with the Surveyor. F3 stated she arrived at the facility at 10:40 AM and R322 was very alert. F3 stated that F3 stated that he had not been eating a lot. F3 stated that around 12:05 PM, the nurse [E43] brought him his meds and I asked the nurse what medications are being given. [E43] replied just the normal daily and Tylenol. F3 stated that the nurse confirmed that he didn't have narcotics and that he knew that [F4] did not want the resident to have any narcotics. At 12:15 PM, lunch was served and [R322] started to ignore me and did not want to eat. E45 (COTA) came in and [R322] was out of it as he didn't want to eat or do anything. At 12:20 PM, [R322] put his bed back. At 12:30 PM, I texted [another family member] that I think they gave him something because he was out of it. At 12:48 PM and 12:50 PM, [R322] kept taking off his nasal cannula off his nose. [R322] slept for little while and woke up at 1:45 PM and asked for ice cream. F3 said that I thought I would give him anything he would eat. F3 said she went to the grocery store at 1:45 PM and returned at 2:15 PM. The supervising nurse told me that they had given [R322] the wrong medications. I called [F4]. E45 (COTA) came back and I told her what happened. F3 stated that the supervising nurse checked vital signs, notified the doctor and called 911. The other nurse [E43] was on the phone with [F4] because [F4] wanted to know what medications were given. F3 stated that R322 ate some ice cream and said he was fine. F3 stated that the EMTs asked if the resident was a DNR and I knew he was a DNR. F3 stated that the nurse [E43] seemed very calm and it didn't seem like a big deal as he kept asking the resident, How are you buddy? [DATE] at 2:08 PM - During a meeting with facility management, the Survey Team notified E1 (NHA), E2 (DON) and E59 (incoming DON) of an Immediate Jeopardy for R322's significant medication error that occurred on [DATE]. [DATE] at 7:12 PM - E1 (NHA) submitted a signed, dated and timed written abatement plan to the State Agency. The facility's abatement included: -Licensed nurses will be assigned education Avoiding Common Medication Errors on Relias platform to complete in a proctored group setting at the Center or individually independently if not on schedule . Those completing it individually and independently will be educated once they are scheduled by a nurse manager on the specifics of the reasons/need for the education. Licensed nurses will complete this education and pass the final exam associated with it. Licensed nurses will complete a return demonstration of the education with a Nurse Manager utilizing a real-life medication administration for one resident. The nurse will be required to demonstrate review of the Rights of Medication Administration prior to administering the medication and passing the return-demonstration. -Administration team was notified of incident on [DATE] @ (at) 5:00 p.m. to be aware of the situation as leaders of the Facility. -Each resident's picture is uploaded into PCC unless refused, and those that refuse have all agreed to wear a wrist identification band. As of [DATE] all photos are up to date and complete for all residents admitted within the last 24 hours. -At time of education, Nurses will be educated on timely reporting of errors to supervisors and physicians . Date of abatement [DATE] @ 11:59 p.m. [DATE] at 10:35 AM - During an interview, E36 (UM/on call nurse) stated that she was on the phone with E44 (House Supervisor) regarding another issue when she was told about R322's medication error. E36 stated that E44 was still upstairs and did not know the details about the med error yet. E36 stated that she found out later that day that R322 was sent to the hospital. E36 confirmed that she called E3 (ADON) on [DATE] regarding the medication error. [DATE] at 2:08 PM - During an interview, E2 (DON) stated that E34 (HR) was the Manager on Duty (MOD) on [DATE]. E2 confirmed that MOD's do not report any incidents to the State Agency, only the DON and ADON. E2 confirmed E3 (ADON) was back up as she was off that weekend. Based on record review of the facility's abatement plan which included nursing staff education, testing, signed attestation and observation of medication administration, follow-up interviews with nursing staff, review of new admissions records for pictures or identification bracelets and no further medication error incidents, the facility's IJ was abated on [DATE] at 11:59 PM. 2. Cross refer to F726, example 3 Review of R48 and R95's clinical records revealed: For R48: [DATE] - R48's census record documented her room and bed as XXX, B bed. [DATE] - R48's [DATE] eMAR revealed the following scheduled medications: - Ambien 5 MG, one tablet, for insomnia at 8 PM; - Tramadol 25 MG, one tablet, for pain at 8 PM; and - Xanax 0.5 MG, one tablet, for anxiety disorder at 9 PM. E55 (LPN) signed off the above medications as administered on the eMAR. In addition, E55 documented in the medication cart's controlled substance tracking book that the above three medications were signed out by E55 between 7:05 PM through 7:10 PM. For R95: [DATE] - R95's census record documented her room and bed as XXX, A bed. [DATE] - The quarterly MDS assessment documented that R95 had a BIMS of 7 (cognitive impairment). [DATE] at 8:00 PM - The facility's incident report documented, [Name of R95] received medications that were for her roommate: Tramadol 25 mg, Alprazolam 0.5 mg and Ambien 5 mg. Patient unable to give description. [DATE] at 9:37 PM - The facility reported the medication error to the State Agency and stated that New orders to monitor vitals and neuro checks. Nurse has been suspended pending investigation. [DATE] (untimed) - A documented telephone interview between E2 (DON) and E55 (LPN) revealed: Tell me about when you were giving medications in room XXX at about 7:00 pm. I confirmed correct name and dosage to computer for the medications for [name of R48]. I took out the 3 meds, Tramadol, Ambien and Alprazolam. Why did you take only the 3 out and not her other scheduled medications? I was going to get the others, but I got sidetracked by the conversation at the nurse's station. Why didn't you also pull out the other scheduled 8:00 pm medications? I like to get the narcotics out and sign them out of the book. I usually get the narcotics then the other meds, but I walked away and when I came back I did not get the other meds out. My relief was there, and they were talking at the nurse's station, and I wanted to confirm with her (nurse relieving) that she was ready to report over, so I could start my documentation. I was up there for a while because I did not want to interrupt anyone's conversation. After I talked to her, I got the medications off the cart and I went into the room to the wrong patient, I got completely sidetracked. Was the nurse relieving you at the nurse's station? Yes, I was pretty sure it was, I wanted to confirm with her. There were other staff up there, I am not sure who everyone is (sic). I had a lot going on, the patient next door had some redness on her foot up to her thigh, her foot and ankle were swollen, I had a lot of stuff going on in my head. I went back to nursing cart, I already had the medication out in a cup, (Tramadol, Ambien, and Alprazolam) it was already prepared and I went to room XXX: (sic) I mistakenly went to the wrong bed, I realized when I went to chart, I gave the meds to A bed. [name of R95] How did you identify the patient when you went into the room? I looked at her and said I had her medications; I did not ask her name. Did you look at her picture in PCC? I looked at the picture and I was in the right room. When I went back from the nurse's station to get the medication off the cart I went to the wrong bed. Were you in the room prior to this time, did either of these residents get medication on the first med pass? Yes, I believe they got the medications that were due around 4:00 p.m. (review of the MAR determined that each resident did receive 4:00 pm medications that were signed out appropriately). 7:30 came and I started on the 8:00 o'clock meds. Did you identify those patients in the room? There was no distraction going on so I as (sic) able to focus. Do you remember how you identified the patients the first time you were in the (sic) there to give medications at 4:00 pm? Yes, I asked their names and I identified them by their picture. How did you ask them their name? I said, 'Hey [name of R95], or [name of R48]', before giving each of them their medications, they said yes that's me or they said yes. What time did you give the medications? It was about 7:30 when I gave the medication. It took about 20 minutes to give report then I went to do my documentation, then I realized I made a mistake, I told the nurse who took over, I got a hold of E60 (RN Supervisor) then E36 (UM/on call nurse) and then [name of E36] called [E2] (Director of Nursing). I came out of the room to give nurse, [name of E44], report at the cart, report and narcotic count were completed. Sat down at the computer to chart medication, I looked and saw the room number I realized it was XXXB bed's meds that I gave to XXXA. I immediately contacted nursing supervisor DON- nurse on call - and the NP. NP gave orders for vitals and neuro checks, and alert charting. [Title and name of R95's resident representative] was contacted 3x to no avail. A voicemail left with call back for contacting. Undated/untimed - A documented telephone interview between E2 (DON) and E44 (on-coming Nurse) revealed: I relieved the nurse for the patient. She realized her mistake and told me; the supervisor was told. We checked the patient, and she was fine. Everyone was notified. The patient was monitored when I was there, she was fine. [DATE] - The facility submitted a five day follow up to the State Agency, which included: - Root cause analysis: The nurse did not follow proper procedure for medication administration causing the medication error. - Result of Investigation: . the resident remained at the facility, vitals and neuro checks remained stable and there were no adverse outcomes in the patient's condition. The nurse had received the 10 rights of medication administration education during the new hire orientation which took place between [DATE] and [DATE]. The nurse remained suspended pending investigation. She will be returned to the facility after education, coaching/counseling and a medication pass observation has been completed . The other resident's medication administration records on the nurse's assignment were reviewed with no discrepancies noted, alert and oriented residents on the nurses' assignment were interviewed and asked if they had any issues with their medications given on ,d+[DATE] (PM) shift on [DATE] and there were no issues. [DATE] at 9:40 AM - During an interview, E44 (on-coming nurse) confirmed that she worked 7 PM to 11 PM on [DATE]. E44 stated that she relieved E55 (LPN) and was made aware of the medication error as E55 immediately self-reported and was upset about it. E44 stated that she was familiar with the resident and monitored R95 closely. E44 stated that the resident did not have a negative outcome. [DATE] at 12:35 PM - Observation of R95 in her room revealed that she was alert and was able to tell this Surveyor her name when asked. The facility failed to ensure R95 remained free of significant medication error. 48409 3. Review of R22's clinical records revealed: [DATE] - R22 was admitted to the facility with diagnoses including diabetes and heart disease. [DATE] - R22's care plans documented, The resident is at risk for complications and blood glucose due to diagnosis of diabetes .and insulin use. [DATE] - R22's quarterly MDS assessment documented a BIMS score of 15 (indicating sufficient judgement to manage every day events.) [DATE] - R22's Medication Administration Record (MAR) documented, Humalog Kwik Pen-injector 100 Unit/ML (fast acting insulin), inject per sliding scale before meals - if 0 - 100 = No insulin; 101 - 150 = 2 units insulin; 151 - 200 = 4 units insulin; 201 - 250 = 6 units insulin; 251 - 300 = 8 units insulin. Humalog Kwik Pen manufacturer ([NAME] Lilly and Company, [DATE]) instructions, Take (insulin) within 15 minutes before or right after a meal. [DATE] 7:30 AM - R22's MAR documented a blood glucose of 124 and received two (2) units of fast acting insulin. R22 was observed receiving a meal tray at 9:45 AM (2 hours and 30 minutes later.) [DATE] 11:30 AM - R22's MAR documented a blood glucose of 224 and received six (6) units of fast acting insulin. R22 was observed receiving a meal tray at 1:45 PM (2 hours and 45 minutes later.) [DATE] 7:30 AM - R22's MAR documented a blood glucose of 295 and received 8 (eight) units of fast acting insulin. R22 was observed receiving a meal tray at 9:45 AM (2 hours and 30 minutes later.) During an interview, R22 stated, I usually get my insulin when they (nurses) check my blood sugar. [DATE] 10:00 AM - During an interview E42 (LPN) stated, I gave the residents their insulin when I checked their blood sugars. 4. Review of R33's clinical records revealed: [DATE] - R33 was admitted to the facility with diagnoses including diabetes and long -term use of insulin. [DATE] - R33's MAR documented, Humalog Kwik Pen 100 Unit/ML (fast acting insulin) inject as per sliding scale before meals: 101 - 150 = 2units; 151 - 200 = 4units; 201 - 250 = 6units; 251 - 300 = 8units; 301 - 350 = 10units; 351 - 400 = 12units [DATE] - R33's care plan documented, .At risk for complications and blood glucose fluctuations related to diagnosis of diabetes mellitus with insulin use .administer insulin as ordered. [DATE] - R33's annual MDS assessment documented a BIMS score of 15 (indicating sufficient judgement to manage every day events.) [DATE] 7:30 AM - R33's MAR documented a blood glucose of 163. R33 received four (4) units of fasting acting insulin. R33 was observed receiving a meal tray at 9:45 AM (2 hours and 15 minutes later.) [DATE] 11:51 AM - R33's MAR d[TRUNCATED]

Based on interview and review of facility documentation as indicated, it was determined that the facility failed to implement their infection control program for COVID-19 after a resident on 8/4/23 tested positive and subsequent positives were identified on 8/15/23 and 8/19/23, putting residents at risk for a severe adverse outcome. On 8/22/23 at 4:40 PM, an Immediate Jeopardy (IJ) was called. Based on review of the facility's corrective actions, the IJ was abated on 8/23/23 at 3:00 PM. Additionally, the facility failed to maintain laundry services in a sanitary manner. Findings include: The facility's policy and procedure entitled COVID-19, dated 5/10/23, stated, . 5. Containment/Management: a. Identification of a new case in a patient: . -Initiate contact tracing and identify close contacts/exposures. -Serial testing of close contacts/exposures: -test immediately, if negative, test again 48 hr later, if negative, test again 48 hr later . -If any new cases are identified, perform contact tracing for new case and initiate serial testing . 7. Case Reporting . b. Notify local and state health authorities of any diagnosed COVID-19 case . 1. Review of the facility's infection control line listing revealed the residents and the dates when each tested COVID-19 positive in the facility: 8/4/23 - R75; 8/15/23 - R359; and 8/19/23 - R130 and R358. 8/22/23 at 1:23 PM - During a combined interview, E3 (Interim DON/IP) and E4 (UM/RN) were asked if the facility conducted contact tracing and testing. E3 and E4 both stated that they did not conduct contact tracing and testing. 8/22/23 at 3:49 PM - During an interview, the Surveyor requested the facility's infection control line listing from E1 (NHA) as soon as possible. 8/22/23 at 4:40 PM - The facility management was notified that an Immediate Jeopardy was being called for the failure to implement their infection control program for COVID-19. The facility failed to do the following: -initiate contact tracing and identify close contacts/exposures; -conduct serial outbreak testing; -notify the Department of Public Health (DPH) of the COVID-19 outbreak as required; and -educate staff working in the building about the outbreak and the use of source control. 8/22/23 at 8:45 PM - The facility's abatement plan outlined the following corrective actions to be initiated immediately: -Infection Preventionist/designee initiated broad-based testing of COVID-19 for residents and staff. -Administrator notified the Department of Public Health of the COVID-19 outbreak. -Administrator/DON and Infection Preventionist educated by the Regional Clinical Director on the COVID-19 infection control program, to include: initiation of contact tracing and identification of close contact/exposures, conducting serial testing, notifying DPH of the COVID-19 outbreak, and educating staff working in the building about the outbreak and the use of source control. -Education of staff on COVID-19 outbreak and the use and availability of source control initiated. All staff will be educated and tested before their next scheduled shift. 8/23/23 at 4:43 PM - E1 (NHA) provided the Surveyor with evidence that DPH was notified of the COVID-19 outbreak, line listings were sent, and communication with DPH would continue on status of outbreak going forward. Review of the facility's staff education and testing documentation and follow-up interviews, the facility abated the immediate jeopardy as of 8/23/23 at 3 PM. 9/8/23 at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (RCD) and E3 (Interim DON). 36017 2. The laundry room tour on 8/21/23 at 10:00 AM revealed the following: 8/21/23 at 10:00 AM - The laundry room back door of the soiled linen room was propped open and not kept closed. Finding was reviewed and confirmed by E24 (Director of Housekeeping) on 8/17/23 at approximately 11:15 AM. 9/8/23 at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (RCD) and E3 (Interim DON).

Based on observation, record review, interview and review of facility and other documentation as indicated, it was determined that for nine ( R172, R143, R165, R182, R121, R132, R509, R513, and R26) out of thirteen residents reviewed for quality of care, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plans. For R172, the facility caused harm by the failure to ensure that R172 received adequate care to prevent a rehospitalization which included emergency procedures to save R172's life. While a resident at the facility, R172 failed to receive a facility arranged outpatient surgical foot doctor appointment after a 5/19/22 hospital discharge. Additionally, R172 did not receive a 5/24/22 dose of a medication to stimulate/increase his red blood cell count. On 5/27/22, R172 was readmitted to the hospital emergency room as a Trauma Code, requiring several lifesaving emergency procedures as a result of his left foot wound bleeding and his critically low blood levels. For R143 the facility failed to ensure that R143 received competent nursing care to address R143's constipation when R143 did not have a bowel movement for six (6) consecutive days, 8/1/23 thru 8/7/23. For R165, the facility caused harm to a dialysis resident who missed treatment on 7/19/23. The facility failed to notify the physician, failed to monitor R165 for fluid overload, failed to obtain, monitor, and document complete vital signs. R165 was admitted to the hospital on 7/20/23 with diagnoses including, but were not limited to, unresponsiveness, hyperkalemia and fluid overload. For R182, the facility caused harm by the failure to initiate and monitor fluid intake when the practitioner ordered a 1,500 ml fluid restriction on 7/14/23 and failed to obtain a BMP lab. R182 was sent to the Emergency Department (ED) on 7/20/23 for a change of condition, admitted to the medical ICU, after hospital lab results revealed the sodium level was 105, a critical level. Additionally for R182, the facility caused harm by the failure to monitor and initiate a bowel protocol regimen, which resulted in R182 being diagnosed with a fecal impaction of the rectum on 7/20/23 after being emergently hospitalized for an unrelated change of condition. For R121 the facility caused harm by the failure to ensure R121 received treatment for continued loose stools/diarrhea and as a result of this failure R121 has developed a red and excoriated buttocks and scrotum area. For R132, the facility failed to ensure R132's abdominal binder and thigh high stockings were applied on him as ordered by the physician and care planned to treat his orthostatic or postural hypotension (low blood pressure caused by postural changes). In addition, the facility failed to ensure a system was in place to monitor R132's actual total volume fluid intake to maintain the 1.5 L (liter)/day fluid restriction. For R513, the facility failed to administer the prescribed elavil, an antidepressant medication, for two occurrences on 8/7/23 and 8/9/23. For R509, the facility failed to ensure that the weekly skin assessments were completed by the nursing staff during R509's scheduled shower days. In addition, the facility failed to ensure that R509's consumption of the Ensure supplement drink was monitored and recorded, and for R26, the facility failed to provide surgical wound care as ordered by the physician. Findings include: 1. Cross refer to F656 and F710. Review of R172's clinical record revealed: 5/10/22 - R172 was admitted to the facility with multiple diagnosis including a recent left foot surgical toe removal, anemia, a bone infection, rehabilitation and a need for personal care. 5/11/22 - A physician's order was written for daily dressing changes to R172's left foot. 5/11/22 - R172 was sent to the hospital when his left foot wound began to bleed heavily. The hospital admitted R172 for foot wound care and the monitoring of R172's Hemoglobin (Hgb-levels of red blood cells). 5/19/22 - R172 was readmitted to the facility upon hospital discharge. The hospital discharge records documented that R172 received one unit of blood during his hospital stay and that his Hgb was stable at 8. According to the Mayo Clinic, a normal Hgb range for a male is 13.2 to 16.6 grams per deciliter (g/dcl.) Additionally, R172 was to have a follow up visit to his surgical foot care doctor in the week after his hospital discharge. 5/22/22 - A physician's order was written by E6 to obtain a Complete Blood Count (CBC) laboratory test. The laboratory test would test for R172's Hgb level. 5/24/22 - A physician's order was written for Epoetin, inject 1 ml one time a day every week for anemia, hold for Hgb less than 10. A review of the prescribing information for Epoetin from the maker of the drug, [NAME] Products, documents that the medication should be given when a Hgb level is less than 10 g/dL. 5/27/22 - Record review revealed R172 was found unconscious in his room with an extensive amount of blood surrounding him and R172 was sent to the hospital by ambulance. R172 was received as Trauma Code in the hospital emergency room with a critically low Hgb, and his blood pressure and blood oxygen level were both unmeasurable. R172 needed to have emergency procedures to support and to maintain his life, including the placement of an emergency airway tube for his breathing, advanced heart life support after R172's heart stopped beating, a surgically placed Intravenous (IV) access to receive blood transfusions, emergency surgery to his left foot to stop wound bleeding and further treatment in the hospital intensive care unit after R172's emergency care was provided. 8/16/23 - A review of R172's Electronic Medical Rrecord (EMR) documentation from 5/11/22-5/27/22 revealed the following: - R172 did not receive an injection of Epoetin on 5/24/22. - R172 was not provided with a surgical foot care appointment after his 5/19/22 hospital discharge, which was to have been scheduled by the facility. - R172's daily dressing changes were not documented in EMR by nursing staff. 8/29/23 - A review of the facility's Nursing Policies and Procedures-Wound Care-General Wound Care/Dressing Changes, effective 11/1/19 revealed the following: Policy: A licensed nurse will provide wound care/dressing changes(s) as ordered by a physician. Procedure: . 9. Document in Progress Notes any unusual findings and follow-up interventions . 8/29/23 10:15 AM - During an interview, E12 (LPN) stated that for the Epoetin order written to hold for Hgb less than 10, that she would have questioned/clarified the order with the provider because she knows that the medication should be given for a Hgb level below 10. 8/29/23 10:30 AM - During an interview, P1 (Surgical Orthopedics office staff) confirmed that R172 did not have a follow up surgical foot care appointment during the week 5/20/22 - 5/27/22. 8/30/23 11:00 AM - During an interview, E18 (Nurse Practitioner) stated that the instructions for the medication order Epoetin 1 ml injection one time for anemia, hold for Hgb less than 10, should have read to hold the medication for a Hgb greater than 10 and that R172 should have received the medication. Upon seeing the Epoetin order written incorrectly in the EMR, E18 stated that the order must have been written incorrectly in the Emr by the nurse at the time that the order was given. R172 experienced harm from the facility not giving the medication Epoetin on 5/24/22, and the lack of the facility scheduling his surgical foot doctor follow up appointment the week of 5/20/22-5/27/22, after his 5/19/22 hospital discharge. 2. Review of R143's record revealed: 7/31/23 - R143 was admitted to the facility with multiple diagnoses including lung cancer and pneumonia. 7/31/23 - A physician's order was written for polyethylene glycol oral powder 17 GM, give 1 scoop by mouth one time a day for constipation. 7/31/23 - A physician's order was written for Fleet enema as needed for constipation, use only if the bisacodyl suppository is ineffective. 8/1/23 - A physician's order was written for bisacodyl suppository 10 mg, insert 1 suppository rectally every 24 hours as needed for constipation. 8/2/23 - R143's entry MDS assessment revealed a BIMS score of 5, which indicated severe mental impairment. 8/27/23 - A review of the facility policy: Medical Facilities of America Nursing Polices and Procedures for Constipation, revised 11/1/19, revealed the following: Policy: Patient's will be monitored for regular bowel movements as evidenced by a bowel movement every three days or as determined by individual assessment, medical condition or functional status. Procedure: 1. Nurse will routinely review to determine patients in need of intervention to facilitate bowel movement. 3. Initiate any or all of the following interventions and document in the clinical record . d. Stool Softeners, suppositories, laxatives and/or enemas as ordered by the physician. 8/28/23 - Review of the facility Documentation Survey Report revealed that R143 did not have a bowel movement from 8/1/23 at 11:19 PM until 8/7/23 at 11:22 PM. The review also revealed that R143 did not receive a bisacodyl suppository or a Fleet enema when R143 did not have a bowel movement after three (3) days from his last bowel movement on 8/1/23 at 11:19 PM. Additionally, R143 did not receive his daily scheduled doses of constipation medication polyethylene glycol oral powder 17 GM for the days 7/4/23 thru 7/8/23. 8/29/23 12:00 PM - During an interview, E56 (LPN) stated that the Electronic Medical Record (EMR) alerts a nurse when a resident has not had a bowel movement for nine (9) shifts/or for three (3) days. E56 confirmed that R143 had not had a bowel movement documented from 8/1/22 at 11:19 PM until 8/7/23 at 11:22 PM and that constipation relieving medications had not been started for R143. E56 stated that a resident's constipation status is not part of a nursing shift to shift report. 8/29/23 12:45 PM - During an interview, E57 (LPN) stated that a constipation alert should had been present in the EMR when a resident has not had a BM for 3 days. E57 confirmed that constipation relieving medications had not been administered to R143 when he had not a bowel movement for three days. E57 stated that a resident's constipation status is not part of a nursing shift to shift report. 48409 3. 11/1/19 - The facility's policy titled, Fluid management/fluid restrictions included .The nursing staff will monitor, and access residents placed on fluid restrictions. 11/1/19 - The facility's policy titled, Transportation and Appointments included .A licensed nurse will ensure that transportation to medically related appointments and will be responsible for coordinating those transports as appropriate. Review of R165' clinical records revealed: 3/2/23 - R165 was admitted to the facility with diagnosis including but not limited to end stage renal disease requiring dialysis (cleansing of the blood by artificial means when kidneys have failed) three times a week, hypokalemia (low potassium level in the blood), and type 2 diabetes mellitus. R165's admission records documented that R165 was scheduled for pickup from the facility between 6:25 AM - 6:55 AM and a chair time (time resident is expected to start hemodialysis treatment) on Monday, Wednesday, and Friday at 7:10 AM. 3/2/23- R165's care plan documented, R165 is at increased risk due to requiring dialysis for end stage kidney disease. Interventions included dialysis every Monday, Wednesday, and Friday, and 1200 ml fluid restriction (480 ml with nursing, and 720 ml with dietary) every 24 hours. 7/19/23 - R165's medical record documented, Patient was not picked up for dialysis this am .transportation company stated that patient only had trips scheduled until 7/17/23. Dialysis center stated they would be unable to see patient today but would see tomorrow (7/20/23) at 11:45 AM. Transportation scheduled for pick up at 10:45 AM The facility lacked evidence that R165 was monitored for fluid overload including assessment of lung sounds, weight, and a complete set of vital signs. The facility also lacked evidence that the physician was notified of the missed dialysis treatment. 7/20/23 - The facility lacked evidence that R165's vital signs were obtained prior to dialysis. 7/20/23 10:50 AM - R165's medical record documented, Patient left facility for dialysis via stretcher .communication binder and lunch sent with patient. 7/20/23 12:13 AM - A nursing note documented, .Received call from dialysis . was notified patient was unresponsive upon arrival . patient was sent to the emergency room . 7/20/23 - R165 was admitted to the intensive care unit with diagnosis including but not limited to . critical hyperkalemia (high potassium in the blood) of 8.7 (normal is 3.5-5.2) and received continued renal replacement therapy (CRRT- 24 hours dialysis therapy for acute kidney injury and fluid overload.) R165 remained in the hospital from 7/20-8/15/23 (26 days). Review of R165's fluid intake records revealed: 5/1/23 - 5/31/23 - No evidence of fluid intake documentation. 6/1/23 - 6/30/23 - No evidence of fluid intake documentation. 7/12/23 = 2240 ml. 7/13/23 = 2500 ml. 7/17/23 = 1440 ml. 7/18/23 = 1440 ml. 8/28/23 1:01 PM - During an interview with E34 (LPN) on the 11-7 shift of 7/20/23 stated he could not remember what R165's status was prior to going to dialysis, I take care of a lot of dialysis patients. 8/28/23 1:21 PM - During an interview with E32 (dialysis center RN) stated, The resident arrived here almost out of it. He was breathing but that was about it. His blood pressure 88/34, pulse 78 and respirations 12. I did not feel that he was stable enough to be dialyzed here, so we called 911 and sent him to the ER. E32 further stated, It is the responsibility of the nursing home to arrange and follow up with transportation for the residents who live there. 9/1/23 10:30 AM - During interview with R37 (LPN) stated that the facility has the responsibility to arrange transportation for the residents. R37 further stated, I am on all of the units, so I don't what is followed up on or not. 32545 4. The facility's policy and procedure entitled Fluid Management/Fluid Restriction, effective date 11/1/19, stated, The nursing staff will assess and monitor adherence to fluid management for patients placed on fluid restrictions. Procedure: Fluid Restrictions . 3. Determine amount of fluids with each meal, before bed time and with medication administration using guidelines in table . and consideration of patient preferences . 4. Monitor for signs of dehydration: . c. Abnormal serum sodium . levels . 5. Notify Physician and Responsible Party as indicated if non-adherence to fluid restriction status noted . 7. Document adherence/non-adherence to fluid restriction status, any signs of dehydration, any unusual findings and follow-up intervention including notification of physician/responsible party in the Progress Note. Document fluid intake. R182's clinical record revealed: 7/3/23 - R182 was admitted to the facility with diagnoses including, but were not limited to, rhabdomyolysis, hypo-osmolality and hyponatremia, urine retention with placement of an indwelling foley catheter on 7/1/23, mild cognitive impairment, chronic kidney disease and history of urinary tract infections. 7/3/23 at 8:09 AM - The Initial Physician Certification for Extended Care Services documented the following under the Malnutrition Review: Monitor oral intake/meal tolerance, supplement as indicated- recent hospitalization . 7/5/23 at 3:27 PM - Lab results revealed that R182's Sodium level was 133 (normal laboratory range 135 - 145). 7/6/23 - R182's care plan for a nutritional problem or potential nutritional problem documented the following interventions: - administer medications as ordered; - encourage to eat; - RD (Registered Dietician) consult as needed; - record meal % (percentage) intake; - review dietary preferences with the resident as needed; - supplements as ordered; - therapeutic diet as ordered; and - weights as ordered. 7/6/23 - A physician progress note, by E17 (NP), documented that the plan for Acute hyponatremia mild, NA (Sodium) 133 on 7/5/23, was 131 on 6/30/23, monitor. 7/6/23 at 9:21 AM - A nutrition assessment documented that there were no issues with R182's eating function; feeding ability was independent with tray set up; no edema, 7/5/23 Sodium lab was 133 (low), diet order was NAS (no added salt) diet, regular texture, thin liquids; at risk for malnutrition with interventions: weekly weights x 4 weeks, monitor PO intake and labs. 7/12/23 - Lab results revealed that R182's sodium level was 124 (low level). 7/12/23 at 11:11 AM - A physician progress note by E17 (NP) documented that R182 was seen and examined. Also noted that Labs from 7/12/23 reviewed and noted with a hyponatremia at 124. trace edema noted to BLE (bilateral lower extremities) . Plan: Acute Hyponatremia Na (sodium) noted to be 124 on 7/12/23, was 133 on 7/5/23, was 131 on 6/30/23, will add Salt tablet 1 gm BID (twice a day), will repeat BMP on Monday and weekly on Mondays . 7/12/23 at 12:05 PM - A Physician order by E17 (NP) stated to give R182 sodium tablet orally two times a day for a diagnosis of hyponatremia. R182's July 2023 eMAR revealed that she did not receive the ordered salt tablet on 7/12/23 evening scheduled dose and two doses on 7/13/23. 7/14/23 - A progress note by E17 (NP) documented that R182 was seen and examined and the plan for acute hyponatremia Na (sodium) noted to be 124 on 7/12/23 . added salt tablet .(twice a day), awaiting supply from pharmacy, discussed with staff, will add fluid restriction 1500 ml/day, will repeat BMP (lab) on Monday and weekly on Mondays. 7/14/23 at 1:33 PM - A physician order by E17 (NP) stated to place R182 on a fluid restriction 1500 ml per day. 7/16/23 at 12:10 PM - A physician order by E17 (NP) stated to obtain a BMP lab every Sunday on night shift. 7/16/23 at 10:45 PM - The July 2023 eTAR revealed that a nurse signed off that the BMP lab was done. R182's clinical record lacked evidence of the 7/16/23 BMP lab, despite it being signed off as completed, and lacked evidence that the ordered fluid restriction of 1500 ml per day was initiated and being monitored. R182's July 2023 CNA Documentation Survey Report revealed that 19 out of 51 meal opportunities documented over 17 days in the facility were blank. The CNA Kardex was not updated to reflect R182's 1,500 ml per day fluid restriction. 7/20/23 at 7:45 AM - A progress note by E74 (Physician) documented .F/u (follow-up) family concern of weakness . She is seen per daughter's request due to a change in patient condition. Daughter states, she visits her mother on a daily basis and she thinks the patient is not at her usual baseline and has asked for a physician to see her. Patient is seen lying in bed before breakfast. Daughter states she gets frequent UTI. Patient has a foley that is draining yellow urine, no odor, her vital signs are stable. All these explained to the patient's daughter, but she insisted to have U/A, C&S done. UA, C&S ordered not yet on chart Patient has no complaints. Her appetite is good . A&Ox1 (alert and oriented x 1 name) . no BLE edema . trace edema .PLAN: change in mental status: Await UA, C&S next lab day, also await repeat of BMP, order on chart to get, will write stat. Hyponatremia: Continue Sodium . tablet . two times a day . 7/20/23 - A physician order documented BMP STAT for hyponatremia. 7/20/23 at 11:01 AM - A nurse's note documented that Pt's (patient's) daughter concerned about her mother's health condition, request patient sent to . ER (emergency room ) for further evaluation. Patient evaluated by E17 (NP), pt denies pain, no signs of distress. Patient left facility 10:55 AM via ambulance. Pt vs (vital signs) Temp (temperature) 97.2 Resp (respirations) 18 HR (heart rate) 88 BP (blood pressure) 143/77 SPO2 (pulse ox) 95% room air. 7/20/23 at 11:52 AM - The hospital lab result revealed that R182's sodium was 105, a critical result. (normal hospital range 136-146) 7/20/22 at 3:22 PM - The hospital's History & Physical documented, .Patient's daughter visits her every day and states that over the last 2 days patient has had increased leg swelling that she reported to the staff .Per daughter there was no administration of diuretics. Today patient became more confused acutely. She was having visual hallucinations which is new for her. She was unable to clearly communicate at times which is also knew for her .Daughter not aware of patient having prior issues with her serum sodium level . Assessment/Plan: Hyponatremia - Patient has presentation with what appears to be subacute severe life-threatening hyponatremia contributing to acute onset metabolic encephalopathy manifest with slowing of thoughts, disorganized thoughts, and hallucinations . She needs admission to the ICU due to her hyponatremia .Metabolic encephalopathy - secondary to severe hyponatremia .Patient remains critically ill requiring ICU level of care due to life-threatening hyponatremia with metabolic encephalopathy. High risk for further decompensation or death from this . 7/20/23 at 3:46 PM - The hospital's ED Physician Record documented, .On July 15, the daughter states they took the foley catheter out. Daughter was upset, and on July 16, they, at her request, put the catheter back in. There was a false passage apparently, it was not draining anything. They reinserted, and on July 17, seem to be draining urine. however the urine volume is way down. Her oral intake of food . way down. For the last 3 days, daughter reports a decreased mental status. When she eats, she has food rolling down her front, which is unusual for her. Is just not as responsive. has a chronic cough intermittently but perhaps coughing more. Has a chronic runny nose. Not seemingly short of breath as per the daughter. She does not report any headache chest pain or abdominal pain. Daughter noted the abdomen was very hard yesterday, seems to have softened up today . spoke with .medical ICU .already spoken with nephrology .They changed the order to sodium levels every 4 hours. He had placed the order for the 3% saline, at 10 mls per hour. I did the urine [NAME], and urine Osmo as an add-on . 8/3/23 at 3:28 PM - The Hospital Discharge Summary documented, Diagnoses Treated This hospitalization . 1. Metabolic encephalopathy; 2. Hyponatremia; 3. UTI due to Enterococcus . 9. Fecal impaction in rectum . presented to the emergency department on 7/20/23 with altered mental status from her skilled nursing facility. She was found to have hyponatremia with a sodium of 105, attributed to possible SIADH as well as E faecalis and Hafnia UTI. She was initially on hypertonic saline and now remains on salt tablets with gradual improvement in her sodium, now within normal limits on the day of discharge . 8/28/23 at 10:57 AM - During an interview, E3 (Interim DON) confirmed that the 7/16/23 ordered BMP lab was never done. 8/29/23 at 11:07 AM - During an interview, E17 (NP) confirmed R182's sodium level upon arrival at the hospital on 7/20/23 was 105, a critical level. E17 stated she has never seen a sodium level that low before. E17 confirmed that her physician orders for a BMP lab to monitor R182's sodium on 7/16/23 and the initiation of a fluid restriction were not taken off and followed despite discussing the plan with nursing staff in person and the orders entered into electronic health record. E17 also stated that R182's foley catheter was not to be removed as she discontinued her previous order after discussing with R182's family member on a possible voiding trial here at the facility. 8/31/23 at 12:10 PM - Findings were reviewed with E1 (NHA) and E3 (Interim DON). 5. The facility's policy and procedure for Constipation Prevention, effective date 11/1/19, stated, Policy: Patient's will be monitored for regular bowel movements as evidenced by a bowel movement every three days or as determined by individual assessment, medical condition or functional status. Procedure: 1. Nurse will routinely review to determine patients in need of intervention to facilitate bowel movement. 2. Assess the patient for the following systems of constipation, such as: a. Smearing of feces. b. Loss of appetite. c. General malaise. d. Drowsiness. e. Elevation of temperature. f. Abnormal vitals signs. g. Frequent bouts of diarrhea. h. Abdominal distention. i. Nausea and/or vomiting. j. Malodorous breath. 3. Initiate any or all of the following interventions and document in the clinical record: a. Prune juice followed by a glass of warm water, or other food preparation assessed by dietary to enhance bowel evacuation. b. Increase activity or exercise as tolerated by patient (short distance ambulation or range of motion). c. High fiber foods with adequate fluids. d. Stool Softeners, suppositories, laxatives, and/or enemas as ordered by the physician. 4. Document bowel movements in the clinical record. 5. Contact physician for any needed orders. 6. Assessment of constipation or the history of constipation will be documented upon admission. 7. The plan for prevention of constipation will be documented on the comprehensive care plan. R182's clinical record revealed: 7/3/23 at 7:51 PM - The nursing admission note documented that R182 had a history of constipation, was alert and oriented x 1/2, and required a sit to stand mechanical lift with transfers. 7/3/23 at 10:39 PM - The facility's Admission Nursing Collection Tool documented that R182 was continent of bowel and was at risk for constipation with interventions to implement the bowel protocol when indicated, observe for signs and symptoms of constipation or extended abdomen that may indicate constipation and track and record bowel movements. The above interventions were captured on R182's at risk for constipation care plan. 7/3/23 at 11:19 PM - A physician's order documented to give two tablets of Senna 8.6 mg one time a day for constipation. R182's July 2023 eMAR revealed that the resident received the Senna medication on a daily basis. Review of the CNAs Kardex for R182 care needs stated to track and record her bowel movements. 7/4/23 - R182 was care planned for at risk for constipation with interventions that included: implement bowel protocol when indicated; observe for signs and symptoms of constipation or extended abdomen that may indicate constipation; and track and record bowel movements. 7/9/23 - The admission MDS assessment documented that R182 required extensive assistance of one staff member for toileting, was always incontinent of bowel, no bowel toileting program in use and no constipation present. R182's CNA Documentation Survey Report revealed that from 7/3/23 through 7/20/23 in the facility, R182 was documented as having a 5 incontinent bowel movements: - 7/4/23 two medium formed BMs; - 7/7/23 medium formed BM; - 7/9/232 medium formed BM; - 7/10/23 medium formed BM; and - 7/16/23 small putty-like BM. Despite having a facility policy and procedure for prevention of constipation, there was no evidence in the clinical record that R182's BMs were being monitored by nursing staff, no initiation of the bowel protocol regimen and no notification to a physician when R182 had no bowel movements from 7/11/23 through 7/16/23, for approximately six days. 7/20/23 at 11:01 AM - A nurse's note documented that R182 was emergently sent to the ER (emergency room ) per her family member's request for a change of condition. 7/20/23 - The hospital diagnostic test revealed that R182 had a finding of a rectal fecal impaction. 8/2/23 at 9:51 - A hospital Consult Note documented that R182's .Constipation resolved with a bowel regimen . 8/31/23 at 12:10 PM - During a combined interview with E3 (Interim DON) and E4 (RN/UM), E3 stated that she hasn't seen the facility's bowel policy and procedure. E3 and E4 both stated that in mid-August 2023, they initiated an alert monitoring system for residents' bowel movements which are discussed during the daily morning meeting. Nursing staff are then informed when a resident does not have a bowel movement over nine (9) consecutive shifts to initiate the bowel protocol and document it's effectiveness. E4 stated that she was planning to educate staff about the new process, but the LTC survey started, which it has been put on hold. 8/31/23 at 12:10 PM - Finding was reviewed with E1 (NHA) and E3 (Interim DON). 6. R182's clinical record revealed: 7/3/23 at 3:30 PM - R182 was admitted to the facility. 7/4/23 - R182 was evaluated by P10 (Wound Care NP) and noted with the following skin integrity issues: - Wound #1: left medial malleoulus; - Wound #2: right shin; and - Wound #3: left forearm. 7/4/23 - R182's physician orders for wound treatments were: - Left forearm: clean site with wound cleanser, apply Xeroform gauze to wound base, top with ABD pad then wrap with cling daily every evening shift. - Left medial malleoulus: clean with wound cleanser, apply Xeroform gauze to wound base and cover with a bordered gauze dressing daily every evening shift. - Right shin: clean with wound cleanser, apply Xeroform gauze to wound base, top with ABD pad and wrap with cling daily every evening shift. 7/12/23 - R182 was care planned for wounds with interventions that included, but was not limited to, treatment per eTAR. R182's eTAR revealed that treatments to her left malleoulus, right shin and left forearm were not done for 3 out of 15 days in the facility, specifically on 7/6/23, 7/15/23 and 7/16/23. 8/31/23 at 4:30 PM - Findings were reviewed with E1 (NHA) and E3 (Interim DON). No further information was provided to the Surveyor. The facility failed to ensure that R182's wounds treatments were consistently done. 7. The facility's Pharmacy policy and procedure for Ordering and Receiving Non-Controlled Medications, last revised on 8/2020, stated, Medications and related products are received from the pharmacy on a timely basis . R182's clinical record revealed: 7/3/23 - R182 was ordered PreserVision AREDS, an over-the-counter medication, twice a day for a supplement. R182's July 2023 eMAR revealed that she was not administered 11 doses out of 32 scheduled opportunities. R182's nurse's notes documented the following reasons why she was not administered a physician ordered medication: -7/4/23 at 12:35 AM - awaiting pharmacy delivery. NP aware. -7/5/23 at 5:30 PM - med (medication) unavail. (unavailable) Awaiting pharm (pharmacy) arrival. -7/6/23 at 12:40 PM - awaiting pharmacy delivery. NP aware. -7/7/23 at 10:34 AM - awaiting pharmacy delivery. NP aware. -7/9/23 at 12:47 PM - on order, rp (representative) aware. -7/12/23 at 8:19 AM - There was nothing documented. -7/16/23 at 9:30 AM - not available. -7/17/23 at 11:14 AM - medication not available, NP is aware, no new orders. -7/18/23 at 9:19 AM - medication not available, NP aware. No new orders. -7/19/23 at 8:32 AM - not available. -7/19/23 at 5:29 PM - not available. 8/31/23 at 12:10 PM - During a combined interview, finding was reviewed with E3 (Interim DON) and E4 (UM/RN). The facility failed to ensure R182 received physician ordered medications consistently according to her plan of care. 39058 8. Review of R121 clinical record revealed: 3/11/23 - A discharge summary documented R121 was hospitalized for stage III metastatic melanoma .and IBD. R121 came to the hospital for nausea, vomiting and diarrhea over the last four months. In the emergency room [TRUNCATED]

Based on interview and record review it was determined that for three (R173, R174 and R410) out of three residents reviewed for accidents the facility failed to ensure the resident's environment was free from accident hazards and/or adequate supervision was provided to prevent accidents. F173, had a fall from bed while reaching for a urinal left out of reach resulting in harm, subsequently sustaining two broken areas in the spine. For R174, the facility failed to provide adequate supervision and assistance with toileting resulting in harm when the resident fell and sustained a broken hip. For R410, the facility failed to assess resident falls and implement measures to prevent falls. Findings included: 11/1/19 - The facility's fall policy titled, Falls Management Program included - A licensed nurse will intervene, assess .investigate, record surroundings the fall, complete post fall assessment .the interdisciplinary team will analyze and trend .and present findings to the Quality Assurance Committee. 1. Review of R173's clinical record revealed: 4/11/22 - R173 was admitted to the facility with a diagnosis including, but not limited to dementia; lymphedema (a condition that results in swelling of the leg or arm); and adult failure to thrive. 4/11/22 - R173 was care planned for alteration in musculoskeletal status with interventions including but not limited to: monitoring for risk of falls, educating the resident, family/caregivers on safety measures to reduce risk of falls (9/18/22), bed in low position (4/12/22); educate resident on calling for help prior to reaching for nightstand (2/6/23); and educate resident on use of reacher and calling for help (2/2/23). 4/12/23 - The annual MDS assessment documented a BIMS (Brief Interview for Mental Status) score of 12 indicating moderately impaired cognition; bed mobility showed extensive assist for self-performance and one person physical assist for support; transfer showed limited assistance for self-performance and one person physical assist for support; eating with supervision for self-performance and one-person physical assist for support; and toilet use with extensive assistance for self-performance and one person physical assist for support. 5/25/23 at 4:15 PM - A nurse's note documented that E60 (RN) was notified that R173 was found on the floor by the nurse E59 (LPN) assigned to the resident. Upon getting to the room R173 was lying on the floor on the left side of the bed and on the left side. Blood was noted on the floor from an injury to the left side of the forehead. The bed was in low position. According to the note, R173 reported trying to reach for a urinal when the fall occurred. The E6 (MD) was made aware, and an order was given for the resident to be sent to the hospital for evaluation. 5/25/23 - Per the facility's investigative reporting written statement from E54 (CNA), the incident occurred at about 4:10 PM on 5/25/23. E54 went to answer R173's light after shift change. Upon the E54's arrival, the resident was sitting on the chair and asked to be put back in bed. During the process E54 noticed R173 had a bowel movement and told the resident a diaper was needed so R173 could be changed. E54 went to get a diaper and had left the bed in low position. E54 realized there were no wipes, upon returning to the room. E54 reportedly left for less than 1 minute and upon return saw R173 on the floor. When asked what R173 was doing before ending up on the floor, the resident said, 'trying to reach urinal'. The witness statement further documented that R173 never asked for the urinal before E54 left for the wipes, and the urinal was not close to the resident because E54 cleared off the area in order to change R173 before setting him back up when done. 5/25/23 (initial vital signs taken at 5:16 PM) - emergency room notes revealed R173 was here after falling out of bed this afternoon. Apparently struck head. Unknown if there was loss of consciousness but nothing reported. [R173] was at baseline confused. The examination showed a 4 - centimeter stellate (resembling a star) laceration over the left forehead with avulsion (layers of skin are removed). C-collar (cervical (neck) collar) in place, no chest wall tenderness, no abdominal tenderness, alert and moving all 4 extremities. Impression: fall, forehead laceration, C1 and C2 (cervical vertebra 1 and cervical vertebra 2 [neck area]) fractures (on CT scan and MRI of the cervical spine). Will be placed in a Miami J collar, anticipate further CT scans to evaluate for any other injury given baseline dementia and difficult historian. 9/6/23 at 11:50 AM - Per interview with E54, while performing rounds, R173's call light was on. When E54 answered the light, R173 requested to be move to a chair. E54 left the room to get wipes and a diaper because there were no supplies in the room. E54 went to the supply cart, which also did not have supplies, then walked a short distance farther down the hall to the supply closet. Upon return to the room, the resident was found lying on the floor. According to E54, R173 reported trying to get the urinal. E54 stated the urinal was not close by the resident because E54 had made the space to change R173. E54 then called another CNA to call the nurse came and examined the resident. E54 noticed the resident's head had been hit and was bleeding in the left forehead area. Per E54, R173 was lying in bed when left alone and had been given the call bell. The Hoyer lift was used by E54, the other CNA and the nurse to pick up R173 from the floor. R173, who was not assessed for an individualized toileting plan, fell trying to use the bathroom independently resulting in a broken neck. 48409 2. Review of R174's records revealed: 3/2/22 6:30 PM - R174 was admitted to the facility with diagnoses including but not limited to acute kidney failure, dementia, need for assistance with personal care, and urinary tract infection. 3/2/22 - R174's admission orders included - keflex capsule 500 mg every 12 hours for three more days for urinary tract infection, bladder scan (non-invasive method to measure the amount of urine in the bladder) every shift. Straight catharize (soft, thin tube used to remove urine from the bladder) for greater than or equal to 400 ml every shift. 3/2/22 - R174's nursing admission assessment documented, Continent (of bladder), bowel continence was not assessed, and fully dependent (on staff) for transfer 3/2/22 - R174's admission care plan documented, At risk for falls due to ambulatory dysfunction with interventions to, Encourage to transfer and change positions slowly, provide assist to transfer and ambulate as needed, and bed in low position. The surveyor was unable to locate a fall score in the clinical record. 3/6/22 4:30 PM - R174's clinical record documented, .Patient stated that she was trying to go to the bathroom and slid to the floor. 3/7/22 - R174's care plan documented, Offer and assist patient with toileting prior to the end of each shift, provide assist to transfer and ambulate as needed. There was no evidence that the facility assessed R174 for an individualized toileting program to prevent falls. 3/8/22 1:52 PM - R174's clinical record documented, .Patient was transferring unassisted back and forth from bed to the wheelchair .one time order obtained for trazodone (an anxiety medication) .ambulated with rolling walker with therapy. 3/8/22 10:43 PM - R174's clinical records documented, Resident is sitting at the nurses' station. New orders for Ativan (anti-anxiety medication) 0.25 mg tab every eight hours as needed for agitation, melatonin (sleep aide) 3 mg at bedtime. Psychiatry consult. 3/9/22 6:47 AM - R174's clinical record documented, .Was restless throughout the night, and trying to get out of bed multiple times. Brought up to the nurses' station for closer observation and monitoring. 3/10/22- R174's MDS documented, a BIMS of 2 indicating severe impairment , no bowel/bladder trial voiding diary, no prompted voiding, no toileting program, frequently incontinent of bladder, and occasionally incontinent of bowel. 3/11/22 1:33 PM - R174's nurses notes documented, Out of bed to wheelchair. Yelling out frequently nurse, help, banging on bedside the table. 3/12/22 11:50 PM - R174's clinical record documented, Called to the room and observed resident sitting on the floor in the bathroom leaning against the wall. Resident complained of right leg pain. No obvious deformity noted to right leg. Resident was assisted back to bed, continued to complain of right leg pain. Received new order for STAT x-ray of right hip to rule out fracture. 3/13/22 3:47 AM - R174's clinical record documented, There is a comminuted (broken bones fractured into more than three pieces) right hip fracture with moderate displacement (ends are not lined up straight.) Resident sent to the emergency room for evaluation. 8/22/23 1:30 PM - During a phone interview R174's son stated that the resident is, Bed bound at another facility. 8/23/23 2:15 PM - Review of R174's clinical documentation failed to show evidence that a fall incident or investigation report was completed, or an interdisciplinary team review was done. Record review also failed to show evidence that the care plan interventions for ambulation were done. A care plan intervention for hipsters (undergarment worn to help reduce hip fractures from falls) was initiated on 3/12/22 but there was no evidence that this care was provided on R174's clinical records. On 3/16/23 a care plan was initiated for toileting before and after each shift and ambulate as needed. R174 was sent to the emergency roiagnom on [DATE]. The facility failed to ensure that R174 received adequate assessment, interventions, and assistance to prevent accidents. This resulted in a fall with a fracture. 3. Review of R410's records revealed: 8/7/23 3:23 PM - R410 was admitted to the facility with diagnoses including but not limited to cognitive communication deficit (difficulty with thinking and language use), urinary tract infection, fracture of the left hip bone. 8/7/23 - R410's nursing admission assessment documented a fall score of 12 (a scale used to evaluate the risk for falls -12 indicated a high fall risk.) The bowel and bladder documented incontinent of bowel and bladder. R410's BIMS (Brief Interview for Mental Status) was 1, which indicated a severe cognitive deficit (difficulty with language and speech) and required assistance of one person with transfers. An evaluation for toileting or a voiding diary was not initiated or done. 8/7/23 - R410's care plan documented, At risk for falls related to cognitive impairment with impulsive behaviors, impaired mobility, and history of falls with fractures. Interventions included but not limited to . low bed, resident wear glasses when out of bed, remind resident to use call light, to ask for assistance with activities of daily living, and wear nonskid socks. R410's care plan also documented, Incontinent of bladder and bowels due to dementia. 8/8/23 9:41 AM - R410's clinical record documented, Resident was walking in hallway, holding on to side rail and placed herself on the floor in a sitting position. Resident educated on asking for assistance with transfers and placed at nurse station for safety. Staff will continue to monitor resident. The surveyor was unable to locate the incident report, investigation, and interventions for this fall. E2 (Regional Clinical Director) confirmed that the report, investigation and interventions were not done. 8/10/23 - R410's clinical record documented a new order for trazodone 25 mg (antianxiety medication) every eight hours as needed for agitation. 8/11/23 9:10 AM - R410's clinical record documented, Resident fell in the room, hit her head, and sustained a laceration (4 cm x 2 cm) on her right elbow. Resident was sent to the emergency room for evaluation. R410' s fall score was on this assessment 12 (high risk.) R410 returned to the facility at 6 PM. The surveyor was unable to locate the interdisciplinary team fall review for this incident. 8/17/23 - R410's fall care plan was updated to include, Scoop mattress placed on resident's bed to help identify bed boundaries due to resident's poor eyesight. Provide toileting hygiene with brief change. 8/23/23 5:15 PM - R410's clinical record documented, Resident had fallen by the lounge resident was wheeled to the nursing station for close monitoring. R410's fall score was now 13 (high risk.) The surveyor was unable to locate the interdisciplinary team's fall review and interventions. 8/26/23 9:13 PM - R410's clinical records documented, Patient restless and agitated will not sit still. Snacks given and diversional activities attempted with no success. Will medicate and evaluate for effectiveness. Review of R410's medication records for the use of PRN (as needed) trazodone 25 mg revealed that was given on 8/12, 8/19, 8/23/23 with effective results, and 8/26/23 with ineffective results. 9/5/23 11:30 AM - R410's clinical records documented, .Resident fell in her room .no new orders . brought up to the nurses station. 9/6/23 5:01 AM - R410's clinical records documented, Still on one-on-one observation to prevent fall, all nursing care on going. Trazodone was given with Ineffective results. Remained in wheelchair for most of the night with increased agitation and trying to walk. Walking unsteady, unable to redirect . Review of R410's medication records for the use of PRN (as needed) Trazodone 25 mg revealed that was given on 9/2, 9/3, 9/4, 9/6, 9/9, 9/10, 9/11/23 with effective results, and 9/5/23 with ineffective results. R410 had a total of 4 falls from 8/7/23 to 9/5/23. The surveyor was unable to locate the interdisciplinary team's fall review and interventions to prevent falls. The facility failed to ensure that R410 was accurately assessed and appropriate interventions were implemented to prevent accidents. 9/8/23 at 12:30 - Findings were reviewed with E1 (Nursing Home Administrator), E2 (Regional Clinical Director), and E3 (Director of Nursing) at the exit conference.

Based on interview and record review it was determined that for two (R167 and R508) out of eight residents reviewed for pain management the facility failed to ensure the treatment and care for was in accordance with professional standards of practice related to pain management. For R167, pain was not managed resulting in the resident being sent to the emergency room for uncontrollable pain to the left hip causing harm to the resident. For R508, the facility failed to provide pain medication to a resident in pain in a timely manner. Additionally, R508 had a recommendation for adding another dose of morphine after being seen in a palliative care center and the facility failed to acknowledge and implement for a week. Findings include: A policy and procedure titled Pain Management Assessments dated 11/01/19 documented .Patient will be assessed for acute and chronic pain by a licensed nurse and a plan of care will be established .1. Assess all patients for pain a part of the admission nursing assessment .2. Initiate a pain assessment any time thereafter should a patient experience pain that is unusual for the patient .3. Administration of pain medication and effectiveness will be documented .4. Non-pharmacological interventions will be documented with administration of PRN (as needed pain medication) .5. If pain is not relieved, notify the physician. Any unusual findings and follow up interventions are to be documented on the progress note including notification of physician and responsible party .6. Care plan specific interventions will be developed based on pain assessment and individual patient needs. 1. Review of R167's clinical record revealed: 3/8/23 - R167 was admitted to the facility with a diagnosis of chronic pain and left hip infection. 3/8/23 - Review of R167'S care plan for Pain related to chronic pain revised 3/27/23 documented .1. The resident will report satisfaction with their pain medication regime through the review period .2. Administer medications as ordered .3. Notify physician as indicated .4. Request pain medication review from physician. 3/8/23 1:36 PM - A physician's order included: Pain assessment every shift. 3/8/23 1:36 PM - A physician's order included: administer non-pharmacological pain intervention as applicable. Use the key below to document non-pharmacological interventions used. 3/8/23 4:05 PM - A physician's order included: oxycodone oral capsule 5 mg (milligrams) give 5 mg by mouth every four hours PRN (as needed) for moderate pain of 4-6. 3/8/23 4:05 PM - A physician's order included: oxycodone oral capsule 5 mg. give 10 mg by mouth every four hours as needed for severe pain of 7-10. 3/11/23 6:18 PM - A nurse's progress note documented . 1. R167 complained of hip pain . 2. pharmacy had been notified that R167 was almost out of pain medication . 3. E51 (LPN) had been told by the Pharmacy that R167 needed another prescription for pain medication . 4. E51 left a message for the physician to call back . 5. E51 had not received a call back from the physician. E51's medication administration note revealed Oxycodone 10 mg had been given to R167 for severe pain 8 out of 10. 3/12/23 12:04 AM - A progess note documented .Give 10 mg by mouth every four hours as needed for severe pain scale of 7-10. 3/12/23 12:10 AM - R167 was administered Oxycodone 10 mg for pain. Further review of R167's controlled drug administration record revealed R167 had been given the last two Oxycodone 5 mg tablets at 12:10 AM. Further review of R167's clinical record revealed no PRN pain medication had been administered to R167 after the last dose had been given on 3/12/23 at 12:10 AM. 3/12/23 7:51 AM - A facility transfer form revealed R167 had uncontrolled pain of 9 out of 10 to the left hip. 3/12/23 12:50 PM - A late progress note composed by E53 (RN) documented R167 requested to be sent to the hospital due to uncontrollable pain of 9/10 in R167's left hip. Additionally, E53 (RN) documented the facility had not been able to reach the Pharmacy for medication. 9/5/23 9:00 AM - Review of R167's hospital note dated 3/12/23 documented . requesting pain management for hip pain. Additionally, R167 revealed to the provider in the emergency room , the facility said they had no pain medication for R167. Further review of the hospital notes revealed, Case management had confirmed Pike Creek Rehabilitation had no Oxycodone available to treat R167's pain. 9/5/23 12:53 PM - In a phone interview E51 (LPN) revealed R167 had been taking PRN Oxycodone 10 mg every four hours for pain. In addition, E51 stated, R167 had been sent to the emergency room for unrelieved pain. The facility failed to send R167 a resident who had uncontrollable severe pain to the hospital for evaluation and treatment in a timely manner. Additionally, R167's pain level on 3/12/23 at 7:51 AM had been assessed and was 9 out of 10. Furthermore, R167 arrived at the hospital on 3/12/23 at 12:13 PM, and had not received pain medication since 12:04 AM on 3/12/23 at the Pike Creek Nursing and Rehabilitation Center. 39058 2. Review of R508's clinical record revealed: 7/24/23 - A most recent admission to the facility with a history of cancer and chronic pain. a. 8/9/23 - A physician's order for oxycodone HCl Oral Tablet 15 mg give 1 tablet by mouth every 4 hours as needed for pain. 8/10/23 - A physician's order for lidocaine external patch 5 % (lidocaine) apply to lower back topically one time a day for pain. 8/12/23 - A care plan for a risk of pain with interventions to administer medications as ordered, notify the doctor as indicated and observe for physical indicators of pain. 8/23/23 5:17 AM - An oxycodone HCl Oral Tablet 15 mg was administered. 8/23/23 10:08 AM - A routine lidocaine patch was applied to the lower back for pain. 8/23/23 11:35 AM - An observation of R508's call bell ringing. E86 (LPN) was nurse's station. 8/23/23 11:43 AM - An observation of R508's call bell ringing. E86 and E92 (RN) were at the nurse's station. 8/23/23 11:52 AM - An observation of R508's call bell ringing. 8/23/23 11:57 AM - An observation of R508's call bell ringing. E86 and E92 were sitting at the nurse's station. 8/23/23 12:05 PM - An observation of E93 (CNA) answering R508's call bell approximately 30 minutes later. 8/23/23 approximately 12:15 PM - An interview with E93 (CNA) revealed that R508 was ringing the call bell because R508 was in pain but E93 thought that the nurse was already aware R508 was in pain. E93 stated I am going to tell her now. 8/23/23 Approximately 12:18 - An observation of E92 telling E40 (RN) that R508 was in pain. 8/23/23 2:32 PM - The MAR documented a pain medication for his knee was administered, three hours after R508 rang the call bell for pain medication. b. 8/15/23 - The MDS assessment documented that R508 had received a scheduled pain medication regimen, Received PRN pain medications or was offered and declined and did not receive non-medication intervention for pain. Pain presence in last 5 days was yes. Pain frequency was almost constantly. Over the past 5 days has pain made it hard for the resident to sleep at night. Over the past 5 days the pain did not limit your day-to-day activity NO. Pain intensity Numeric rating was a 10 on a 0-10 scale. 8/15/23 - A palliative care consult note documented that Given [R508's] near-constant joint pain, I believe it is reasonable to increase his MS Contin (morphine) 30 mg from every 12 hours to TID and we will keep his PRN oxycodone as it is. 8/18/23 1:52 PM - A late entry progress note documented that R508 went for a palliative care appointment today. Spoke to family who wants morphine sulfate ordered three times a day. The physician was notified and made aware. Also, passed on to this information to the oncoming nurse. 8/22/23 5:57 PM - During an interview with FM1, it was revealed that the facility does not listen, it was promised to me last Thursday (8/17/23) someone would follow up on the morphine recommendation from the palliative care practitioner. The recommendation was to increase the morphine order from two times to three times a day. FM1 gave the document to the facility when returned from the appointment that day. FM1 stated [E28 (MD)] was supposed to get it and on Thursday. FM1 stated I approached [E4 (UM)] and asked where the paperwork from the palliative care practitioner was, [E4] did not know. It was further revealed There has not been a medication change to date. A request was made by the surveyor to E1 (NHA) for R508's palliative care visit consult note, but it was never received. 8/23/23 4:00 PM - An order for MS Contin (morphine sulfate) oral tablet extended release 30 mg give 1 tablet by mouth every 8 hours for pain. The recommendation from the palliative care specialist to increase the morphine sulfate from every 12 hours to every 8 hours on 8/15/23 was never acted on until seven days later. 9/6/23 4:14 PM - During an interview E28, revealed he was not aware of the recommendation from the palliative care specialist until 8/22/23 when E25 (SW) inquired about the medication change. E28 further revealed that he had felt R508's pain was doing better and indicated that the resident was never in unmanaged pain. 9/8/23 at 12:30 - Findings were reviewed with E1 (Nursing Home Administrator), E2 (Regional Clinical Director), and E3 (Director of Nursing).

Based on interviews, review of a clinical record, and facility and staff agency (SA) documentation as indicated, it was determined that the facility failed to have a system in place to ensure that four (E9, E12, E23 and E24) out of four (4) licensed agency nurses working in the facility during the year of 2020 were oriented to the facility's practices, trained, and/or had competency and skills assessed prior to providing resident care. For E12, a newly hired agency LPN, the facility failed to ensure that E12 had specific orientation and training to facility practices prior to providing care to residents, which was necessary to care for and to assure the safety of R3, a newly admitted resident. As a result of the facility's failure, R3 had a serious adverse outcome, death. An immediate jeopardy (IJ) was called on 1/22/2021 at 3 PM and was removed on 1/22/2021 at 6 PM based on corrective actions implemented by the facility. The deficient practice continued at a scope and severity of E after the IJ was removed. Findings include: 1. Cross refer to F760 E12, a newly hired agency LPN from SA (Staffing Agency) #1, worked a double shift from 2:45 PM on Friday, 12/4/2020, to 6:45 AM on 12/5/2020. This was E12's first time working in the facility. At 12:05 AM, E12 received a new admission from the hospital. E12 did not complete the admission process, which included entering the 13 prescribed medications and accuchecks into R3's electronic medical record and E12 did not communicate this critical information during the shift report to the oncoming nurse. R3 went for 30 hours after admission to the facility without receiving any medications or accuchecks. R3 was found unresponsive and was pronounced dead on 12/6/2020 at 6:25 AM. 12/7/2020 - The conclusion of the facility's investigation into the 12/6/2020 death of R3 in the facility, included, but was not limited to, that R3's code status, physician orders, quick ADT (Admission Discharge Transfer), and admission assessments were not completed. The investigation failed to identify that the facility lacked a system for ensuring that licensed agency staff were oriented to the facility's practices which were necessary to provide care before starting to work in the facility. 12/8/2020 at 2 PM - E12 (agency LPN) was interviewed via telephone by E1 (NHA) and E3 (agency DON). E12 stated, . I know when the admission arrived . 11-7 only nurse on the floor. Two EMTs gave me brown envelope at approx. 1:00 am . never got a call from hospital with report. Open packet & (and) saw pts (patient's) name . Called NP (E29) & verified medications & approved. I did not enter the medications into the computer. Report given (sic) the oncoming nurse 7-3 . I don't know how to put medications back into computer. I did not ask for help. By that time I didn't have time to put them in doing pt care. I understand that I am responsible for the pt. Despite E12's written statement that report was given to the oncoming nurse, the receiving nurse contradicted E12's statement that critical information involving R3's admission process was not passed on. 12/10/2020 at 11 AM - An email sent from E30 (facility's Scheduling Coordinator) to three nurse staffing agencies (SA #1, SA #2 and SA #3) stated, Going forward we're asking that all new nurses and new CNA's that you send in to work at manor care schedule a time to come in before their shift. It is important that the nurses come in for education training and to be put into the time clock and the same goes for the cna's so that they may chart and clock in . 1/21/2021 at 10:56 AM - During an interview, E26 (RN) stated that she has worked in the facility since June 2018 and was promoted to Supervisor in September 2020. E26 stated she was assisting E4 (ADON) with educating all licensed nurses on the admission process in response to the 12/6/2020 incident with R3. When asked about the facility's process for agency nurses before they start providing care on the floor, E26 stated that they have to go to payroll and then to human resources to obtain their sign-in information. E26 stated that she had never oriented an agency nurse to the facility's policies and procedures before they started working on the floor prior to the changes made in mid-December. 1/21/2021 at 11:23 AM - During an interview, E1 (NHA) confirmed there was no facility orientation for licensed agency nurses before working on the floor until after the 12/6/2020 incident with R3. E1 stated the facility initiated a new form entitled Agency Orientation Checklist on 12/10/2020. 1/22/2021 at 9:16 AM - During an interview, E7 (RN) stated that she started educating licensed agency nurses about the new Agency Orientation Checklist in mid-December 2020. E7 stated that the facility's agency orientation process takes about 45 minutes. E7 stated that the agency nurses have to know how to document in the electronic medical record, including entering physician orders, otherwise they cannot work. E7 stated that the facility educator and the licensed agency nurse are required to sign and date the new Agency Orientation Checklist to ensure completion. 1/22/2021 at 3 PM - After the surveyor's consultation with the State Agency, E1 (NHA) was notified that an IJ was being called for the facility's failure to have a system in place to ensure that new agency staff had specific orientation and training to the facility's practices prior to providing care. l/22/2021 at 6 PM - The IJ was removed after the facility implemented the following removal plan: -All agency staff currently in the building on 1/22/2021 at 4:25 PM were oriented to the facility and documentation was provided. -The staff coordinator will contact the staffing agency to schedule orientation prior to the first day of a scheduled shift. The agency and/or agency employee contacts the staffing coordinator with a designated time. Thereafter, the staff development coordinator and/or designee will provide all of the required education prior to the first shift worked. -The unit managers/supervisors will check the agency training binder every shift to ensure those agency staff scheduled to work have been properly trained. If an agency employee is identified as not having been trained, the unit manager/supervisor will schedule to train the agency employee(s) prior to the shift that day or take them off the schedule until training has been completed. 2. In addition to the lack of orientation to the facility practices as outlined in example #1 above, the facility lacked evidence of E12's competencies and skills as per the facility's signed agreement with SA #1. On 1/24/2020, the facility signed an agreement with SA #1 where they would provide temporary nursing staff. The agreement stated that SA #1 would maintain an employee's comprehensive skills inventory that was appropriate to the job classification and age-specific self-assessment; the facility had the right to request copies of documents concerning the qualifications of the staff placed by SA #1; and the facility would provide written policies and procedures for patient care. Review of the facility's payroll records revealed that E12, a licensed agency LPN from SA #1, worked from 12/4/2020 at 2:45 PM through 12/5/2020 at 6:45 AM. This was the first time E12 worked in the facility. After reviewing the agreement between SA #1 and the facility, the surveyor asked for documentation of E12's comprehensive skills inventory from SA #1. E1 (NHA) provided the surveyor with a copy of another skilled nursing home's form, dated 1/8/2020, that E1 received directly from SA #1 as evidence that E12 had the required skills and competencies. The form had no evidence of the specific education, skills and/or competencies completed by a nursing educator. 1/21/2021 at 11:23 AM - During an interview, E1 (NHA) confirmed that the facility did not have a system in place to ensure that licensed agency nurses were oriented, trained and/or competent before providing care to residents. 3. Review of the facility's payroll documentation revealed that E23, a licensed agency RN from SA #1, started working in the facility on 7/14/2020. During the survey, the surveyor asked for documentation of E23's comprehensive skills inventory from SA #1. E1 (NHA) provided the surveyor with a copy of another skilled nursing home's form, undated, that she received directly from SA #1 as evidence that E23 had the required skills and/or competencies. This was the exact form provided for E12 in the above example. The form had no evidence of the specific education, skills and/or competencies completed by a nursing educator. In response to the surveyor's request during the survey and 24 hours post exit conference, the facility lacked evidence of E23's orientation to the facility practices and lacked evidence of E23's education, skills and/or competencies from SA #1 prior to working her first shift in the facility on 7/14/2020. 4. Review of the facility's payroll documentation revealed that E9, a licensed agency RN from SA #2, started working in the facility on 8/7/2020. In response to the surveyor's request during the survey and 24 hours post exit conference, the facility lacked evidence of E9's orientation to the facility practices and lacked evidence of E9's training and/or competencies from SA #2 prior to working her first shift in the facility on 8/7/2020. 5. Review of the facility's payroll documentation revealed that E24, a licensed agency RN from SA #3, started working in the facility on 2/20/2020. In response to the surveyor's request, the facility provided evidence that on 11/1/2019 a licensed RN trainer with SA #3 conducted new hire and skills orientation/inservices with E24 on the following subjects, including, but was not limited to: communication; documentation: POC/EMAR; recognizing, preventing and reporting patient abuse/neglect/exploitation; and department specific skills competency inservice for nurses. Despite the evidence provided by SA #3, the facility lacked evidence during the survey and 24 hours post exit conference that E24 was oriented to the facility's practices prior to her starting her first shift on 2/20/2020. It was not until 1/24/2021 that E24 received a one-on-one in-service on the new Agency Orientation Checklist by E26 (facility RN Supervisor). 1/25/2021 at 4:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (MNHA), E5 (RDOO) and E6 (IQAC).

Based on interviews, review of clinical records and facility documentation as indicated, it was determined that for one (R3) out of three (3) sampled residents reviewed for CPR, the facility failed to ensure that R3's thirteen (13) prescribed medications, including insulins, were entered into the resident's electronic medical record during the admission process after her arrival from the hospital with complications from diabetes at 12:05 AM on Saturday morning, [DATE]. As a result, R3 never received any of her prescribed medications and no accuchecks were performed for the next 30 hours. At 6 AM on Sunday, [DATE], R3 was found unresponsive and was pronounced dead in the facility by the Paramedics at 6:25 AM. The facility's failure placed R3 in a situation with a serious adverse outcome, death. On [DATE], an immediate jeopardy (IJ) was identified as occurring on [DATE] and was removed on [DATE] based on corrective actions implemented by the facility. Findings include: Review of R3's clinical record revealed: [DATE] at 11:48 AM - The hospital's discharge summary stated, discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Primary goals are avoid [CONDITION(S)] and acute complications of [CONDITION(S)]/DKA . R3's hospital discharge medications were: - Insulin Asparte 1 to 11 units sliding scale based on accuchecks, SQ, scheduled before meals - used to treat diabetes; - Insulin Asparte 3 units SQ, scheduled before meals - used to treat diabetes; - Insulin [MEDICATION(S)] 10 units SQ every day - used to treat diabetes; - [MEDICATION(S)] 112 mcg oral tablet every day - used to treat hypothyroidism; - [MEDICATION(S)] 2.5 mg oral tablet two times a day - used to treat aFib; - [MEDICATION(S)] 80 mg oral tablet every day - used to treat high cholesterol; - [MEDICATION(S)] extended release 150 mg oral tablet every 24 hours - used to treat depression; - [MEDICATION(S)] 5 mg oral tablet with breakfast and lunch - used as a dietary supplement; - [MEDICATION(S)] 12.5 mg oral tablet two times a day - used to treat high blood pressure; - [MEDICATION(S)] 15 mg oral tablet at bedtime - used to treat depression; - [MEDICATION(S)] 5 mg oral disintegrating tablet at bedtime - used to treat depression; - [MEDICATION(S)] delayed release 40 mg capsule two times a day - used to treat gastric reflux; - [MEDICATION(S)] 90 mcg inhalation aerosol 2 puffs every 6 hours as needed for cough, wheeze. [DATE] at 12:05 AM - R3 was admitted to the facility status post [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] - According to the CNA Documentation report: - at 9:37 AM, R3 refused to eat breakfast; - at 1:53 PM, R3 ate 25% of lunch; - at 6:29 PM, R3 ate 25% of dinner and refused a bedtime snack. [DATE] at 10:52 PM - A nurse's note, documented by E22 (RN), stated, Res (Resident) awake and alert. One episode of vomiting undigested food prior to dinner. Res stated her stomach felt better after vomiting. Denied anymore nausea. Bowel sounds positive . abdomen soft non-tender. Appetite at dinner was poor, res ate ice cream and two spoons of soup. Res only accepted small sips of fluids. On-call provider made aware of vomiting episode . [DATE] at 6:25 AM - According to the Prehospital Report by the Paramedics, R3's . Skin . pale . cool . jaw was in full rigor, incompatible with life . [DATE] at 7:36 AM - A nurse's note, documented by E25 (RN), stated, .made aware by CNA and RN that patient was unresponsive in room. When arrived in room at (6 AM) pt had no pulse and was unresponsive. Code blue called and CPR started at (6:02 AM). CPR given until EMS arrival (6:15 AM). [DATE] (untimed) - The facility's investigation report concluded, but was not limited to, that R3's admission process was incomplete, including entering R3's physician orders, quick ADT (Admission Discharge Transfer) and code status and completion of the nursing admission assessments. The facility's investigation included the following nursing staff statements: - E12 (agency LPN) worked a double shift from 2:45 PM on Friday, [DATE], to 6:45 AM on [DATE]. E12 stated, . I know when the admission arrived . ,d+[DATE] only nurse on the floor. Two EMTs gave me brown envelope at approx. 1:00 am . never got a call from hospital with report. Open packet (sic) & saw pts (patient's) name . Called NP (E29) & verified medications & approved. I did not enter the medications into the computer. Report given the oncoming nurse ,d+[DATE] . I don't know how to put medications back into computer. I did not ask for help. By that time I didn't have time to put them in doing pt care. I understand that I am responsible for the pt. (Interview conducted [DATE] at 2 PM) - E18 (LPN) worked 6:45 AM to 2:45 PM on Saturday, [DATE]. E18 stated, . Night nurse (E12) came back and we did the count. I asked her for a brief report and she touched on a few pts .finished counting other cart. In the middle of the last cart, CNA . came up & asked me about a patient. Night nurse (E12) agitated had worked 2 shifts had to go boyfriend waiting for her. I counted the other cart with her because that nurse was still on phone. I never was told there was a new admission. I was never told that there was (sic) things I needed to follow-up on. I saw in the computer there was a pt in that room. I asked CNA to get the vitals . During med pass I clicked on her & didn't see any medications. I did see routine orders, but no medications . (Interview conducted [DATE] at 3 PM) - E22 (RN) worked 2:45 PM to 10:45 PM on Saturday, [DATE]. E22 stated, . I had (R3) on my assignment. I was given report on (R3). Resident had no medications on day shift to be given. I was told patient came in the day before but nothing else. No diagnosis . Did not eat for the CNA, I attempted to feed her. She took some ice cream & 2 spoonful of soup and then she did not eat anymore . (Interview conducted l[DATE] at 6:45 PM with follow up [DATE] at 2:30 PM) - E25 (RN) worked 10:45 PM on Saturday, [DATE], to 6:45 AM on Sunday, [DATE]. E25 stated, (name of R3) coded on Sunday morning. CNA made me aware of unresponsive pt after RN asked her to grab another nurse. When I got to the room patient was unresponsive with no pulse. CPR initiated immediately . EMS arrived and pronounce (sic) pt. (Interview conducted [DATE] at 7:50 AM) [DATE] at 11:18 AM - During an interview, E3 (agency DON) stated that the facility became aware that E12 (agency LPN) did not know how to enter physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In response, E3 stated that the facility conducted an audit of residents admitted in the past 14 days and were still present in the facility; they changed the admission process by combining multiple admission forms and initiated an Admission Checklist packet; and they educated licensed nurses (including agency) individually on the new process using the Admission Checklist packet. E3 stated that new admissions and readmissions are reviewed in the morning clinical meeting at 9 AM Monday through Friday. On weekends, E4 (ADON) or the on call unit managers are spot checking that orders were being entered for new admissions/readmissions. Following the interview, E3 provided the surveyor with a copy of the Admission Checklist packet and evidence of the monitoring plan the facility implemented. [DATE] at 3:50 PM - An IJ was called in the presence of E2 (MNHA), E3 (agency DON) and E6 (IQAC). The facility's IJ removal date was identified as [DATE] after the following was completed: -An audit was performed to ensure current admissions/readmissions in the past 14 days were not immediately affected; -The Admission Checklist packet was initiated as an internal tool for licensed nursing staff to ensure completion of the admission process; -The licensed nursing staff directly involved in the [DATE] incident were educated; -All agency staff currently in the building on [DATE] were oriented to the facility and documentation provided; -A plan was developed to ensure all agency nursing staff were oriented prior to working at the facility. [DATE] at 4:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (MNHA), E5 (RDOO) and E6 (IQAC).

Based on review of clinical records, interviews, review of other facility documentation, and the Emergency Medical Services (EMS) report, it was determined that for one (R1) out of three sampled residents reviewed for CPR, the facility failed to provide basic life support, including CPR, to R1 who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at approximately 2:30 PM, R1 was found unresponsive and was assessed to be without a pulse or respirations and R1 had fixed (non-responsive) pupils. Despite this, the facility failed to call 911 until [DATE] at 3:50 PM (one hour and 20 minutes later). EMS staff arrived at the facility at 4:00 PM and initiated CPR at 4:01 PM. R1 was pronounced as deceased by EMS at 4:40 PM on [DATE]. The facility's failure placed R1 in a situation with a serious adverse outcome, death. This deficiency was determined to be past-non-compliance. Findings include: The facility's policy and procedure entitled Emergency Management, last revised ,d+[DATE], stated, .Emergency Response Guidelines: To establish a process defining the roles and responsibilities of nursing staff involved in the care of a patient in an emergent situation: -First person to arrive at the scene calls for assistance either by voice or emergency call light system. Notify nurse immediately, if first staff to arrive is not a nurse. Do not leave the patient alone unless immediate response is anticipated. -First licensed nurse that arrives on the scene. Evaluates patient level of consciousness, circulation, airway and breathing. Directs additional licensed nurse to review chart for living will or do not resuscitate (DNR) documentation, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .g. Code Blue, Paging Dr. Blue, etc.) . Review of R1's clinical record revealed the following: [DATE] - R1 was readmitted to the facility from the hospital and had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] 6:12 PM - A Nursing Progress Note by E9 (agency RN) stated, .The RN (E9)was alerted to room by staff due to change in patient's condition. Patient was found unresponsive, without apical pulse (heartbeat), respiration or pupil response. Administration was notified (Name of Nurse Practitioner, E16) and EMS was notified. Patient pronounced dead at 16:40 (4:40 PM). Patient daughter at bedside . [DATE] - The EMS report stated that they received the 911 call from the facility regarding R1 at 3:50 PM on [DATE], EMS staff arrived at the facility at 4:00 PM, initiated CPR on R1 at 4:01 PM, and pronounced R1 as deceased at 4:40 PM. [DATE] 4:00 PM- The facility identified their failure and instituted a plan to ensure the failure would not occur again. On [DATE] the facility plan included: - [DATE] 8:00 AM: The facility contacted E9's (agency RN's) Contracted Nursing Staffing Agency and requested that E9 be placed on the facility's Do Not Send List. - [DATE]: The facility initiated an in-service of all Contracted Nursing Agency staff prior to them working at the facility. - [DATE] 8:00 AM to 4:00 PM: The facility initiated in-service education with current licensed nursing staff and completed 26 of 31 staff education. - The facility had a plan in place to ensure the remaining five current licensed nursing staff were in-serviced prior to their returning to work at the facility which was implemented. [DATE] 1:15 PM - An interview with E3 (agency DON) was conducted. E3 stated on [DATE], R1 was found unresponsive and was assessed by the assigned nurse, E9 (agency RN). R1 had no pulse, no respirations, and no pupil response. R1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . E3 stated that she was made aware of the incident upon her return to the facility on [DATE] and she started an investigation of the incident. As a result of the investigation, it was revealed that licensed nurse education was required for emergency management of residents to include Code Protocol and CPR. [DATE] from 2:30 PM to 3:15 PM - Interviews were conducted with six licensed nurses, E8 (RN UM), E13 (agency LPN), E14 (agency LPN), E17 (LPN), E18 (LPN), and E19 (LPN). Two (2) were Contracted Agency Licensed Nurses, E13 and E14. All were able to verbalize where to locate the resident's Code Status and what actions were to be taken if they encountered an unresponsive resident. In addition, all six licensed nurses confirmed that they had recently received in-service education on emergency management. [DATE] at 9:05 AM - A telephone interview was conducted with E9 (agency RN). E9 stated that she was notified by E10 (Housekeeper) on [DATE] at approximately 2:30 PM that R1 appeared to be dead and E9 proceeded to assess the resident immediately. R1 was without a pulse or respirations and R1's pupils were not reactive. E9 stated that R1's skin was warm to touch. E9 went to the Nurse's Station to access the facility's electronic medical records and E9 realized his [R1] Code status was Full Code. E9 stated that she found out R1's Code status about ,d+[DATE] minutes after assessing R1, at approximately 2:40 PM. After identifying R1's Code status, E9 confirmed that she did not initiate the code as required, by paging it overhead. Instead, E9 telephoned E4 (ADON) who worked earlier during the day shift and had since left the facility. E9 stated that she called E4, but there was no answer. E9 was unable to provide the approximate times that she called E4. E9 called again and spoke with E4. E9 informed E4 that R1 expired and after E9's assessment, she realized that R1 was a Full Code. E9 stated that E4 instructed E9 to call the On-Call medical provider to review the circumstance and to call 911. E9 called the on-call Medical Practitioner, E16 (NP) to review the situation. E9 confirmed that no emergency care was provided to R1, including CPR by any staff in the facility and that CPR was initiated by EMS at approximately 4:00 PM. E9 stated that she has worked at the facility on an as needed basis, mostly on the weekends since 2019. E9 stated that she had previously provided care to R1. E9 was asked whether she received orientation to the facility before she started to work at the facility. E9 stated, No, however, on [DATE], E9 confirmed that she received an in-service on emergency management, including where to ascertain a resident's Code status and the actions to be taken when a resident was found unresponsive without a pulse or respirations. E9 stated, I really did not know when asked the reason she did not check the Code Status immediately after assessing R1 and why she did not initiate emergency care, including CPR. [DATE] - The Surveyor was provided a written statement from E4 (ADON) which stated, I [E4] was notified on [DATE] at 3:19 PM (approximately 50 minutes after E9 [agency RN] assessed R1 via voicemail message from E9 that she had a death and wanted to know what to do and E9 stated that she had given notification to family and that the family wanted to come to the facility. When E4 reached E9 at 3:24 PM, I then asked her whom the patient was and began to pull up his (R1's) chart in PCC (Point Click Care). I saw he was a full code. She stated she did not perform CPR and pronounced (R1's name). I instructed her to initiate CPR, call 911 and notify MD asap (as soon as possible). I then notified the Administrator at 3:38 PM that a full code pt. (patient) was not given CPR. I spoke with her (E9) again at 4:04 PM and she said (sic) notified 911 and she wanted to know what to do about the family and if they can come in the facility .While talking to (E9's name) and making her aware of the issue with the patient not being coded, she began to get upset and stated, I know better! I spoke with Administrator at 4:33 PM and updated her on the event. [DATE] 3:50 PM - A meeting was held with E2 (MNHA) and the facility was notified of the IJ. [DATE] 4:45 PM- After the survey team confirmed the facility's plan was put in place on [DATE], it was determined the IJ was past non-compliance. The surveyor determined past non-compliance IJ based on confirmation that the facility's plan was in place and completed on [DATE]. [DATE] 4:30 PM - Findings were reviewed with E1 (NHA), E2 (MNHA), E5 (RDOO), and E6 (IQAC) during the Exit Conference.

Based on clinical record review, interview and review of facility documentation as indicated, it was determined that for 1 (R81) out of 3 sampled residents, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible. For R81, an unsafe transfer was performed using a sit to stand mechanical lift with only one CNA, resulting in a fracture of R81's right ankle. The unsafe transfer caused R81 harm. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey for F689, the specific regulatory requirement, the deficiency was determined to be past non-compliance. Findings include: The facility's policy entitled Mechanical Lift, last revised on 1/2014, stated, Purpose: To move immobile or obese patients for whom manual transfer poses potential for staff or patient injury .Note: Although one person can operate most models of mechanical lifts, it's advisable to have two staff members present to stabilize and support the patient .C. Selecting Appropriate Lifting Devices. Determining the method for transferring a patient is a serious matter and cannot be taken lightly; the risk of injury to the patient or the employee is too great. Understanding key characteristics of a patient's condition will assist the employee in completing safe transfers. Specific methods of transferring and lifting are designated for each patient. Different methods may be necessary for different tasks; these designated methods are clearly recorded and accessible to all staff performing lifting and transferring tasks and contained in the Care Plan. This information is communicated through the Care Plan assignment and the Kardex found in the P[NAME] system . Review of R81's clinical record revealed: 12/12/18 - R81 was admitted to the facility for rehabilitation with [DIAGNOSES REDACTED]. 12/13/18 (last revised) - R81 was care planned for being at risk for falls due to weakness and a history of falls. The approaches included, but were not limited to, provide assistance to transfer and refer to the therapy plan of treatment in the medical record for more detail. 12/13/18 (last revised) - R81 was care planned for ADL self care deficit related to physical limitations. The approaches included, but were not limited to, ADL assist-mechanical lift with purple sling for toileting transfers with 2 person assist. 12/19/18 - R81's admission MDS assessment stated that the resident was cognitively intact, required extensive assistance of 2 staff people for transfers and toileting, was 5 feet 3 inches tall and weighed 248 lbs. 12/26/18 - The CNA Kardex stated, ADL Assist- Transfer to toilet with the use of stand up lift with purple sling and 2 people. The facility's investigation report and supporting documents stated the following: - 1/2/19 at 3 PM - R81 was being transferred using a sit to stand lift in the resident's bathroom with the assistance of one CNA, E12. Patient's care plan and Kardex listed (R81) as an extensive assist with sit to stand lift and two person assist .During transfer (R81) attempted multiple times to adjust lower extremity. (R81) returned to toilet for rest break. After rest break transfer attempted and resulted in (R81)losing (his/her) balance/footing. - 1/2/19 (untimed) - E12's (CNA) initial statement stated, I didn't care for patient but I did assist with toileting. Patient stated (he/she) didn't want a 'gender' taking (him/her) to the bathroom so E14 (CNA) stood outside bathroom while I helped patient. As I began to take patient off the toilet, (he/she) asked to be sat back down due to leg buckling (sic). I sat patient back down. As we tried a second time, I pull (sic) patient close up before we moved, patient leg buckled. While still holding on to lift, E14 (CNA) then came to assist. - 1/3/19 (untimed) - R81's initial statement: Some time after dinner, I asked the CNA (E12) to take me to the bathroom. The CNA asked me, 'Do you use the stand up lift?' I stated yes. CNA then left (sic) room and returned with the stand up lift. Then I asked CNA, 'Are you doing this by yourself?' CNA stated, 'By the time I go get someone, you would have mess (sic) yourself.' CNA then hooked me up to the standup lift, she placed my feet at the base of the lift, made sure my knees were in place, the sling to stand up did not fit around my waist. CNA lifted me up with stand up and transported me from the w/c to the toilet. When the CNA started to lower me to the toilet, the standup gave way and I came down on my right leg. At this point I was holding on to the lift, to keep myself from falling, while the CNA left to get help. CNA returned with another CNA (E14) and they got me to the toilet . 1/3/19 at 1:35 PM - The hospital record stated that R81's discharge [DIAGNOSES REDACTED]. Additional statements obtained during the facility's investigation included: - 1/4/19 (untimed) - E14's (CNA) statement: I was called in by CNA (E12) to assist pt (patient) to get off the toilet via stand up lift. Pt was already sitting on toilet. At that time pt asked me to leave because (he/she) preferred no 'gender' while being cleaned up. I stepped out into the hallway to wait. I was called back into the bathroom by the aide, attends were pulled up. (He/She) was in a collapsed position where both knees were buckled and (his/her) right ankle was rolled out. We then notified the nurse of patient status. - 1/7/19 (untimed) - E12's (CNA) second statement: .R81 did not want a 'gender' helping .with the bathroom .I went down there to put the patient on the stand up lift outside the bathroom door .E14 (CNA) was outside the room popping in and out because (he/she) was looking for a different sling for the stand-up lift. I lifted the patient up onto the stand-up lift and then brought the patient into the bathroom while on the lift. I sat (him/her) down onto the toilet .When I came back .I put the lift back on the patient securely. I attempted to stand the patient; (his/her) leg wouldn't get adjusted in the lift. (He/She) kept grabbing it and bringing it back on the lift. Once (he/she) did that, I stood (him/her) up and that same leg was giving (him/her) trouble, (he/she) said put me back down. So I put (him/her) back down. I sat (hIm/her) back on the toilet to give (him/her) 2-3 minute rest. I asked (him/her) if (he/she) was ready to try again. (He/She) said yes. The second time, I stood (him/her) back up and pulled up (his/her) brief. I must have been turned around because I didn't witness patient actually drop down in the lift. When I turned to look at (him/her), I noticed (he/she) was slouched down in the lift holding onto the bars in a squatted position. (His/Her) feet came off the lift and were on the floor. I tried to put (him/her) back onto the toilet but was unable to. E14 (CNA) was outside the room and I asked (him/her) to come in for help .The stand-up lift did not malfunction .Patient didn't complain of any pain. Patient asked me if it was broken . - 1/7/19 (untimed) - R81's second statement: I had to use the bathroom. E12 (CNA) came into the room with the stand-up lift. I asked (him/her) if (he/she) needed a second person and (E12) said no it was fine because (E12) had worked here for a while. CNA put me on the lift and began to transfer me to the toilet. My foot kept popping off of the foot rest on the lift and I had to keep putting it back on the lift. I think there was an issue with the lift because the CNA kept putting it up and down. At some point the lift crashed down and I was hanging from the lift. My foot was 'flopping'. The CNA went and got E14 (CNA) to assist and they both put me back on the toilet .The Nurse Practitioner (E13) came in to see me. I told her I have no feeling from the knee down from a previous break. I didn't have any pain at that time. In the morning right before I left for [MEDICAL TREATMENT] I started to have some discomfort in that foot. While at [MEDICAL TREATMENT] the pain got worse and they sent me to the ER for an x-ray which showed that it was broken. - 1/11/19 (untimed) - A progress note, written by E16 (physician), stated that R81 told him, I was in a .lift in the restroom with my aide and was lifted above the commode when suddenly the .lift gave out and I came crashing to the floor in the bathroom and my right leg became twisted underneath me. 1/16/19 - The actions taken during the facility's investigation included, but were not limited to, the following: 1. E12 (CNA) was suspended pending the investigation; 2. Sit to stand mechanical lift was removed from the floor and inspected by the service company; 3. Therapy evaluation completed and transfer status clarified; 4. Care plan updated. 1/18/19 - Based on the completion of the investigation, the facility issued E12 (CNA) a first written warning as E12 did not have previous warnings. E12 was educated regarding the facility's policy and procedure for transferring residents and was required to demonstrate her skills using mechanical lifts before resuming her duties on the floor. Based on the facility's thorough investigation, the root cause analysis identified that the facility failed to properly follow the patient's plan of care when transferring a patient which resulted in injury. Recognizing the failure, the facility immediately initiated a Performance Improvement Plan (PIP) to ensure patient safety during mechanical lift transfers. The PIP interdisciplinary team met weekly to measure progress. The interventions included the following: - Identification: Reviewed patients who required a mechanical sit to stand lift to determine if there was a [DIAGNOSES REDACTED]. - Human Resources Audit: Human Resources will audit nursing new hires within the last year to validate skills checklist were completed/handed in; - Therapy Evaluation: Therapy will evaluate patients currently listed as a mechanical sit to stand transfer to validate that transfer remains appropriate; - Lift Program Skills: Check off sheets being performed with CNA's on mechanical lift transfers with return demonstration; - Care Plan Review: Care plans were reviewed for patients who require the mechanical lift for transfers to ensure sling color and 2 person assist were included on the transfer status; - Education: Staff Development/Designee will educate licensed nurses on the lockout/tagout program and reporting it on TELs. Education on recognizing when a patient is not tolerating transfers/care and immediately stopping. - Education: Staff development/Designee will educate CNAs to review kardex prior to transferring a patient, utilizing 2 person assist for mechanical lifts, recognizing when a patient is not tolerating transfer/care and immediately stopping, education on lockout/tagout program and reporting on TELs. - Audits: Unit managers to perform random checks on staff members utilizing a mechanical lift to ensure the use of 2 person, proper lift and sling being used. In addition, all mechanical lifts used in the facility were evaluated for any problems by the service company's technician. 2/1/19 - The facility's Performance Improvement Plan in response to the 1/2/19 incident involving R81 was determined to be successful. 3/6/19 at approximately 12:30 PM - During a combined interview with E2 (DON), E3 (ADON) and E17 (Corp. Nurse), findings were reviewed. The facility confirmed that an unsafe mechanical lift transfer was performed by E12 (CNA), resulting in R81's [MEDICAL CONDITION] ankle. The facility conducted a thorough investigation and identified this failure. The facility immediately initiated a Performance Improvement Plan with multiple interventions to ensure patient safety during mechanical lift transfers. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey for F689, the specific regulatory requirement, the deficiency was determined to be past non-compliance.

Based on interviews and reviews of the residents' clinical records, facility documentation, hospital records and nursing standards of practice, it was determined that for two (R379 and R88) out of 55 sampled residents, the facility failed to ensure that the residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. For R379, the facility failed to perform complete neurological assessments of R379 after her 8/14/17 fall; failed to identify abnormal neurological assessment findings; failed to consider the potential of head and/or cervical trauma based on the [MEDICATION NAME] mechanism of R379's fall, the assessment observations of R379's laceration to the left eyebrow and forehead, swelling and hematoma on the left side of her face, incoherent sentences after the fall, and unstable vital signs; and failed to immediately call 911 to transfer her to the emergency room (ER) for evaluation and treatment after a physician's orders [REDACTED]. R379 was received and assessed as a Trauma Code in the ER, underwent surgery for [REDACTED]. In addition, the facility failed to monitor R379's blood pressure and heart rate prior to administering her two anti-hypertensive medications upon readmission to the facility on [DATE]. The facility failed to follow a physician's orders [REDACTED]. For R88, the facility failed to obtain a physician's orders [REDACTED]. Findings include: Mosby's nursing book entitled Medical-Surgical Nursing: Assessment and Management of Clinical Problems 6th Edition, dated 2004, stated, .Spinal Cord Trauma .Causes of spinal cord injury include .falls .After stabilization at the accident scene, the person is transferred to a medical facility .Fractures can occur as a result of .[MEDICATION NAME] trauma .All patients with facial injuries should be treated as though they have a cervical injury until proven otherwise by examination and imaging studies . Mosby's nursing book entitled Priorities in Critical Care Nursing 5th edition, dated 2008, stated, .Trauma .[MEDICATION NAME] trauma is seen most often with .falls. Injuries occur because of the forces sustained during a rapid change in velocity (decleration) .The goal of prehospital care is immediate stabilization and transportation. This is achieved through .immobilization of the patient, and immediate transport .to the closest appropriate medical facility. Personnel providing prehospital care should also communicate information needed for triage at the hospital. Nursing management of the patient with traumatic injuries begins the moment a call for help is received .Assessment .The neurological assessment is the most important tool for evaluating the patient ., because it can indicate severity of injury, provide prognostic information, and dictate the speed with which further evaluation and treatment must proceed . The facility's policy entitled Mechanical Lift, last revised 1/2014, stated the Purpose: To move immobile or obese patients for whom manual transfer poses potential for staff or patient injury .Note: Although one person can operate most models of mechanical lifts, it's advisable to have two staff members present to stabilize and support the patient .Procedure: .6. Ask another caregiver to assist with positioning by standing on opposite side of the bed and having patient roll toward second caregiver, away from lift side .Note: Patient may be lifted from bed, chair or floor using similar steps with a mechanical lift . The facility's policy entitled Neurological: Neurological Evaluation, stated the Purpose: .used to establish a baseline neurological status upon which subsequent evaluations may be compared and changes in neurological status may be determined .Procedure: 1. Initiate and document a baseline neurological evaluation as indicated on the Neurological Evaluation Flow Sheet. 2. Notify physician of specific patient event, initial findings and baseline neurological evaluation. 3. Obtain orders for subsequent neurological evaluations .or other medical care as clinically indicated. 4. After the completion of initial neurological evaluation with vital signs, continue evaluations every 30-minutes x4 .NOTE: More frequent neurological evaluations may be necessary if clinically indicated .5. Subsequent neurological evaluation should be compared to baseline and previous neurological evaluations .8. Evaluate pupils. (It may be necessary to darken room or ask patient to close eyes for 30 seconds prior to evaluation.) Upon opening eyes, use a penlight or flashlight to evaluate Pupil Size and Pupil Reaction for both the left and right eyes. Document using the following responses: E=equal pupil size, U=unequal pupil size, R=reacts to light, NR=no reaction to light. 9. Evaluate motor movement by providing patient with simple motor commands. Document Y=Yes or N=No responses to the following: moves right and left upper limbs, moves right and left lower limbs, facial symmetry. 10. Evaluate communication/language by providing simple communication commands. Document Y=Yes or N=No responses to the following: [MEDICAL CONDITION], receptive [MEDICAL CONDITION], speech slurred, communication changes. 11. Evaluate for unusual/new observations. Document observation responses using the following: W=weakness, T=tremors, D=dizziness, H=headache, V=vision changes, N=numbness, O=other. 12. Evaluate vital signs. Record baseline vital signs and compare subsequent vital signs to baseline and previous evaluations. Document the following information: blood pressure, pulse, pulse ox % .temperature, respiration rate, respiration pattern - N=normal/regular/unlabored or AB=abnormal. NOTE: Pay close attention to respiratory patterns. Notify physician regarding any Abnormal findings or any changes in respiratory rate or pattern. NOTE: Notify physician of any neurological evaluation findings which are a change from baseline or previous evaluations . The facility's policy entitled Oxygen Administration, dated (YEAR), stated, Purpose: .During a respiratory emergency, it is appropriate for nursing to administer oxygen immediately and obtain physician's orders [REDACTED]. 1. Review of R379's clinical record and hospital records revealed the following: 9/30/15 - R379 was admitted to the facility with [DIAGNOSES REDACTED]. 3/16/16 - R379 was care planned for the following: - ADL Self Care Deficit related to physical limitations/deconditioning with an approach that included to transfer with a stand-up mechanical lift and 2 staff assist. - Falls, at risk for falls due to physical limitations/deconditioning related to balance/poor coordination with approaches that included, but not limited to, low bed (initiated 4/14/16), provide assistance for transferring as needed (initiated 4/14/16) and scoop/perimeter mattress (initiated 6/14/16). 6/21/17 - The quarterly MDS assessment stated that she had short-term and long-term memory problems, had no ability to recall the season/her room location/staff names or faces or that she was in a nursing home, required extensive assistance with 2 staff for transfers and was not steady - only able to stabilize with staff assistance for surface-to-surface transfer between bed and wheelchair. The assessment stated that R379 was 5 feet 1 inch tall and weighed 167 pounds. 8/13/17 at 2:45 PM - R379 fell out of wheelchair, without hitting her head. Post-fall nursing assessments, including neurological checks, of R379 revealed that she had no apparent injury or pain. Vital signs and neurological checks were stable. The facility's fall investigation stated that R379 had impaired balance/poor coordination during transitions and required foot rests for her wheelchair. 8/14/17 at 7:30 PM - R379 fell again. The facility's incident report, completed by E22 (RN), stated, .Location of Incident: Patient's room .CNA reported that patient had a fall upon being transferred with a stand-up lift from wheelchair. On assessment, patient was noted with a hematoma on the left side of her forehead .Was physician notified? Yes .8/14/17 8:00 PM .Physician name: E26 (NP). By whom notified: E22 (RN) .Describe care and medications, if any, provided to patient following incident, and by whom provided: Neurochecks initaiated (sic). Ice pack applied to hematoma on L (left) side of face. Was patient taken to a hospital? Yes. If yes, Date: 14-Aug-2017 9:30 PM .(Family) Date notified: 8/14/17 8:30 PM .Phone conversation. Name of staff person notifying: E22 (RN) . 8/14/17 at 7:40 PM - The first neurological assessment, performed by E22, revealed that R379 was alert, oriented to person; left pupil reaction had no reaction to light; right pupil reacted to light; R & L pupil sizes lacked assessment; able to move 4 limbs; facial symmetry lacked assessment; no communication/language changes were noted; unusual/new observations were not noted; vital signs: BP 155/134, pulse 91, pulse ox 99%, temperature 97.6 degrees F, respirations 18. The facility failed to perform a complete assessment of R379's neurological status. In addition, the facility failed to identify abnormal neurological findings. 8/14/17 at 8:10 PM - The second neurological assessment, performed by E22, revealed that R379's left pupil continued to have no reaction to light; R & L pupil sizes lacked assessment; R379's left lower limb movement lacked assessment; facial symmetry lacked assessment; vital signs were BP 155/111, pulse 119, pulse ox 90%, temperature 97.8 degrees F, respirations 18. The facility failed to perform a complete assessment of R379's neurological status and failed to identify abnormal neurological findings and vital signs. It was unclear in R379's clinical record whether she was administered oxygen via nasal cannula at this time when her pulse ox was 90%. 8/14/17 at 8:40 PM - The third neurological assessment, performed by E22, revealed that R379's left pupil continued to have no reaction to light; R & L pupil sizes lacked assessment; R379's left lower limb movement lacked assessment; facial symmetry lacked assessment; vital signs were BP 150/59, pulse 96, pulse ox 92%, temperature 97.6 degrees F, respirations 18. The facility failed to perform a complete assessment of R379's neurological status and failed to identify abnormal neurological findings. 8/14/17 at 9:04 PM - E22 recorded R379's HR 110 and pulse ox 94% on (undocumented) liters of oxygen via nasal cannula. It was unclear as to when the administration and how many liters of oxygen via nasal cannula was started as R379's clinical record lacked evidence of documentation. 8/14/17 at 9:17 PM - E22 called 911. 8/14/17 at 9:20 PM - The fourth neurological assessment, performed by E22, revealed that R379's left pupil continued to have no reaction to light; R & L pupil sizes lacked assessment; R379's left lower limb movement lacked assessment; facial symmetry lacked assessment; vital signs were BP 154/60, pulse 97, pulse ox 86%, temperature 97.1 degrees F, respirations 18. The facility failed to perform a complete assessment of R379's neurological status and failed to identify abnormal neurological findings. It was unclear how many liters of oxygen R379 was administered when her pulse ox was recorded as 86%. 8/14/17 at 9:26 PM - EMS arrived at the facility; GCS=15, .Chief Complaint: (name of R379) fell and hit her head when being loaded into bed x 2 hours .Primary Symptom: Pain .Cause of Injury: Fall .Mechanism of Injury: [MEDICATION NAME] History: Dispatched to a nursing home for a [AGE] year old female .The patient was found lying semi-fowlers in her bed in the nursing home with her eyes closed .The patient's nurse walked into the room with the BLS crew and informed us that the patient had fallen and hit her head while being loaded into bed. The nurse stated that the patient has dementia and is currently in her normal mental status. After a rapid assessment and noticing that the patient fell and landed on her head, a C-collar was put on to protect from further spinal injury if there is any. It was also noticed that the patient had a laceration to the left eyebrow and forehead with swelling and controlled bleeding from the left eye. It was also noticed that the patient had a small laceration on the top left of her head with older, dried up blood, possibly from the fall yesterday. The patient was then moved to the stretcher .Events prior to the incident: The patient had fallen out of bed .and the nursing home neglected to call 911 to have the patient checked out. When being loaded into bed via a standing lift and assisted by 2 facility staff members, the patient fell and landed directly on her head without using her arms to brace her fall. The patient came up with a laceration to the left forehead and eyebrow with swelling and controlled bleeding from the left eye. The patient was put back into bed and the nursing home waited for 2 hours to call 911 . 8/14/17 at 9:37 PM - EMS left facility with R379. 8/14/17 at 10:43 PM - The facility's Change of Condition NN stated, At around (7:35 PM), staff reported to this nurse that pt had incurred a fall while being transferred using a standard lift with assist of two CNA's. Pt was observed on the floor on the right side of her bed next to the bedside lamp stand with face down. Upon assessment patient noted with a hematoma on the left side of her face and with some slight bloody discharge from her left eye. Assessed B/L upper and lower extremity for deformities none noted. Range of motion performed on all limbs no s/s of pain or distress noted. Neuro checks initiated and vital signs checked as ordered. Patient responds, but with confusion that is within baseline. E26 (NP) on call for (E3, physician) made aware at (8:30 PM) and new order given to send patient out to (hospital) for Evaluation. Family notified. Paramedics transferred patient from facility at around (9:30 PM). 8/14/17 - The facility's investigation revealed the following: - E22 (RN) stated she was assigned to care for R379; she found R379 on the floor in a prone position; R379 was incoherent (sentences were not clear) when R379 was asked what she was doing when she fell ; R379 was within baseline with respect to her behavior during the shift (prior to the fall); and stated, Patient was in prone position rolled to back and transferred to bed. - E28 (CNA) stated she witnessed R379 fall; R379 exhibited normal behavior during the shift (prior to the fall); and R379 was leaning on the left side. - E29 (CNA) stated, .R379 leaned to the left and forward and fell face first to the floor. E28 was unable to get to R379 because she had to back up a little bit for me to move the stand-up lift out of the way. R379 laid there for a couple of seconds then she shook almost like she was having a [MEDICAL CONDITION] then she yelled 'help, help I'm cold'. E28 ran out and got the nurse (E22) right away. E22 came and asked what happened, we told her what happened, E22 assessed the patient, and we got E30 (CNA) to come help us. We put a flat sheet under the patient and we picked R379 off the floor and back to bed. E22 put ice on R379's head. R379 continued with the shaking and yelling even when we did vital signs. R379 fell around 7:35 and after she was settled in bed it was going on 8 PM. - E30 (CNA) stated that she saw R379 laying on her belly. - E31 (RN) stated that she did not observe R379 on the floor and answered I don't know to the question to describe the environment. 8/15/17 at 12:51 AM - The hospital's TRAUMA H&P stated, .Patient .subsequently fell forward impacting her head and hyperextending her neck. She sustained a hematoma to the L forehead with associated ecchymosis about the L eye. In the ED patient underwent a CT of the head and C-spine. CT of the head was notable for a large left frontal subgaleal hematoma as well as a left parietal hematoma, however there were no obvious fractures or intracranial bleeding noted. CT of the C-spine was notable for a Type II odontoid fracture with approximately 5mm of distraction cut without significant subluxation .Disposition: .She will be admitted to TSU for serial neuro checks, hard cervical collar, spine surgery consultation . 8/15/17 at 7:20 AM - The facility's post Fall Assessment after R379's fall on 8/14/17 at 7:35 PM stated that her physical performance limitations included difficulty maintaining sitting balance and impaired balance during transitions; and [DIAGNOSES REDACTED]. 8/15/17 at 10:54 AM - The hospital's H&P stated, .History of Present Illness: .suffered a fall .History is limited by her current mental status and most information is obtained from the chart. She was apparently in her normal state of health prior to the fall. It was witnessed by a staff member who reported that she hyperextended her neck. In the ED, she was found to have an odontoid fracture and a significant amount of bruising around the left eye. Since admission to the trauma service, she has also been found to have a vertebral artery dissection . 8/15/17 at 11:19 AM - The hospital's neurosurgery consult note stated, .Neurosurgery was consulted for evaluation of her type II odontoid fracture .Patient is rather lethargic, and is having difficulty maintaining conversation .Assessment/Plan: .She was found to have a type II odontoid fracture with 5mm of distraction and slight anterior displacement of C2. These represent unstable fractures, and are usually treated with an odontoid screw placement for stabilization. Patient is not on anticoagulation. She does have an injury/dissection of the .vertebral artery for which aspirin is the treatment. She already takes an aspirin 81mg at home. Dose will be increased to 162mg and a repeat CTA in 6 weeks for re-evaluation per neuro IR .(neurosurgeon) would like to take patient to OR for placement of odontoid screw . 8/16/17 at 9:09 AM - The hospital's Progress Note stated, .admitted s/p fall with odontoid fx s/p ORIF with screw last evening, has had increasing lethargy along with [MEDICAL CONDITION] and [MEDICAL CONDITION] overnight. Concerned that she is unable to protect her airway .(family) made the decision to make her a DNR with the limitations indicated in the orders . 8/16/17 at 5:16 PM - The hospital's Progress Note stated, During AM report pt only arousing to pain and not able to follow commands .Throughout day pt (patient) at times awakens to voice and basic neuro able to (sic) completed other times requiring nail bed pressure to withdraw . 8/17/17 at 11:40 AM - The hospital's Discharge Summary stated, .Discharge Diagnoses: [REDACTED].Hospital Course: .Patient had CAT scans of the head and cervical spine was identified she had a type II odontoid fracture neurosurgery was consulted as well as neuro [MEDICATION NAME] post CTA of the neck. (Neurosurgeon) discussed with family risk and benefits of surgery and was decided patient will go on to have an ORIF of the odontoid fracture with screw. Post surgery patient lethargic not swallowing or waking for any nutrition. Patient also with episodes of [MEDICAL CONDITION] and [MEDICAL CONDITION] .On day of her discharge patient more awake speaking able to tolerate oral liquids .Significant Labs/Imaging/Diagnostic Tests: Patient will need follow-up for her vertebral artery injury recommending CTA of the neck on 10/1/17 .Medications at Discharge: CHANGED .Aspirin 81mg EC - take 2 tabs daily for your vertebral artery dissection .Additional Instructions Given to Patient: Patient may wear a soft collar for comfort measures. Recommended for her long-term facility at (name of facility) to monitor her blood pressure and heart rate before giving her antihypertensive medications . 8/17/17 at 1 PM - R379 was discharged from the hospital and returned to the facility. 8/17/17 at 1:30 PM - The facility's NN stated that R379 was readmitted from hospital with [DIAGNOSES REDACTED]. 8/22/17 untimed - The facility's physician progress notes [REDACTED]. F/U c surgery, pain control. 2) R Vertebral Artery Dissection . 2/26/18 at 5:30 PM - During an interview, E28 (CNA) stated the following regarding the 8/14/17 fall: - she was the spotter; - she was too short to stand on the other side of R379's bed so she stood to the right side and behind the stand-up lift as she was blocked because the stand up lift was next to the dresser which was closest to the HOB; - when E39 moved the stand up lift away from the bed, R379 fell forward as she was sitting on edge of bed and landed on the tiled floor; - vital signs were taken and 4 staff placed R379 on a sheet and transferred her to the bed; - the hoyer lift was in the Medbridge unit; - the resident was alert and talking during the transfer; - E28 demonstrated the position of the stand-up lift, where she was standing, and how high the bed was elevated in order to use the stand-up lift so it would not get stuck under the bed frame. It was approx. 24 inches from the top of the regular mattress (used in the demonstration) to the floor. 2/26/18 at 6:03 PM - During an interview, E29 (CNA) stated the following regarding the 8/14/17 fall: - she was operating the stand up lift; - R379 was already leaning forward in the wheelchair before the transfer; - the night stand was not next to the bed, but moved away from the bed; - E28 was on the right side as the lift was being pulled out and that she moved back to get out of the lift's way; - R379's feet were not on the the ground and she fell hitting the left side of her face; - R379 kept saying help, I'm cold; - E28 went to get E22 (RN); - E22 assessed R379 on the floor; - E29, E28, E22 and E30 (CNA) used a sheet to transfer R379 from the floor to the bed; - Once in bed, she observed R379 shaking (looked like seizing) for approx. 30 to 45 minutes; - E22 placed ice on R379's head then went to call someone; - the 3-11 PM shift house supervisor, E31, was on a medication cart on the Linden unit; - R379 was complaining that her head was hurting after the fall; - the CNA's were upset that it took 2 hours for R379 to be sent out to the ER and she didn't know why it took so long; and - she knew the resident very well. 2/28/18 at 1:11 PM - During a telephone interview, E22 (RN) stated the following regarding the 8/14/17 fall: - E28 told her that R379 was on the floor; - observed R379's face was on the floor near the dresser; - R379 was saying, get me up, get me up, I'm cold; - asked R379 if she fell and R379 said she could not remember; - R379 was on her left side and she took her vitals and couldn't get her BP and took it again and it was 150 over something; - looked for ROM for injuries and then noticed swelling and hematoma; - They (E22, E28, E29, E30) got her on the bed and took another vital signs and neuro checks; - Noticed R379 had bloody drainage from her left eye and took her BP again and it had dipped a little bit and she was concerned; - Could not remember, but believed R379 was on a baby aspirin, but was a bit concerned with the swelling and the BP going down; - Called the doctor and left message for call back; - E26 (NP) called back and she provided her assessment; - E22 stated that she told E26 she thought they needed to send R379 out just to be on the safe side because she hit her head and has a hematoma. E22 told E26 of the bloody drainage on her left eye and started to wonder if it could be a subdural hematoma. The discharge was a clear bloody discharge. E26 told E22 that you are with the patient, so let's send her out; - E22 said what got her concerned was the dropping BP, which prompted her to call for the paramedics who came, assessed her and took her. - E22 said the CNAs told her that R379's fall was not during the transfer. R379 was already on the bed. E22 questioned the CNAs and they told her that R379 did not fall from the lift. - E22 confirmed that they used a sheet to transfer R379 from the floor to the bed; - E22 stated that R379 kept saying to get her off the floor and she was laying face down in a fetal position and E22 was trying to figure out how she was going to get her up to the bed. - E22 stated that once off the floor, she felt she could properly look at R379. - E22 stated that E29 stayed with R379 in the room; - E22 stated the nurse gets the first set of vitals then the CNA stays in the room and gets the vitals from that point and anything of significance, the CNA will get the nurse who will do another set of vitals. - E22 stated she went back to the Nurse's Station and placed the call and waited for a call back. - E22 confirmed that E26 (NP) called back at 8:30 PM and gave the order to send R379 to the ER. - When asked who put R379's paperwork together, E22 could not remember. - When asked who called 911, E22 could not remember. - E22 stated first blood pressure was taken while on the floor. - E22 stated that she had R379 move her legs and arms. - E22 said when she turned R379 over, she noticed the hematoma and not the bloody eye drainage until they got her in bed. E22 confirmed there were no eye issues prior to the fall. - When asked if transferring a resident via sheet was normal practice at the facility, E22 said no. - E22 said because of her position, they could not get a lift to her as they could not get it between the dresser and the bed. - When asked if the dresser was next to the bed, E22 said yes and she was concerned about pulling R379 back. - When asked about immobilizing the resident after the fall, E22 stated that R379 said she was okay. E22 then said that she did not notice the hematoma until she got her in bed. - E22 said that if there is obvious injury they usually let the paramedics move them. - When asked if E22 went about her other duties until the ambulance arrived, E22 stated that this is a priority, however she has to look at other patients too. Being on the Arcadia Unit, they have to keep an eye on the other patients who wander into other rooms. - When asked about who recorded the BPs as only 5 BPs were noted during the 2 hour timeframe, E22 did not respond. - When asked about the first neurological check where her left eye was non-reactive to light and if that was a concern, E22 said that was a concern, but could not offer an explanation. - When the surveyor pointed out that the fall occurred at 7:30 PM, E22 received a call back from E26 (NP) at 8:30 PM with an order to send R379 to the hospital, and the medics arrived at 9:30 PM, why was there a delay in sending her out, E22 said she can't remember. - When asked if any other nurse, including the house supervisor, was involved in R379's care after her fall, E22 could not recall. E22 stated she was the only nurse on the Arcadia Unit. When asked about the Medbridge Nurse, E22 stated that it was a critical time for her to be passing meds and doesn't remember her being involved. - When asked if it was the facility's practice to move a resident back to bed when they have fallen and landed on their face, E22 said yes if done safely. When asked even if the resident was cognitively impaired, E22 said she can tell you if she was in pain. - When asked if it ever entered E22's mind that R379 could have injured her head and neck before they moved her, E22 said she would not move anyone if there is suspected injury. E22 stated that she depended on being told by the CNAs as to what happened and knew she did not fall from the lift. - When asked about her dependence on being told by the CNAs as to what happened and the CNAs said she fell from the bed, E22 said she didn't bother to look at the height of the bed and that she was more interested in the resident. 3/1/18 at 5:50 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON). For R379, the facility failed to perform complete neurological assessments of R379 after her 8/14/17 fall; failed to identify abnormal neurological assessment findings; failed to consider the potential of head and/or cervical trauma based on the [MEDICATION NAME] mechanism of R379's fall, the assessment observations of R379's laceration to the left eyebrow and forehead, swelling and hematoma on the left side of her face, incoherent sentences after the fall, and unstable vital signs; and failed to immediately call 911 to transfer her to the emergency room (ER) for evaluation and treatment after a physician's orders [REDACTED]. R379 was received and assessed as a Trauma Code in the ER, underwent surgery for [REDACTED]. 1b. Review of R379's clinical record and facility documents revealed the following: 8/17/17 at 11:40 AM - The hospital's Discharge Summary stated, .Recommended for her long-term facility (name of) to monitor her blood pressure and heart rate before giving her anti-hypertensive medications . 8/17/17 to 12/6/17 - R379's clinical record lacked evidence of monitoring her blood pressure and heart rate before administering her two anti-hypertensive medications. 8/21/17 untimed - The facility's physician progress notes [REDACTED]. 3/1/18 at 9:50 AM - During an interview, E4 (SDC) confirmed the findings. The facility failed to monitor R379's blood pressure and heart rate before administering her two anti-hypertensive medications from 8/17/17 through 12/6/17 (110 days). 3/1/18 at 5:50 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON). 1c Review of R379's clinical record revealed the following: 12/6/17 at 2:14 PM - A telephone physician's orders [REDACTED]. 12/6/17 at 2:34 PM - A NN from day shift stated that R379's pulse ox was 88% and oxygen was applied via nasal cannula. R379's pulse ox was rechecked and revealed 90% on 2 liters. 12/6/17 during 3-11 PM shift - R379's clinical record, including NN and eTAR, lacked evidence that R379's pulse ox was rechecked and titrated to keep R379's oxygen level greater than 92% during the shift. The facility failed to follow a physician's orders [REDACTED].>12/7/17 at 2:11 AM - The eMAR revealed that R379 was administered an [MEDICATION NAME] nebulizer (breathing treatment) for shortness of breath and decreased pulse ox. 12/7/17 at 6:59 AM - A NN from night shift stated, Approximately 0100, nurse went to patient room, noted patient with labored breathing, with difficulty breathing. Nurse assessed patient POX noted to bed (sic) 69% at 2L/NC. Nurse adjusted patient O2 and pox came to 96% and then dropped to 83%. E32 (on call NP) notified and gave n/o for [MEDICATION NAME] .for SOB . 3/1/18 at 9:50 AM - During an interview, E3 (physician) stated that the issue with low pulse ox on 12/6/17 during 3-11 PM shift sounded like a documentation problem. E3 stated that yes, he would have expected the nurse to reassess R379's pulse ox. 3/1/18 at 5:50 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON). The facility failed to follow a physician's orders [REDACTED]. 4. Review of R88's clinical record revealed the following: The facility's policy entitled Catheter Care: Indwelling Catheter, last revised 4/2016, stated, .Procedure: 1. Verify physician's orders [REDACTED].

Based on record review, staff interviews, and review of other facility documentation as indicated, it was determined that for one (R2) of six sampled residents, the facility failed to provide the necessary care and services for the resident to attain her highest level of physical and mental well-being. R2 experienced a new onset of acute pain of the left thigh and a change in mobility status from independent ambulation to requiring a wheelchair. The facility failed to conduct a comprehensive clinical assessment, including pain assessment. The facility failed to notify the physician about the new onset of acute pain and change in R2's mobility status. Although R2 was displaying negative vocalization of pain, as evidenced by crying and moaning, the facility failed to provide pain medication for approximately 11 hours after the first identification of pain. An x-ray later showed R2 had a broken hip. There is inconsistent documentation in the clinical record between the right and left hip and consequently in this report. Additionally interviews with E5 (LPN) and E4 (RN) recorded below demonstrate a lack of documentation regarding the events that occurred on 3/14/17 which inhibited an accurate investigation of the trauma sustained by R2. Findings include: The pain management standards, approved by the American Geriatrics Society in April 2002, included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management. Review of facility policy entitled Pain Practice Guide, issued on November 2011 included: - The PAINAD Scale is used for patients who cannot communicate (verbal, written, gesture) about their pain. The observations are converted to numeric score with 0 being absence of pain and 10 as being the worst pain. This may include patients who are unable to complete the pain interview ., have cognitive impairment or cannot verbally communicate. The non-specific signs and symptoms that may suggest the presence of pain include vocal (crying, moaning, groaning), rubbing (body guarding), resisting movement or care, change in gait, loss of function. - Obtain pain scale scores daily and before and after administration of PRN pain medication. Review of R2's clinical record revealed: 8/17/16 - Admission to the facility with [DIAGNOSES REDACTED]. 8/17/16 - Physicians' orders included PRN Tylenol every 4 hours PRN for pain. 12/28/16 - Quarterly MDS Assessment documented R2 was severely cognitively impaired, walked in room and unit with supervision by staff. In addition, R2 did not receive any scheduled or PRN pain medication and R2 did not have any sign of pain or any documentation of pain within the last 5 days. 1/23/17 - Care plan problem for pain related to arthritis left hand 4th and 5th digit, had the goal that R2 will express that pain management is within acceptable limits. Interventions included to report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing. 3/1/17 through 3/13/17 - Progress Notes had no documented behavior of crying or moaning. 3/14/17 and timed 3:56 PM - The Pain Level Summary documented that R2 had a pain scale of 0 indicating no pain. However CNA (E6) statement noted R2 expressed pain at 3:50 PM during toileting. No further assessment of R2's new onset of pain was noted. 3/14/17 and timed 9:49 PM - A telephone verbal order by prescriber, E10 (MD) for x-ray of the hip, two views to rule out a fracture. 3/14/ 17 and timed 9:52 PM - Progress Note, by E5 (LPN), documented R2 was very tearful and holding on to her left hip sitting in the dining room (exact time not documented) and R2 was ambulating on the unit without any difficulties earlier this shift. R2 was assessed by E4 (RN supervisor) and E9 (NP) was made aware and ordered an x-ray of the left hip to rule out a fracture. Although this progress note documented that R2 was assessed by E4, record review lacked evidence of a comprehensive assessment of the new acute pain. 3/14/17 - 3:00 PM to 11:00 PM shift, Medication Administration Record [REDACTED]. 3/15/17 and timed 3:27 AM - Progress Note, by E8 (LPN), 11:00 PM - 7:00 AM shift, documented continues to monitor VS and right hip pain. R2 continues with signs and symptoms of pain when her legs are moved and x-ray to be done in the AM. PRN Tylenol given for pain pending results. Denies pain at this time. (An interview (6/19/17 at 10:30 AM) with E8 confirmed this documentation was accurate, in reference to the right hip pain, despite other documentation of left hip pain). 3/15/17 and timed 3:30 AM - The Pain Level Summary documented that R2 had a pain scale of 5 indicating moderate level of pain. 3/15/17 and timed 3:30 AM - Progress Note, by E8 documented Tylenol given for complaint of right hip pain with a pain score of 5 out of 10. (An interview with E8 confirmed this documentation was accurate, in reference to the right hip pain). 3/15/17 - MAR indicated [REDACTED]. 3/15/17 - 11:00 PM - 7:00 AM shift, MAR indicated [REDACTED]. 3/15/17 and timed 5:09 AM - Progress Note, by E8 documented that the pain medication was effective with R2 with no S/S of pain, able to move her legs without moaning. Although the post pain assessment indicated effective, the facility failed to utilize the same scale for post pain assessment. 3/15/17 and timed 11:14 AM - Progress Note, by E11 (LPN), documented that R2 remains in bed and needs are met and awaiting x-ray to left hip. 3/15/17 and timed 12:03 PM - Progress Note, by E11, documented Tylenol administered at 12:03 PM for pain score of 4, indicating mild to moderate level of pain. 3/15/17 and timed 12:03 PM - The Pain Level Summary documented that R2 had a pain scale of 4, indicating mild to moderate level of pain. 3/15/17 - 7:00 AM - 3:00 PM shift, MAR indicated [REDACTED]. 3/15/17 and timed 1:50 PM - Progress Note, by E11, documented x-ray results pending and R2 was seen by E12 (PA) and gave new orders for [MEDICATION NAME] PRN for moderate to severe pain. 3/15/17 and timed 1:51 PM - Progress Note, by E11, documented R2 remains in bed until results of x-ray return. R2 given meals in bed. R2 medicated as ordered for pain (Tylenol at 12:03 PM). No bruising noted to left hip, R2 complain of pain when turning in bed. 3/15/17 and timed 2:28 PM - Progress Note, by E11, documented results of left hip x-ray given to NP and NP ordered to send to ER for evaluation and 911 called. 3/15/17 and untimed Progress Note, by E12 (PA), documented that E12 was asked, by nursing to see patient who is having difficulty with ambulation and holding left thigh secondary to pain. There is no documented witnessed fall. VS BP 119/65, P 100, R 18, T97.6 F. Upon exam, noted decrease ROM of left hip with tenderness of hip and thigh. Plan included x-ray, [MEDICATION NAME] PRN every 6 hours. On the back of this progress note, documented the results of the x-ray, as a fracture with moderate displacement (out of alignment) and plan was to send R2 to the emergency room . 3/15/17 - Fire company pre-hospital care report documented that the 911 call was received at 2:33 PM and R2 arrived at the hospital at 3:14 PM. 6/8/17 at approximately 3:00 PM, an interview with E4 (RN Supervisor) in the presence of E2 (DON) was held. E4 verbalized that she was notified by E5 (LPN) that R2 was crying and rubbing her left leg. E4 verbalized that she attempted to complete a comprehensive physical assessment while R2 was sitting in the dining room chair before dinner, approximately 4:30 PM to 5:00 PM, however, R2 resisted and E4 was unable to complete the assessment. E4 reported that R2 attempted to take a couple of steps but quickly sat down on the chair and became tearful. E4 related that she instructed E5 to administer Tylenol and monitor R2's condition. E4 indicated that she had left early during that shift before 8:00 PM and she did not have any further contact with R2 on 3/14/17. E4 related that she did not notify R2's attending physician. 6/8/17 at approximately 3:15 PM, an interview with E5, in the presence of E2 was held. E5 verbalized that she was notified by E7 (CNA) that R2 was crying after dinner at approximately 6:00 PM. E5 observed R2 crying and rubbing her left thigh. E5 verbalized that she had contacted E4 and E4 had assessed R2 soon thereafter. E5 reported that R2 had stopped crying at some point and when R2 was put into bed around 9:00 PM, R2 started to cry again. E5 proceeded and contacted E4 (RN Supervisor) and E5 recalled a reassessment of R2 was completed by E4. In addition, E9 (NP) was contacted due to the resident moaning in bed. 6/8/17 at approximately 3:55 PM, an interview with E7 (CNA), in the presence of E2 was held. E7 verbalized that he was not the assigned CNA for R2 during the 3:00 PM - 11:00 PM shift but rather E6 (CNA) was the assigned CNA. E7 did confirm that E7 informed E5 that R2 was crying, while sitting in the dining room chair before dinner on 3/14/17. In addition, E7 reported that he assisted E6 in turning and repositioning R2 in bed at approximately 8:00 PM since R2 was unable to do so and was crying during this activity. E7 verbalized that prior to this date, R2 was independent in turning and repositioning in bed. 6/13/17 at approximately 12:10 PM, an interview with E6 (CNA) was conducted in the presence of E2. E6 confirmed that she was the assigned CNA for R2 during the 3:00 PM - 11:00 PM shift on 3/14/17. E6 recalled that R2 was in a wheelchair at the beginning of the shift and at approximately 3:50 PM, when E6 took R2 to the toilet. When R2 stood up, so that the adult brief could be removed, R2 had pain and E6 informed E5 (LPN). Sometime after 8:00 PM, R2 was found sitting on the floor in the dining room in the secured unit and E6 informed E5. E6 and E7 (CNA) were instructed to pick the resident up from the floor, place the resident in the wheelchair and place R2 in the bed. E6 verbalized that R2 was placed in bed and remembered that R2 was crying and hunched over to the right side of the bed. Again, E5 was made aware that R2 was experiencing pain and crying. E6 reported that she checked on R2 approximately two hours afterwards and no incontinence care was needed at that time. 6/13/17 at approximately 3:15 PM, a subsequent interview with E5 was conducted in the presence of E2 (DON). E5 verbalized that it was her recollection that R2 had a behavior of crying, thus, it was E5's determination that crying was not a sign of R2 experiencing pain and PRN Tylenol was not administered during her shift from 3:00 PM to 11:00 PM. E5 denied that R2 was found on the floor after dinner on 3/15/17. 6/14/17 at approximately 1:00 PM, a telephone interview with E12 (PA) was conducted. E12 verbalized that she was familiar with R2 and that R2 was independent with ambulation in the unit. E12 did not recall when she assessed R2 on the morning of 3/15/17, however, did order [MEDICATION NAME] for pain due to the left thigh pain. E12 verbalized that she was made aware of the x-ray results soon after the assessment of R2 and an order was communicated to send the resident to the hospital for treatment. E12 verbalized if a comprehensive clinical assessment could not be performed on the evening of 3/14/17 by a RN, and R2 had a change in mobility, R2's attending physician should have been contacted. 6/14/17 at approximately 1:50 PM, a telephone interview with E9 (NP) was conducted. E9 verbalized that she is not familiar with R2 and does not recall the specifics of the information that she was provided with on the evening of 3/14/17. However, if a resident is experiencing a new onset of pain, in the thigh area, her standard would be to order an x-ray to rule out a fracture. 6/14/17 at approximately 2:20 PM, an interview with E2 (DON) was held. E2 verbalized a comprehensive clinical assessment of pain in the thigh area would include range of motion, rotation, length of leg. When E4 (RN Supervisor) was unable to complete this assessment on 3/14/17 due to R2's refusal and E4 observed change in R2's ability to bear weight and had to quickly sit down after taking couple of steps, E2 would have expected that R2's attending physician be notified. E2 confirmed that pharmacological intervention of Tylenol was not administered, as instructed by E4 and as ordered by R2's attending physician, during the 3:00 - 11:00 PM shift, when R2 was displaying signs and symptoms of pain, which included crying and moaning. Additionally, E2 confirmed no VS were completed during this shift. 6/19/17 approximately 10:30 AM, a telephone interview with E8 (LPN) revealed that his recollection was that R2 was experiencing pain in the right hip, as evidenced by moaning when her legs were moved while she was in bed during the 11:00 PM to 7:00 AM shift on 3/15/17. The facility failed to: -conduct a comprehensive clinical assessment, including pain assessment when R2 developed a new onset of acute left thigh pain in conjunction with a change in mobility status. -failed to provide pain medication for approximately 11 hours after the first identification of pain. Findings reviewed on 6/14/17 at approximately 4:00 PM with E1 (NHA), E2 (DON) , E3 (QAC), and E14 (ICP).

Based on clinical record reviews, interviews, observations and review of other facility documentation including hospital records, it was determined that the facility failed to ensure that four (R214, R355, R359 and R396) out of 47 Stage 2 sampled residents, who were incontinent of bladder, received appropriate treatment and services to restore as much normal bladder function as possible. All four residents experienced a decline in continence. For R214, R355, R359 and R396, the facility failed to comprehensively assess their urinary incontinence; failed to complete voiding diaries; failed to individualize toileting plans, resulting in the decline of their urinary continence. Findings include: The facility's guideline (Incontinence Management Practice Guide) entitled, Ongoing Management Strategies issue date 3/2012, stated, Implementing the Bladder Diary will assist in analyzing any voiding patterns as the patient may have. Complete the patterning for at least 3 days on all day (7-3) and evening (3-11) shifts. Voiding records help detect urinary patterns or intervals between incontinence episodes and facilitate providing care to avoid or reduce the frequency of incontinence episodes .Risk Factors for incontinence development, Dementia .impaired mobility .aging . The Guideline failed to include the 11-7 shifts. According to the American Medical Directors Association's (AMDA/The Society for Post-Acute and Long Term Care (LTC) Medicine) Clinical Practice Guideline for Urinary Incontinence stated, .Urinary incontinence should be managed, can often be modified, and sometimes be significantly improved or eliminated in frail older adults, including people with dementia who reside in LTC facilities . Refer to: <http://www.amda.com/tools/guidelines.cfm> 1. Review of R359's record revealed the following: 5/21/15 at 10:02 PM- R359 was admitted to the facility from the hospital ED (after an unwitnessed fall from home). The discharge ED Physician Record dated 5/21/15 at 8:30 AM indicated that R359 had no medical concerns .on her laboratory evaluation. The discharge laboratory report called Urine Studies dated 5/21/15 at 8:34 AM, did not indicate any findings of urinary tract infection or abnormalities. 5/21/15 at 10:02 PM-The facility's Patient Admission/Readmission Screen record indicated that R359's Cognitive Skills for Daily Decision Making were moderately impaired: decisions poor; cues/supervision required. This admission screening indicated that R359 was continent of bladder. The facility initiated a toileting schedule for R359 based on their routine toileting procedures of upon awakening, before and after each meal and at bedtime. Review of the CNAs Toileting documentation revealed the following: 5/23/15 at 2:42 PM, R359 was found incontinent of urine. She was last toileted 5 hours before on 5/23/15 at 9:23 AM. This also indicated that she was not toileted before lunch as per the facility's routine toileting schedule; 5/24/15 at 8:34 AM, R359 was found incontinent of urine; 5/24/15 at 2:43 PM, R359 was again found incontinent of urine. She was last toileted 6 hours before at 8:34 AM. The toileting documentation did not indicate that R359 was toileted before and after lunch. 5/25/15 at 3:45 PM, R359 was found incontinent of urine; 5/27/15 at 7:05 AM, R359 was found incontinent of urine; 5/27/15- The facility initiated a care plan entitled, Urinary incontinence related to dementia, impaired mobility. The care plan goals were: Will have no complications due to incontinence and Will be maintained in as clean and dry dignified state as possible. Interventions included: Provide assistance with toileting, Provide incontinent care as needed, Report signs and symptoms of UTI . The care plan lacked goals that included restoration toward R359's normal bladder function or prevention of a decline and a UTI. The care plan also lacked the interventions to implement a voiding diary and to implement a toileting schedule based on the result of that voiding diary. There was lack of evidence in the clinical record that a Voiding Diary was implemented for R359, despite the facility's knowledge of her urinary incontinence episodes. 5/28/15 - 14 day Admission MDS assessment identified that R359 was occasionally incontinent of bladder, during the seven (7) day review time period (5/21/15 through 5/28/15) and there was no trial of a toileting program. 5/28/15 -14 day admission MDS assessment indicated that R359's [DIAGNOSES REDACTED]. R359's cognition was severely impaired and needed extensive assist of staff with her ADLs such as transfer, toilet use, dressing, personal hygiene and bathing. She needed one person/staff assist to walk in the room and between locations in her room. The facility was aware that R359 was experiencing incontinence of bladder based on their assessments, (from continent to occasionally incontinent) and care plan, however, the facility lacked documentation that a Voiding Diary was implemented when R359 had episodes of incontinence. The CNAs Toileting documentation showed that the facility proceeded with their routine toileting schedule of upon awakening, before and after each meals and at bedtime for R359. The facility failed to analyze R359's voiding patterns to help detect R359's need for an individualized toileting schedule to reduce or avoid the frequency of incontinence and or intervals between incontinence episodes. Review of R359's nurses' notes revealed the following: 5/30/15 -dark yellow urine with strong odor; 5/31/15 at 5:00 AM - toileted with assist of one, urine light orange in color, appears cloudy with strong odor. Specimen for UA/C&S obtained awaiting pick up by the laboratory 6/1/15 at 6:50 AM- .patient with some confusion .restless thru the night .UA sent out for analysis On 6/1/15 at 1:30 AM, CNAs Toileting record stated, R359 was incontinent of urine. On 6/1/15 - A Physician ordered the antibiotic (Cipro) for R359. 6/1/15 - A care plan entitled, Infection of urinary tract was initiated. The goal of this care plan was: Resident's Infection will be resolved without complications. The interventions were: Administer medication per physician orders; Maintain precautions as indicated; obtain labs as ordered and notify physician results; Record temperature as clinically indicated. It was unclear why, despite these findings, the facility failed to revise the care plan, complete a urinary incontinence evaluation using a voiding diary to individualize a toileting program for R359 as per the facility's guideline. 6/2/15 - UA & C&S result showed positive for bacteria. The UA & C&S showed >100,00 CFU/ml of Escherichia coli. 6/4/15 - The physician ordered to [MEDICATION NAME] prescribed a different antibiotic, [MEDICATION NAME], for 10 days. Review of R359's 6/2015 CNAs Toileting documentation revealed that R359 had 28 urine incontinent episodes in 30 days. 7/14/15 Nurse's note stated R359 was experiencing lethargy and the physician ordered a UA/C&S. 7/15/15 - Result of the UA & C&S indicated that there were few bacteria but had no growth. The physician ordered [MEDICATION NAME] tablets twice a day for R359 for 10 days. Review of R359's 7/2015 CNA Toileting documentation revealed that R359 had 38 incontinent episodes in 31 days. 8/19/15 -Quarterly MDS assessment stated that R359's cognition was severely impaired and bladder continency was assessed as frequently incontinent. The same MDS stated that despite R359's frequently incontinent status there was no trial of a toileting program. The record lacked evidence that interventions were put in place to restore or prevent a further decline in R359's bladder function, despite this decline. 8/25/15 an 11:16 AM Nurse's note stated Received verbal order for UA/C&S. R359 has had increased behaviors and tearfulness. Gait is very unsteady . 8/26/15- UA and C&S which resulted in no growth and no new orders. Review of R359's 8/2015 CNAs Toileting documentation revealed that R359 had 53 urine incontinent episodes in 31 days. 9/2/15 A physician's orders [REDACTED]. Review of R359's 9/2015's CNAs Toileting documentation revealed that R359 had 40 episodes of urinary incontinence. In addition, the Toileting documentation revealed that R359 had no documented record of toileting on the following dates: 9/5/15 - 7 AM-3 PM shift from 8:10 AM through 4:59 PM (9hrs.). 9/10/15-3 PM-11 PM shift from 3:35 PM through 12:39 AM 9/11/15 (9hrs). 9/13/15 - 7 AM-3 PM shift from 7:36 AM through 3:11 PM (7 1/2 hrs). 9/15/15-7 AM-3 PM shift from 8:35 AM through 4:05 PM (7 1/2 hrs.). 9/16/15 - 3 PM-11 PM shift from 3:55 PM through 1:51 AM 9/17/15 (13 hrs). 9/21/15 - 7 AM-3 PM shift from 7:39 AM through 2:24 PM (7hrs). 10/15/15 -1:39 PM through 6:31 PM (5 hrs). 10/17/15 - 3:46 PM through 10/18/2015 at 3:33 AM (11 hrs). It is unclear if R359 had episodes of urinary incontinence between these times. Review of R359's 10/2015 (10/1/15-10/20/15) Toileting documentation revealed 20 urine incontinent episodes in 20 days without implementation of a voiding diary. Although the facility had an Incontinence Management Practice Guide, the facility failed to ensure that this system was appropriately implemented for R359 when this resident showed four (4) incontinent episodes that started on 5/23/15 (2 days post admission). R359's urinary function declined from being (0) continent on admission, to (1) occasionally incontinent and further declined to being (2) frequently incontinent as per the quarterly MDS assessment dated [DATE]. This finding was discussed with E3 (Corporate Nurse), and E4 (DCD) on 10/19/15 at approximately 3:40 PM and with E1 (NHA), E2 (DON), and E3 on 10/20/15 at approximately 4:00 PM. This finding was also discussed on 10/22/15 at approximately 4:00 PM during the exit conference with E1 and E2. 2. R355 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing Patient Admission/Readmission Screen, and Nursing Admission Evaluation, both dated 5/16/15, stated R355 was continent of bladder. The 5/18/15 physician's H&P stated R355 was occasionally incontinent of bladder. The 5/23/15 admission MDS assessment stated R355 was independent for daily decision making skills, required extensive assist of one (1) staff for bed mobility, transfer and toilet use. The MDS assessment also stated R355 was occasionally incontinent of bladder during the assessment period (5/17/15 through 5/23/15) and there was no trial of a toileting program. R355's clinical record lacked evidence of a 3 day voiding diary having been completed to determine patterns of incontinence. The facility failed to ensure that a voiding diary was completed and they failed to develop an individualized toileting plan based on the voiding diary for R355. On 5/29/15 a urinary incontinence care plan was developed. One goal of this care plan was Will attain/maintain continence, based upon usual voiding pattern. Since the facility failed to complete a voiding diary to determine R355's voiding patterns, this goal was not attainable. Interventions included: adjust toileting times to meet patient needs; provide assistance with toileting; and report changes in amount, frequency, color or odor of urine. Review of electronic documentation for Toileting, completed by CNAs, revealed the following: - 5/16/15 through 5/31/15 - six (6) documented episodes of incontinence; - 6/1/15 through 6/30/15 - seven (7) documented episodes of incontinence; - 7/1/15 through 7/31/15 - approximately 125 documented episodes of incontinence; - 8/1/15 through 8/14/15 - approximately 77 documented episodes of incontinence. A nurse's note, dated 6/24/15, stated R355 had an appointment on 6/26/15 to receive a lower back injection for pain management. The 60 Day Medicare MDS assessment, dated 7/16/15, stated R355's daily decision making skills were moderately impaired and he required extensive assist of two (2) staff for toilet use. The 7/16/15 assessment also stated R355 was now frequently incontinent during the assessment period (7/10/15 through 7/16/15) and there was no trial of a toileting program. This was a decline from the 5/23/15 MDS assessment, when R355 was occasionally incontinent. The clinical record lacked evidence that R355 was re-evaluated after the urinary continence decline, lacked evidence of care plan revision, lacked evidence of a voiding diary being completed and lacked evidence that the physician was aware of the increase in incontinence and was involved. Review of the clinical record for July, 2015 revealed R355 was experiencing [MEDICAL CONDITION] and increased pain. R355 was refusing to get out of bed, refusing therapy, medications, and refusing to eat. Readjustments were being made to antidepressant and pain medications. During an interview on 10/21/15 at 2:15 PM, E29 (CNA) stated that she had cared for R355 regularly during his stay at the facility. E29 stated that initially he improved with therapy but then got worse and for a time wouldn't get out of bed or participate in therapy. E29 stated that initially he used a urinal independently and was continent, but then declined and she would go in every two (2) to three (3) hours to ask if he needed to toilet. E29 stated that they do not do voiding diaries, that they go in every 2 to 3 hours and ask the resident if they need to go or check to see if they are wet. In an interview on 10/21/15 at 2:25 PM, E30 (COTA) stated the resident had a long history of back pain and had an increase in depression and would not get out of bed for a week, resulting in a significant decline. E30 stated R355 initially made progress but then declined and was not able to tolerate getting on a toilet due to pain. On 10/21/15 at 2:50 PM during an interview, E31 (R355's physician) stated R355 had chronic lower back issues and had back injections several times which can cause irritation of the nerve in the lower back which can then affect bladder function. E31 stated the resident was very depressed and had given up. The facility failed to ensure that R355, who entered the facility occasionally incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. There was no initial voiding diary completed and no individualized care plan developed based on the residents' voiding patterns. Although R355 remained mostly continent until July 2015, the 7/16/15-60 Day Medicare MDS assessment stated there was a decline in urinary status to frequently incontinent. The facility failed to re-assess the resident after this decline, failed again to complete a voiding diary to determine voiding patterns, failed to revise the plan of care and lacked evidence that the residents' physician was involved or informed of this decline. Findings were reviewed on 10/21/15 at 4:30 PM with E3 and on 10/22/15 at approximately 4:00 PM during the exit conference with E1 and E2. 3. R214 was admitted to the facility on [DATE] for short term rehabilitation. 4/8/15 timed 9:15 PM - The nursing admission screen stated that R214 was independent with daily decision making, continent of bladder, required assistance for toileting and was ordered diuretic medication. 4/15/15 - The admission MDS assessment stated R214 was cognitively intact, occasionally incontinent of bladder and not on a toileting program. Review of R214's clinical record revealed a lack of evidence of a comprehensive assessment of her urinary incontinence, including a bladder diary to determine her voiding pattern. Despite the lack of a comprehensive urinary assessment, the facility care planned R214 for urinary incontinence. 4/20/15 - R214 was care planned for urinary incontinence related to loss of bladder muscle tone and impaired mobility. One of R214's goals for her urinary incontinence care plan was to attain/maintain continence, based upon usual voiding pattern. The care plan approaches included: remind and assist as needed with toileting at routine times such as upon arising in AM, with meals and at bedtime; adjust toileting times to meet patient needs; provide incontinent care as needed. It was unclear in the clinical record how the facility could meet R214's goal to attain/maintain continence based upon her usual voiding pattern when the facility lacked a comprehensive urinary assessment, including a bladder diary to determine her voiding pattern. The facility failed to individualize the care plan to meet the needs of R214. 4/22/15 - The Medicare 14-day MDS assessment stated R214 was occasionally incontinent of bladder. R214 was hospitalized from [DATE] to 5/1/15. 5/1/15 timed 5:31 PM - The nursing readmission screen stated that R214 was independent with daily decision making, continent of bladder, required assistance for toileting and ordered diuretic medication. R214 was hospitalized from [DATE] to 5/13/15. 5/13/15 timed 7:05 PM - The nursing readmission screen stated that R214 was independent with daily decision making, continent of bladder, required assistance for toileting and ordered diuretic medication. 5/20/15 - The admission MDS assessment stated R214 was cognitively intact and continent of bladder. 5/27/15 - The Medicare 14-day MDS assessment stated that R214 was occasionally incontinent of bladder. It was unclear in R214's clinical record how the facility responded when her urinary continence declined and she became occasionally incontinent according to the 5/27/15 MDS assessment. The facility failed to comprehensively assess R214's urinary incontinence when she became occasionally incontinent. R214 was hospitalized from [DATE] to 6/17/15. 6/17/15 timed 9:06 PM - The nursing readmission screen stated that R214 was independent with daily decision making, continent of bladder, required assistance for toileting and ordered diuretic medication. 6/24/15 - The significant change MDS assessment stated that R214 was cognitively intact, frequently incontinent of bladder, required extensive assist of two staff persons for toileting and ordered diuretic medications. The facility failed to comprehensively assess, which included completion of a bladder diary, when R214 was identified as frequently incontinent of bladder. In addition to the lack of a comprehensive urinary assessment, the facility reinitiated the same 4/20/15 urinary incontinence care plan for R214. 6/29/15 - R214's care plan for urinary incontinence remained the same. It was unclear in the clinical record how the facility could meet R214's goal to attain/maintain continence based upon her usual voiding pattern when the facility lacked a comprehensive urinary assessment, which included completion of a bladder diary to determine her voiding pattern. The facility failed to individualize the care plan to meet the needs of R214. 7/3/15 - The Medicare 14-day MDS assessment stated that R214 was frequently incontinent of bladder. It was unclear in R214's clinical record how the facility responded to her continued frequent incontinence. 7/13/15 - The Medicare 30-day MDS assessment stated that R214 was occasionally incontinent of bladder, which was an improvement in urinary incontinence from the previous assessment. R214 was hospitalized from [DATE] to 8/7/15. 8/7/15 timed 7:52 PM - The nursing readmission screen stated that R214 was independent with daily decision making, continent of bladder and required assistance for toileting. Upon readmission, R214 was not ordered diuretic medication for the remainder of her stay at the facility. 8/14/15 - The admission MDS assessment was cognitively intact and occasionally incontinent of bladder. Although R214's urinary incontinence improved from frequently to occasionally, the facility failed to comprehensively assess, which included completion of a bladder diary. 8/21/14 - The Medicare 14-day MDS assessment stated that R214 was occasionally incontinent of bladder. 8/26/15 - R214 was discharged from the facility. Review of R214's monthly documentation of urinary incontinence episodes revealed the following: - April 8-27, 2015 - incontinent 6 times; - May 1-2, 2015 and May 13-31, 2015 - incontinent 9 times; - June 17-30, 2015 - incontinent 17 times; - July 1-28, 2015 - incontinent 29 times; and - August 8-26, 2015 - incontinent 5 times. Review of the physician's progress notes during R214's entire stay at the facility from April 2015 through August 2015 lacked evidence of her urinary incontinence. Review of the clinical record revealed that in eight (8) out of nine (9) MDS assessments, R214 was identified as being either occasionally or frequently incontinent of bladder. The facility failed to comprehensively assess her urinary incontinence, which included completion of a bladder diary. In an interview on 10/19/15 at 3:21 PM, E4 (DCD) stated that bladder diaries were not completed for R214 upon admission and three (3) subsequent readmissions to the facility. Findings were reviewed on 10/20/15 at 3:20 PM with E1, E2 and E3. The facility failed to ensure that R214 received appropriate treatment and services to maintain as much normal bladder function as possible. 4. R396 was admitted to the facility on [DATE] for short term rehabilitation after being hospitalized for [REDACTED]. The nursing admission screen, dated 7/15/15 and timed 6:43 PM, stated that R396 was alert and oriented, continent of bladder, and required assistance for toileting. The admission MDS assessment, dated 7/22/15, stated R396 was cognitively intact, occasionally incontinent of bladder and not on a toileting program. Review of R396's clinical record lacked evidence of a comprehensive assessment for urinary incontinence, including a bladder diary to determine her voiding pattern. Although the 7/22/15 admission MDS triggered the CAAs and was checked to develop a urinary incontinence care plan, review of R396's care plans lacked evidence of a urinary incontinence care plan. It was unclear in the clinical record how the facility could attain/maintain R396's continence based upon her usual voiding pattern when the facility lacked a comprehensive urinary assessment, including a bladder diary to determine her voiding pattern. Review of R396's physician's progress note, dated 7/23/15, stated that R396 had bowel and bladder incontinence. Review of electronic documentation for Toileting for R396, completed by CNAs, revealed the following: - 7/15/15 through 7/31/15 - sixteen (16) documented episodes of incontinence; - 8/1/15 through 8/31/15 - three (3) documented episodes of incontinence; - 9/1/15 through 9/11/15 - three (3) documented episodes of incontinence, (urinalysis was negative on 9/8/15). R396 was hospitalized ,[DATE]-[DATE] for complaints of abdominal discomfort and nausea with dry heaves. R396 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission screen, dated 9/22/15 and timed 7:38 PM, stated that R396 was alert and oriented, continent of bladder, and required assistance for toileting. The significant change MDS assessment, dated 9/29/15, stated R396 was cognitively intact, required extensive assistance of two+ staff for toileting, was frequently incontinent of bladder, and was not on a toileting program. [DIAGNOSES REDACTED]. The 9/29/15 significant change MDS again triggered the CAAs and was checked to develop a care plan for urinary incontinence. However, once again, review of R396's care plans lacked evidence of a urinary incontinence care plan. Review of electronic documentation for Toileting for R396, completed by CNAs, revealed the following: - 9/22/15 through 9/30/15 - fourteen (14) documented episodes of incontinence; - 10/1/15 through 10/14/15 at 08:26 AM - nine (9) documented episodes of incontinence (On 10/7/15, R396's physician ordered the diuretic, [MEDICATION NAME] 20 mg daily for increased swelling in her legs). During an observation and interview on 10/12/2015 at 2:30 PM, R396, who was alert and oriented, stated that she had diarrhea since this morning. R396 denied any problems with care in the facility and stated that her pad (disposable brief) was changed a couple of times a day. When asked if she was toileted, she stated, yes. When asked how she was toileted, with assistance or independently? . R396 stated, 2 person assist . with a hoyer lift. R396 stated, I've had my setbacks . [MEDICAL CONDITION] . since my admission . was in the hospital for 11 days. R396 was observed in bed with the call bell in reach and no signs or symptoms of urinary incontinence. During an interview on 10/13/15 at 2:50 PM, E4 (DCD) confirmed there was no care plan for incontinence despite the CAAs being triggered on both R396's admission MDS, dated [DATE] and significant change MDS, dated [DATE]. The decision to care plan for urinary incontinence had been checked as yes on both CAAs. E4 denied completion of a 3 day voiding diary or full bladder assessment for R396. E4 stated that R396 was alert and oriented, able to use the call bell and make her needs known. She stated that the resident currently uses a bedpan and has been toileted per the facility, Standard times of upon arising, around meal times and at bedtime and as needed per the resident's request. E4 was unable to state what type of incontinence R396 had. She stated she would interview R396 to determine the type of incontinence and if she could identify any other problems. E4 stated she would then initiate an incontinence care plan. On 10/13/15 at 3:32 PM, R396 was observed neatly groomed, with no signs or symptoms of incontinence, with her call bell in reach, and was interviewed regarding an increase of incontinence. R396 stated that since she was hospitalized , she returned more tired. R396 stated she used her call bell to request/use the bedpan. R396 denied any problems with care and stated that her call bell was answered timely. R396 stated that she was offered a bedpan or was changed when she got up in the morning during morning care, around lunch and dinner times and at bedtime. She denied any incontinence at night. R396 denied the need for additional toileting times and stated being satisfied with her care. Findings were reviewed on 10/20/15 at approximately 3:35 PM with E1, E2, E33 (ADON), E3 and E34 (Regional Therapist). When asked if R214, R359 or R396 had been seen by therapy for incontinence, E34 stated, No, none of these 3 residents. The facility failed to ensure that assessment, monitoring, reviewing, and revising approaches to care (as needed) were done to manage R396's urinary incontinence and to restore as much normal bladder function as possible upon her 7/15/15 admission and 9/22/15 readmission, when R396 had a decline in urinary incontinence (from occasionally incontinent to frequently incontinent). Additionally, the facility failed to utilize the facility guideline (which included completing a 3 day voiding diary) and failed to have an incontinence policy and procedure in place.

Based on observation, interview and record review, it was determined that the facility failed to provide 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 two (R2 and R5) out of six sampled residents. For R2, the facility failed to assess/monitor and identify the significance of the increasing swelling and bruising at the right chest wall extending under the right armpit with progression to the left chest wall, for a [MEDICATION NAME] (blood thinning medication) dependent resident. Additionally, for R2, the facility failed to follow the plan of care and failed to correctly transcribe a medication order leading to a failure to administer the number of doses of the medication ordered by the physician. For R5, the facility failed to follow the plan of care when the doctor's order of 1/14/14 for the restorative nursing program was not implemented. Findings include: According to Mosby's 2013 Nursing Drug Reference, used by the facility, [MEDICATION NAME] is an anticoagulant (blood thinner) and [MEDICAL CONDITION] (reduces blood clots). Nursing considerations included to assess for bleeding and to report any signs of bleeding: gums, under skin, urine and stools (bowel movements). The manufacturer's package insert for [MEDICATION NAME] stated, "Geriatric Use... treatment of [REDACTED].= 2.2 pounds) once a day or 1 mg/kg every 12 hours". Also according to manufacturer's recommendations, [MEDICATION NAME] should not be used in patients who are actively bleeding or who have a low count of blood cells called platelets, which aid in clotting. [MEDICATION NAME] must be used with care in patients who have kidney problems and excessive bleeding. 1A. R2 was admitted to the facility on [DATE] from the hospital where the resident had been treated for [REDACTED]. R2 also had dementia (loss of mental functions such as memory and reasoning that is severe enough to interfere with a person's daily functioning). The following documentation was contained in the clinical record, facility documents and hospital record: 12/24/13 - Admission Assessment indicated that R2 was a fall risk due to a history of falls, weakness, unsteadiness, the resident was on scheduled pain medication and had bruising on both lower legs and three skin tears. 12/24/13 - Care plan entitled, "At risk for falls due to impaired balance/poor coordination, unsteady gait, history of falls and potential medication side effect", initiated on 12/24/13 and last revised on 1/28/14, with a goal to minimize the risk for falls. Interventions included: Administer medications per doctor ' s orders; Encourage to transfer and change positions slowly; Low bed; Provide assist to transfer and ambulate as needed; Reinforce need to call for assistance; Report development of pain, bruises, change in mental status, ADL (activities of daily living) function ... per facility guidelines after a fall; Obtain urinalysis with culture and sensitivity to rule out a UTI (urinary tract infection); Therapy evaluation and treatment per orders. 12/31/13 - The admission Minimum Data Set Assessment (MDS) stated that R2's mental functions were severely impaired, required extensive assistance of two persons for bed mobility and transfers, did not walk in the room or in the hallway and was dependent with assistance of one person for locomotion on and off the unit. The fall history was unable to be obtained but the resident had no falls since admission. This MDS stated that the resident weighed 169 pounds. 1/8/14 - A facility incident report, timed 8:43 PM, revealed that R2 had an unwitnessed fall. According to the investigation report, dated 1/8/14 at 8:45 PM, "Patient found lying on the floor on her right side with the wheelchair beside her on its side in the hallway ... No injuries noted at this time, positive movement of all extremities (arms and legs) with mild pain to right arm ... ". 1/27/14 - The progress note at 2:30 PM stated that R2 was noted with swelling, warmth and pain to the right knee. R2's doctor/nurse practitioner was notified and orders were given for an x-ray of the right knee, an ultrasound of both legs and laboratory (lab) tests. 1/27/14 - The ultrasound report of the legs revealed that both legs had non-occluding (not totally blocking the blood flow of the vein) deep venous [MEDICAL CONDITION] ([MEDICAL CONDITION]/blood clots). 1/27/14 - R2's doctor ordered [MEDICATION NAME] solution 80 mg (milligrams) to be administered via a needle every twelve hours to treat R2's blood clots. Review of the eMAR (computerized Medication Administration Record) revealed that R2 received [MEDICATION NAME] 80 mg by injection at 8 PM. 1/28/14 - The lab results revealed the following: - High white blood cell (help fight infections) count of 14.3 (normal = 3.8 -10.8); - Low red blood cell (deliver oxygen throughout the body) count of 2.97 (normal = 3.8-5.10); - Low hemoglobin (a protein in red blood cells that carries oxygen) count of 9.2 (normal = 11.7 - 15.5); - High blood urea nitrogen (nitrogen in the blood which indicates how well the kidneys are functioning) of 30 (normal 7 - 25); - High creatinine (creatinine in the blood which indicates how well the kidneys are functioning) of 1.12 (normal = 0.60 - 0.88); and - High uric acid (a natural breakdown of the body ' s cells and food eaten) level of 9 (normal range = 2.5 - 7). The last three lab results indicate that kidney function had decreased. 1/28/14 - A care plan entitled, "Anticoagulant therapy to treat BL LE [MEDICAL CONDITION] (bilateral lower extremity [MEDICAL CONDITION] - blood clots in both legs): at risk for adverse effects", had the goal that R2 will have no adverse effects. Interventions included: Administer per physician orders; Obtain labs as ordered and notify doctor of results; Report adverse effects such as blood in urine/stool, gums/nose bleeding, bruising. 1/28/14 - A facility incident report, timed 9 PM, revealed that the resident was found on the floor in a supine position (lying face up) with her legs stretched out and the wheelchair behind her. A head to toe assessment was done with no injuries found. 1/28/14 - 1/31/14 - Review of the 1/2014 eMAR revealed that R2 received [MEDICATION NAME] 80 mg by injection at 8 AM and 8 PM from 1/28/14 through 1/31/14. 2/1/14 - Review of the 2/2014 eMAR (computerized Medication Administration Record) revealed that R2 received [MEDICATION NAME] 80 mg by injection at 8 AM on 2/1/14. 2/1/14 - The progress note at 12:21 PM, stated, "... Noted with a 9 cm (centimeter) x (by) 11 cm semi hard swelling to her upper right chest wall extending under her right armpit. Resident c/o (complained of) pain when area is touched. No redness, warmth, or bruising noted. Call put out to MD (doctor)". 2/1/14 - The doctor returned the call at 12:45 PM. R2's doctor ordered x-rays of the right ribs and chest. 2/1/14 - Review of the 2/2014 eTar (computerized Treatment Administration Record) revealed that R2 had a body audit done at 2:45 PM, noted by a checkmark. However, this body audit was incomplete. On 2/1/14 at 12:21 PM, R2 was observed with a 9 cm by 11 cm semi hard swelling to her upper right chest wall extending under her right armpit. Despite doing a body audit at 2:45 PM, there was a lack of evidence in R2's record that the right chest wall and armpit areas were assessed and measured. 2/1/14 - The progress note at 6:12 PM, stated that the x-ray results came back with no abnormalities seen in the right ribs but the right lung had findings that were compatible with pneumonia. The on-call doctor was called, made aware of the of the x-ray results and ordered an antibiotic. 2/2/14 - A progress note at 3:16 AM, revealed a late entry for 2/1/14 at 6:12 PM that stated, "Resident noted with bruising under right breast of about 10 cm by 5 cm. No warmness, but tender when touched. MD (doctor) made aware, new order to make a note for patient to be seen on Monday (2/3/14)". There is no evidence that in the presence of swelling and bruising to the right chest wall that the doctor was notified that R2 was on [MEDICATION NAME]. There is also no evidence that the right chest wall was assessed with [REDACTED]. 2/1/14 - Review of the 2/2014 eMAR (computerized Medication Administration Record) revealed that R2 received [MEDICATION NAME] 80 mg by injection at 8 PM. There was no evidence that the doctor was called prior to the administration of [MEDICATION NAME] despite the presence of swelling and bruising to the right chest wall. 2/2/14 - A progress note at 4:57 AM, stated, "C/o (complaining of) pain, facial grimace noted when rt (right) arm is touched". There is no evidence that the swelling and bruising on the right chest wall was reassessed at this time. 2/2/14 - A progress note at 6:48 AM, stated, "Swelling to pt's (patient's) right breast is noted to have increased bruising and swelling. The area now measured 45 cm by 22 cm, while bruising to left is 10 by 6 cm. Medicated x1 (once) for pain. Pt is currently resting comfortable in bed." This was the first assessment and measurement of the bruising in more than 12 hours and showed an increase in size on the right chest wall from 10 cm by 5 cm to 45 cm by 22 cm with progression to the left chest wall. 2/2/14 - A progress note at 8:01 AM, stated, "Pt. was picked up by ambulance at 0800 AM. Family is aware". 2/2/14 - The hospital CT scan (Computerized Tomography/CAT scan - an x-ray procedure) of the chest showed, "Findings: Small to moderate sized bilateral (both sides) simple pleural effusions (a condition in which excess fluid builds around the lung), right somewhat greater than left ...Large right ...chest wall ...with subacute hematomas (a less than acute localized swelling filled with blood) The anterior (front) chest wall component measures 8.6 x 14.1 x 15.1 cm in size. Right lateral/axillary (armpit area) component measures 6.1 x 11.4 x 10.0 cm in size ... Structures of the chest reveal subacute fractures (broken bones) of the 11th, 10th, 9th, 8th, and 7th right ribs ... subacute [MEDICAL CONDITION] 3rd rib anteriorly is also noted. Impression: 1. Two large right chest wall subacute hematomas surrounded by substantial chest wall [MEDICAL CONDITION] (swelling) ...2. Multiple subacute right rib fractures. 3. Moderate sized bilateral pleural effusions." 2/2/14 - The hospital History and Physical for R2, dictated at 11:03 AM, stated that the resident presented, "... To the emergency room with right chest wall swelling ... She fell out of her wheelchair on Tuesday ... It has gotten markedly worse over the past 24 hours and now she has a bulging hematoma over her right breast. She was brought into the emergency room with a blood pressure 81/47 (normal = 120/80). She was found to have a hemoglobin of 5.9. CAT scan showed a right sided chest wall hematoma with multiple rib fractures ...Right chest wall hematoma in the setting of recent fall and recent initiation of anticoagulation (blood thinner) ....We will complete the blood [MEDICAL CONDITION]". The resident's hemoglobin when last tested in the facility on 1/28/14 was low at 9.2 but had decreased to 5.9 on arriving at the hospital. 2/2/14 - The "Forensic Nurse Examiner Elder Physical Abuse And Neglect Forensic Evaluation", at 12:45 PM, stated that a full examination was done and information was obtained from the facility and from R2's family. Under the assessment of abuse patterns, it stated, "...Physical other (checked) 'Pt c (patient with) bruising + (and) ribs fxs (fractures) noted upon assessment, unk (unknown) hx (history) of events'". Under "current level of pain based on the 'Wong Baker pain faces scale' was circled 5-6, hurts even more with location of pain R (right) chest". Types of findings were in a diagram as follows: "1. (referring to front chest wall) BR (bruise) described as large area of bruising, dark blue, purple in color, Pt. c/o (patient complaining of) tenderness, large area of swelling noted, cont. (continuing) to side; 2. (referring to left arm) BR - smaller bruise red to blue in color; 3. (referring to left arm) ST (skin tear) bruise red to blue in color, 0 (no) active bleeding; 4. (referring to abrasion (scraped area) left elbow) abrasion c (with) scabbing noted to elbow; 5. (referring to right front arm area) BR -areas of bruising blue to dark purple noted to R (right) arm; 7. (referring to left ear) BR - bruise blue to purple in color to ear ...". 2/11/14 - The facility's doctor for R2 wrote a post discharge note that stated, "Pt was sent from (name of facility) to (name of hospital) where she was found to have multiple 'subacute' rib fractures on CT. Interestingly those were not seen on CXR (chest x-ray) here or at (name of the hospital). I do not know when these occurred; Conceivably they could have happened in December with her syncopal ([MEDICAL CONDITION]) event or when she fell here (referring to when R2 fell twice while she was a resident at the facility). The late bruising undoubtedly was worsened by her [MEDICATION NAME] anticoagulation". 3/4/14 - At 1:30 PM, in an interview, E13 (Certified Nurse's Aide/CNA) stated that R2 could stand and was transferred with two people at times. E13 stated that she did not remember using any lift to transfer the resident. E13 reviewed her statement from an interview on 2/2/14 and stated that the incident was 2/1/14 not 2/2/14 as per the written statement. E13 stated that her statement was accurate and after dinner when she cared for the resident that she noticed that the right breast was very swollen and bruised and called the nurse to show it to her. 3/4/14 - At 1:45 PM, in an interview, E14, (CNA) stated that on 1/31/14, 7 - 3 shift he used the stand-up lift with another CNA to transfer the resident. E14 stated, "One person stayed with the resident while the other CNA operated the stand-up lift... the resident did not complain of pain, moan at any time during the transfer or during the dayshift". E14 stated that after the stand-up lift was used to transfer the resident to the toilet and back into the wheelchair, R2 was wheeled into the dining room for breakfast. E14 further stated that later R2 was able to pivot transfer with one person assistance to the toilet and to the wheelchair. 3/4/14 - At 2:01 PM, in a telephone interview, E7 (Licensed Practical Nurse/LPN) stated that on 2/1/14 at 6:12 PM she, "Called her (referring to the on call doctor for R2) about the x-ray results and the swelling that I was told about when I came onto the shift ...It was just about the antibiotics, I did not tell the covering doctor about any of the resident's other medications, including [MEDICATION NAME]. I told the covering doctor that there was bruising under the right breast. The on call doctor told me to make a note for the regular doctor to see the resident on Monday" (2/3/14). 3/4/14 - At 2:30 PM, in an interview, E15 (LPN) after reviewing her progress note for R2 on 2/1/14 at 12:21 PM, stated, "The resident had a semi hard swelling on her right upper chest that extended to the right armpit. The area was not warm, discolored or bruised. It measured 9 cm by 11 cm and the resident complained of pain when the area was touched... I called the doctor and he ordered x-rays of the right ribs and chest... 12:21 PM was the first that the right rib/armpit swelling was identified". E15 further stated that she cared for R2 on 1/31/14 and with regards to the right rib and armpit swelling, "It was not there on 1/31/14". 3/4/14 - At 3:25 PM, in an interview, E12 (LPN), after reviewing the nurse's note and witness statement she wrote after R2's fall on 1/28/14 at 9 PM, stated that the resident was offered to go to bed but the resident did not want to go to bed. The resident wanted to go home and she was seated in her wheelchair by the nurses' station. E12 stated that she went down the hallway to give another resident medication and a few minutes later she found the resident on the floor lying on her back with the wheelchair behind her. E12 further stated, "I did a head to toe assessment, asked the resident to move her arms, legs, did neuro checks (neurological checks used to check for injury or issues with the brain) and vital signs. I found no injuries. I asked the resident if she would agree to go to bed, which she did. I then examined her and there were no bruises". E12 stated that the staff, including herself: toileted the resident; made sure the wheel chair was locked; when the resident was in bed that the bed was in the lowest position; that the resident was dry; and that the call bell was at the bedside even if the resident could not always use it. 3/4/14 - At 3:40 PM, in an interview, E8 (Registered Nurse) stated that she got report on 2/1/14 from E7 who also worked a double 3 to 11 and 11 to 7 shifts. E8 stated that she had R2 as part of her assignment for the 2/1/14 to 2/2/14, 11 to 7 shift. E8 stated, "I go at the beginning of the shift, I think to give her medicine, there was no grimacing at that time. I did look at the area but did not measure it". E8 stated that on 2/2/14 about 4:57 AM that the CNA (Certified Nurse's Aide) told her that the resident had facial grimacing when she was turned and repositioned so, "I gave her [MEDICATION NAME] (narcotic pain reliever) for pain. She had facial grimacing noted when her right arm was touched. Even though I did not document it, I saw that the right breast and under the right armpit had increased in size but I did not measure it. It was bruised, purple blue in color. At 6:48 AM, the size had increased more from earlier with bruising and I measured it. Then, I said we have to send her out, called the nurse supervisor and called the doctor". 3/4/14 - At 4:10 PM, in an interview, E4 (Registered Nurse, Director of Care Delivery) stated, "This was being monitored over the last 24 hours. I don't know if a two hour delay was significant. If she (referring to E8) saw it at 4:57 AM (on 2/2/14) and didn't feel she needed to call the doctor then, she did look at it at 6:48 AM and then did call the doctor and sent her out. We don't know how much difference there was in the 2 hours". E4 did acknowledge that R2 did require blood [MEDICAL CONDITION] at the hospital. 3/5/14 - At 7:40 AM, in an interview, E2 (Director of Nursing) stated that E8 was interviewed on 3/4/14, by herself and other facility staff, after the surveyor had interviewed E8 and had left for the day. E2 stated when asked the question as to what was increasing for R2 (referring to the swelling and the bruising of the right breast and under the armpit area on 2/2/14) that E8 stated that it was the size not the bruising that was increasing. The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being when it failed to: - Assess/monitor and identify the significance of the increasing swelling and bruising at the right chest wall extending under the right armpit with progression to the left chest wall for R2, a [MEDICATION NAME] dependent resident with an abnormal Hgb; - Identify that R2 was on [MEDICATION NAME], on 2/1/14 at 6:12 PM, when speaking with the doctor, despite the initial swelling at the right ribs area noted on 2/1/14 at 12:21 PM and initial bruising under the right breast first noted on 2/1/14 at 6:12 PM; - Obtain clarification from R2's doctor regarding whether to administer [MEDICATION NAME] on 2/1/14 at 8 PM and failed to provide the opportunity for the doctor to give further orders; - Do complete assessments and measurements of the swelling and bruising/bleeding of the right chest wall, armpit and left chest wall areas despite multiple opportunities and despite developing symptoms from the onset on 2/1/14 at 12:21 PM to 2/2/14 at 6:48 AM. The time period was over eighteen (18) hours. The swelling and bruising/bleeding into the right chest wall/ breast area and under the armpit with progression to the left chest wall resulted in R2's hemoglobin dropping from 9.2 to 5.9. R2 was admitted to the hospital and required blood [MEDICAL CONDITION]. 1B. On 1/24/14, R2's doctor ordered [MEDICATION NAME] swish and swallow for three times a day for seven days as part of the plan of care when oral thrush (fungal infection where the mouth becomes sore and red, and white spots sometimes develop) was diagnosed . A care plan entitled, "Infection of mouth - oral thrush" was initiated on 1/27/14 with the goal that the infection will be resolved without complications. Interventions included: "Administer medication per doctor's order...". Review of the 1/2014 eMar (computerized Medication Administration Record) revealed that the order was incorrectly transcribed for six days and one dose rather than for seven days. Additionally, since [MEDICATION NAME] was not dispensed promptly, R2 did not receive the first dose until 1/27/14 at 8 AM. The eMAR was not revised so R2 received only 11 out of 21 doses ordered. The facility failed to follow the plan of care and failed to administer [MEDICATION NAME] as per R2's doctor's order. On 3/4/14 at 4:10 PM in an interview, E4 (Registered Nurse, Director of Care Delivery) confirmed the findings. 2. Review of R5's care plan entitled, "ADL (activities of daily living) Self care deficit related to limited mobility (ability to move freely and easily), dementia (loss of mental functions such as memory and reasoning that is severe enough to interfere with a person's daily functioning) and [MEDICAL CONDITIONS]", initiated 4/2/13 and last revised on 8/7/13, had the goal of will receive assistance necessary to meet ADL needs with a target date of 5/21/14. Interventions included: "Restorative ambulation: Ambulate 300 feet with rolling walker and close supervision 2 x (times) day...". R5 had two falls in early December 2013 and her doctor ordered Physical Therapy services. The Physical Therapy summary, with an initial date of 12/10/13, stated that R5 was evaluated on 12/10/13 due to, "s/p (status [REDACTED]./Immobility is the state of not being able to move around.)". On 1/14/14, upon completion of Physical Therapy services, R5's doctor ordered a Restorative Nursing Program ((RNP) restorative nursing interventions promote the resident's ability to adapt and adjust to living as independently and safely as possible) for R5 to ambulate with a single point cane, contact guard assistance (Have one or two hands on the person's body to help with balance.) for 200 feet 5 times per week. Review of the computerized CNA documentation from 1/15/14 through 2/24/14 revealed that R5 was incorrectly being ambulated with a roller walker and close supervision twice a day rather than a single point cane as per R5's doctor's order. On 2/24/14 at 1:10 PM, an observation was made of R5 walking in the hallway with a roller walker with E9 (Certified Nurse's Aide/CNA) holding a gait belt that was around the resident's waist for safety and E10 (CNA) pushing the wheelchair behind R5 in the event that she needed to sit down. The resident walked with the roller walker from her room to the elevator and back to her room. On 2/24/14 at 1:30 PM, in an interview, E9 stated that as part of the restorative nursing program that the resident was walked 300 feet with the rolling walker and close supervision twice a day unless she refused. On 2/24/14 at 2:10 PM, in an interview, E11 (Physical Therapist) stated that R5 had reached her maximum with physical therapy services and then was placed on a restorative nursing program on 1/14/14. E11 stated that it was his expectation that the facility would be following the program R5's doctor ordered for the resident on 1/14/14. The facility failed to follow R5's plan of care and implement the 1/14/14 doctor's orders for the restorative nursing program. On 2/24/14 at 2:27 PM in an interview, E4 (Registered Nurse, Director of Care Delivery) confirmed the findings.

Based on observation, interview, record review and review of other documentation as indicated it was determined that one (1) out of 3 sampled residents (R2) was not free of significant medication errors. The facility inadvertently administered medications belonging to another resident to R2 on 5/1/11 after R2 already received his own medications. As a result, R2 experienced a change in mental status and became hypotensive (low blood pressure). R2 was subsequently hospitalized for [REDACTED]. R2, currently [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 was on hospice services and resided in the locked dementia unit (he no longer resides in the facility). Review of R2's clinical record revealed he had severe cognitive impairment with little speech (unintelligible), he was dependent on staff for all activities of daily living and was non-ambulatory. Review of facility incident reports and the investigation revealed that R2 was given the wrong medications at 10 AM on 5/1/11 after a prn nurse (works wherever needed in the facility) misidentified R2 using the picture in the medication administration record (MAR). R2 did not have a name band on. E1 (prn nurse) was observed by E2 (LPN nurse assigned to R2) giving R2 crushed medications on a teaspoon in the dining room. E2 immediately stopped E1 from administering the remainder of the medications in the medicine cup. The MD, nursing supervisor and family were notified. The facility received an order to monitor R2 for a change in mental status and to notify the MD. Review of R2's MAR revealed that on 5/1/11 at approximately 9 AM, he received [MEDICATION NAME] 5 mg. (hypertension), [MEDICATION NAME] 320 mg. (hypertension), [MEDICATION NAME] 400 mg. (calcium supplement), Multivitamin, Natural Tears eye drops, and Senna S 2 tablets (constipation) as ordered. On 5/1/11 at 10 AM, R2 incorrectly received [MEDICATION NAME] 400 mg., Multivitamin, [MEDICATION NAME] 40 mg (reflux), Klonopin 1 mg. ([MEDICAL CONDITION] as well as other off label uses), [MEDICATION NAME] 25 mg. (hypertension and other cardiac uses), and [MEDICATION NAME] 50 mg. (antipsychotic) at 10 AM. [MEDICATION NAME] was listed as a medication allergy (reported [MEDICAL CONDITION] or [MEDICAL CONDITION]) on R2's MAR. Of particular importance, R2 received [MEDICATION NAME], a medication he was reportedly allergic to, as well as multiple antihypertensive medications. R2 was monitored as ordered and vital signs were as follows: 10 AM- 97.1- 68-20-131/66 (temperature, pulse, respirations, BP) 11 AM- 97.2-78-20-111/60 12:20 PM- 96.8- 63-18-108/56- PO2 98% on RA (oxygen level on room air) 1:20 PM- 59- 16-85/53- PO2 97% on RA A Clinical Assessment Report, completed by the facility on 5/1/11, stated that R2's blood pressure (BP) was 85/53 at 1:20 PM. R2's BP prior to his AM medications was 133/74. R2 was lethargic and he vomited x 1. He was unresponsive to staff or family. A nurse's note, dated 5/1/11 and timed 2 PM, stated that 911 arrived to take R2 to the ER. R2 was monitored and treated in the ER then hospitalized from [DATE] until 5/4/11 when he returned to the facility. Review of the hospital Discharge Summary, dated 5/4/11, listed "accidental administration of medications at nursing home... [MEDICAL CONDITION]" as principle diagnoses. A medication pass was completed in the dementia unit (Arcadia) on 10/3/11. The observed nurses checked resident name bands prior to administering medications. One resident did not have a name band on and the nurse confirmed with another staff member the residents identity prior to administering medications. The Arcadia Identification Records for R2 and the other resident were reviewed. In addition to a picture, other information included: residents name, height, weight, hair and eye color, skin complexion, and emergency information. R2 was listed as 5'7", 134 lbs., and his picture revealed him with his eyes closed in a wheel chair without glasses. The resident that the 10 AM medications were intended for was listed as 6'2", 215 lbs., and his picture showed him smiling and alert with glasses in place. Review of the Arcadia MAR on 10/5/11 revealed the same Identification Records in place for each resident. Interview with E3 (Unit Director) on 10/5/11 confirmed that she keeps the information sheets updated as information or resident appearance changes (for example, if resident lost weight) and she stated that the same form was in use on 5/1/11. E4 ( LPN) in the Arcadia unit was interviewed on 10/5/11. When asked how she identified residents in Arcadia when administering medications, she stated she would first check for a name band, if none, she would use the photo ID in the MAR and if unsure, she would check the residents identity with another staff member. Review of facility Counseling/Education provided to E1 on 5/2/11, stated that E1 , "... did not follow the procedures in place requiring her to identify patient with picture that is on the MAR... works through the entire building on all three units (as needed)... is not entirely familiar with all of the patients. The patient who received the incorrect medication (R2) did not have an arm band on for further identification due to patient's behavior of removing arm band and arm band causing skin tears... In lieu of an identifying arm band , (E1) will ask for assistance from other nursing staff to properly identify patients prior to medication administration and if patient does not have an arm band present, request a new arm band from Medical Records to be applied to patient."